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BMC Med. 2018 Aug 31;16(1):153. doi: 10.1186/s12916-018-1128-1.

Gestational weight gain across continents and ethnicity: systematic review and meta-analysis of maternal and infant outcomes in more than one million women.

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Monash Centre for Health Research and Implementation, Monash University, Clayton, VIC, Australia.
Monash Diabetes and Endocrine Units, Monash Health, Locked Bag 29, Clayton Rd, Clayton, VIC, 3168, Australia.
Kaiser Permanente, Southern California, Los Angeles, USA.
Tianjin Women's and Children's Health Center, Tianjin, China.
Pennington Biomedical Research Center, Baton Rouge, LA, USA.
University Hospital, Messina, Italy.
Copenhagen University Hospital, Righospitalet, Copenhagen, Denmark.
Department of Obstetrics and Gynecology, School of Medicine, Ewha Womans University, Seoul, Republic of Korea.
Norwegian Institute of Public Health, Oslo, Norway.
Michigan State University, East Lansing, MI, USA.
Cheil Genetal Hospital and Women's Healthcare Centre Dankook University College of Medicine, Seoul, South Korea.
Department of Development and Regeneration KU Leuven, University of Leuven, Leuven, Belgium.
Faculty of Medicine and Health Sciences, Centre for Research and Innovation in Care (CRIC), University of Antwerp, Antwerp, Belgium.
Faculty of Health and Social Work, Research unit Healthy Living, UC Leuven-Limburg, Leuven, Belgium.
Department of Obstetrics and Gynaecology, University Hospitals KU Leuven, Leuven, Belgium.
Department of Obstetrics, Gynaecology and Fertility, GZA Campus Sint-Augustinus, Wilrijk, Belgium.
University of California, Irvine, CA, USA.
Monash Centre for Health Research and Implementation, Monash University, Clayton, VIC, Australia.
Monash Diabetes and Endocrine Units, Monash Health, Locked Bag 29, Clayton Rd, Clayton, VIC, 3168, Australia.



The association between Institute of Medicine (IOM) guidelines and pregnancy outcomes across ethnicities is uncertain. We evaluated the associations of gestational weight gain (GWG) outside 2009 IOM guidelines, with maternal and infant outcomes across the USA, western Europe and east Asia, with subgroup analyses in Asia. The aim was to explore ethnic differences in maternal prepregnancy body mass index (BMI), GWG and health outcomes across these regions.


Systematic review, meta-analysis and meta-regression of observational studies were used for the study. MEDLINE, MEDLINE In-Process, Embase and all Evidence-Based Medicine (EBM) Reviews were searched from 1999 to 2017. Studies were stratified by prepregnancy BMI category and total pregnancy GWG. Odds ratio (ORs) 95% confidence intervals (CI) applied recommended GWG within each BMI category as the reference. Primary outcomes were small for gestational age (SGA), preterm birth and large for gestational age (LGA). Secondary outcomes were macrosomia, caesarean section and gestational diabetes.


Overall, 5874 studies were identified and 23 were included (nā€‰=ā€‰1,309,136). Prepregnancy overweight/obesity in the USA, Europe and Asia was measured at 42%, 30% and 10% respectively, with underweight 5%, 3% and 17%. GWG below guidelines in the USA, Europe and Asia was 21%, 18% and 31%, and above was 51%, 51% and 37% respectively. Applying regional BMI categories in Asia showed GWG above guidelines (51%) was similar to that in the USA and Europe. GWG below guidelines was associated with a higher risk of SGA (USA/Europe [OR 1.51; CI 1.39, 1.63]; Asia [1.63; 1.45, 1.82]) and preterm birth (USA/Europe [1.35; 1.17, 1.56]; Asia [1.06; 0.78, 1.44]) than GWG within guidelines. GWG above guidelines was associated with a higher risk of LGA (USA/Europe [1.93; 1.81, 2.06]; Asia [1.68; 1.51 , 1.87]), macrosomia (USA/Europe [1.87; 1.70, 2.06]; Asia [2.18; 1.91, 2.49]) and caesarean (USA/Europe [1.26; 1.21, 1.33]; Asia [1.37; 1.30, 1.45]). Risks remained elevated when regional BMI categories were applied for GWG recommendations. More women in Asia were categorised as having GWG below guidelines using World Health Organization (WHO) (60%) compared to regional BMI categories (16%), yet WHO BMI was not accompanied by increased risks of adverse outcomes.


Women in the USA and western Europe have higher prepregnancy BMI and higher rates of GWG above guidelines than women in east Asia. However, when using regional BMI categories in east Asia, rates of GWG above guidelines are similar across the three continents. GWG outside guidelines is associated with adverse outcomes across all regions. If regional BMI categories are used in east Asia, IOM guidelines are applicable in the USA, western Europe and east Asia.


Caesarean section; Gestational diabetes; Ggestational weight gain; Large for gestational age; Macrosomia; Maternal and infant outcomes; Obesity; Pregnancy; Preterm birth; Small for gestational age

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