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Association Between Prepregnancy Body Mass Index and Severe Maternal Morbidity

Open access
Lisonkova, Sarka, Muraca, Giulia M., Potts, Jayson, Liauw, Jessica, Chan, Wee-Shian, Skoll, Amanda, Lim, Kenneth I.·2017·JAMA
DOI 10.1001/jama.2017.16191PMC PMC5820710
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Abstract

Importance: Although high body mass index (BMI) is associated with adverse birth outcomes, the association with severe maternal morbidity is unclear. Objective: To examine the association between prepregnancy BMI and severe maternal morbidity. Design, Setting, and Participants: Retrospective population-based cohort study including all singleton hospital births in Washington State, 2004-2013. Demographic data and morbidity diagnoses were obtained from linked birth certificates and hospitalization files. Exposures: Prepregnancy BMI (weight in kilograms divided by height in meters squared) categories included underweight (<18.5), normal BMI (18.5-24.9), overweight (25.0-29.9), obesity class 1 (30.0-34.9), obesity class 2 (35.0-39.9), and obesity class 3 (≥40). Main Outcomes and Measures: Composite severe maternal morbidity or mortality included life-threatening conditions and conditions leading to serious sequelae (eg, amniotic fluid embolism, hysterectomy), complications requiring intensive care unit admission, and maternal death. Logistic regression was used to obtain adjusted odds ratios (ORs) and adjusted rate differences with 95% confidence intervals, adjusted for confounders (eg, maternal age and parity). Results: Overall, 743 630 women were included in the study (mean age, 28.1 [SD, 6.0] years; 41.4% nulliparous). Prepregnancy BMI was distributed as follows: underweight, 3.2%; normal weight, 47.5%; overweight, 25.8%; obesity class 1, 13.1%; obesity class 2, 6.2%; and obesity class 3, 4.2%. Rates of severe maternal morbidity or mortality were 171.5, 143.2, 160.4, 167.9, 178.3 and 202.9 per 10 000 women, respectively. Adjusted ORs were 1.2 (95% CI, 1.0-1.3) for underweight women; 1.1 (95% CI, 1.1-1.2) for overweight women; 1.1 (95% CI, 1.1-1.2) for women with class 1 obesity; 1.2 (95% CI, 1.1-1.3) for women with class 2 obesity; and 1.4 (95% CI, 1.3-1.5) for women with class 3 obesity compared with women with normal BMI. Absolute risk increases (adjusted rate differences per 10 000 women, compared with women with normal BMI) were 28.8 (95% CI, 12.2-47.2) for underweight women, 17.6 (95% CI, 10.5-25.1) for overweight women, 24.9 (95% CI, 15.7-34.6) for women with class 1 obesity, 35.8 (95% CI, 23.1-49.5) for women with class 2 obesity, and 61.1 (95% CI, 44.8-78.9) for women with class 3 obesity. Conclusions and Relevance: Among pregnant women in Washington State, low and high prepregnancy BMI, compared with normal BMI, were associated with a statistically significant but small absolute increase in severe maternal morbidity or mortality.

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  • In the US, assisted reproductive technology has been associated with an elevated risk of maternal mortality.

    “In the US, ART has been associated with an elevated risk of maternal mortality [43, 44]”

    From Age-related disparities in national maternal mortality trends: A population-based study (2025) · cites this paper as [43]

    The Statistical Analyses section lists assisted conception only as a variable used to adjust the analysis of BMI and severe maternal morbidity or mortality. The Conclusions tables report assisted-conception counts and deaths by BMI, but not an association between assisted reproduction and maternal mortality. Searched for assisted reproductive technology, ART, and assisted conception; page numbers were not available in our copy. (LLM, conf=0.76)

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  • The use of assisted reproductive technology may have contributed to the elevated maternal mortality observed in this study among older women.

    “its use may have contributed to the elevated maternal mortality observed in our study among older women”

    From Age-related disparities in national maternal mortality trends: A population-based study (2025) · cites this paper as [43]

    The Data Sources and Statistical Analyses sections record assisted conception as a maternal characteristic and an adjustment variable. The Discussion addresses maternal deaths but does not suggest that assisted reproductive technology contributed to elevated mortality among older women; searches for assisted reproductive technology and older-age mortality found no such passage. Page numbers were not available in our copy. (LLM, conf=0.76)

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Authors
Lisonkova, S., Muraca, G. M., Potts, J., Liauw, J., Chan, W.-S., Skoll, A., & Lim, K. I.
Affiliations
University of British Columbia (CA)
Corresponding author
Lisonkova, Sarka
ORCID
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
2017-11-14
Volume
318
Issue
18
Pages
1777
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.2017.16191
PMC
PMC5820710
OpenAlex
W2769427421
Cited by
210
References
38
Citations by year
2026: 13 · 2025: 13 · 2024: 31 · 2023: 23 · 2022: 32 · 2021: 29 · 2020: 23 · 2019: 30 · 2018: 15 · 2017: 1
FWCI
20.61
Type
journal article
Language
en
Open access
Locations
  • JAMA (publishedVersion)
  • Europe PMC (PubMed Central) (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Funders
Canadian Institutes of Health Research
Topics
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Maternal and fetal healthcare
  • Health Sciences › Medicine › Obstetrics and Gynecology › Gestational Diabetes Research and Management
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Obesity, Physical Activity, Diet
Keywords
pre-pregnancy body mass index, severe maternal morbidity, maternal mortality, maternal obesity, maternal underweight, maternal overweight, amniotic fluid embolism, hysterectomy, intensive care unit admission, singleton births, Washington State, maternal outcomes, parity, maternal age, hospital birth, birth certificates, hospitalization records, health disparities, health equity
MeSH terms
Adolescent, Adult, Female, Humans, Maternal Mortality, Pregnancy, Pregnancy Complications, Retrospective Studies, Risk Factors, Thinness, Washington, Body Mass Index, Logistic Models, Overweight, Young Adult

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