Abstract
- Aim: The aim of this research focuses on the factors that affect the weight gain during pregnancy. While conducting this research we analyzes that weight gain is a significant factor in predicting morbidity and mortality of mother and infants during pregnancy.
- Strategic Plan: This research was based on longitudinal method of research.
- Methods: This research consisted of a cluster sample, the total number of 734 women were selected. The data was collected from various segments like socio-economic and midwifery questionnaires, economic and social culture, psychological variables, domestic abuse, expected social support and shortage of food and many others.
- Results: whereas the results suggested that 28.7%, 49.6% and 21.7% of contestants obtain insufficient, and excessive weight gain during their pregnancy. When we analyze the factors related to health in our model like age of mothers, preparatory body mass index, direct and indirect prenatal care, household’s size, stress, anxiety, pregnancy‐specific stress and violence also have positive and increasing impact on weight gain during pregnancy.
- Conclusion: while evaluating the weight gain during pregnancy the factors like nutritional status, and mental well-being should also be assessed, especially in the case of unwanted pregnancy. Healthcare workers should conduct programs for pregnant women in order to guide and educate them.
INTRODUCTION
The current study is conducted to describe the factors and importance of weight gain during pregnancy. According to Maternal/gestational weight gain (GWG), the weight gain by women during her pregnancy, time is one of the major intrauterine nutritional environment. Following are some elements which explain why the women gain weight during pregnancy. It is very important for a women that she gain weight during pregnancy because as baby grow the weight of women automatically increases or we can say that increase of weight during pregnancy show that baby and women both are healthy.
The Hazards and Consequences of Excessive Weight Gain during Pregnancy:
In 1990 the weight gain during gestational time period the guideline was made by The Institute of Medicine (IOM) for women those have normal, low, and high pre-pregnant BMI (weight for height), after that these strategies are imposed as standard guidelines for obstetric practice. Now IOM announce that as per our researches weight gain in gestational and their effect on women and infant are inadequate.
The above guideline related to increase in weight in gestation period by IOM leads in long run as increasing weight of women increase the risk for infant to become overweight. According to results of Mr. Gunderson, as per sample of 1200 pregnant women, the ratio of high gestational weight gain which have a chance of obesity are 3.19 (CI 1.87–5.44).
In 1990 to 1996 .Mr. Schieve evaluate the pattern of weight gain of pregnant women with sample of 120,531 women of all ages are examined in this study. He proposed that almost 34% of women’s gains weight as per the guideline time the percentage of increasing weight is recommended from 41.5% to 43.5%, and more than 60% of women who were already overweight before pregnancy. More than 35% of women gain weight were recommended in gestational period in 330 sample of African American primigravida adolescents.
Irrespective of the BMI group of pre pregnant women. The young women who were overweight as per IOM guideline are likely 4.6 times more obese during pregnancy as compare to those who gain less as per defined by the guidelines. Almost 63 women were examined by Butte and others, and they suggested that the weight gain during pregnancy are positively associated with postpartum weight and in obesity and the number of women’s who gain weight as per guideline are significantly greater.
Due to postpartum, increase in weight for long time period a women fails to reduce their weight within 6 months. Failing to lose pregnancy weight by 6 months of postpartum results in more weight retention over the long time. According to Rooney and Schauberger research, they collected sample of 450 women. As per their research they stated that during pregnancy women get more weight as per the recommended weight ratio are 8.4kg within 8 to 10years after delivery, and women with normal increase in their weight within recommended level are like 6.5 kg. Whereas on other hand women who lose their weight within 6months after delivery gain only 2.4kg, and women who lost their pregnancy weight by 6 months postpartum were 2.4 kg heavier.
Women’s Beliefs and Attitudes toward Pregnancy Weight Gain:
A study was conducted on 130 low risk pregnant women that focuses on the attitudes of women in weight gain during pregnancy. Some women experience negative attitude in weight gain even if their increase in weight was within prescribed level. Some women are very keen about their increase of weight so they use different strategies like dieting, walk etc. and reduce their weight. While on other hand women who have positive attitude during pregnancy they found positive changes in their body so they get more beneficial result, and they gain more weight as compare to the women who have negative attitude.
According to an assumption sufficient increase in weight during pregnancy is linked with pre-pregnant BMI which effect real weight gain during pregnancy. The researcher Mr. Stotland and other researcher examine the women who gain more weight as per BMI high gain weight than the women who gain less weight in longitudinal study with more than 1000 sample of women while BMI is major predictor to measure the targeted weight gain. With the sample of 2,237 women the advisors for gestational weight gain are correlated with the real increase in weight are examine.
For some women the advisor didn’t give any guideline for their weight gain so they increase their weight outside the suggested guideline. Mr. Stotland notice that there are more women who have less or more weight than the women with normal weight just because these women didn’t get any authentic advice which leads toward safe and healthy pregnancy for both child and for women, these women sometime get incorrect advises from invalid resources.
Literature review
For healthy maternal and infant the BMI of pregnant women and gestational weight gain are very important factor for the results of pregnancy (Frederick, Williams, Sales, Martin, & Killien, 2008). During gestational period the increase in women’s weight indicate that the infant is healthy as per the guidelines of prenatal care (Abrams, Carmichael, & Selvin, 1995; Brawarsky et al., 2005).
For health of an infant it was advised that mothers have to examine their weight on regular basis prescribed by doctor or nurse to know that whether the mother is gaining proper weight or not, the increase in weight of women show that baby is healthy (Abrams et al., 1995; Garmendia, Mondschein, Matus, Murrugarra, & Uauy, 2017).
The recommended weight during gestational period based on BMI of women like: Women with a BMI of less than 18.5 = 13–18 kg, Women with a BMI of 18.5–24.9 = 11 to 16 kg, women with overweight BMI of 25–29.9 = 7 to 11 kg, women over 30 gain 5 to 9 kg are recommended for obese women (Cunningham, Leveno, Bloom, Spong, & Dashe, 2014).
The adverse results of prenatal are associated with increase gestational weight of pregnant women as above and below the prescribe guideline (Brawarsky et al., 2005), the excessive increase in weight are link with poor pregnancy outcomes such as initial asphyxia, injury during birth and hypoglycemia (Asvanarunat, 2014; Catalano & Shankar, 2017; Reynolds et al., 2013), although the insufficient increase in weight increase the risk of fetal/prenatal outcomes like restriction of intrauterine growth, premature delivery and weight of infant is low I big gestational age infants (Brawarsky et al., 2005; Rooney & Schauberger, 2002).
There are many studies which identify and investigates biological and non-biological risk factors of excessive and insufficient increase in weight by (Brawarsky et al., 2005; Olson & Strawderman, 2003). Now a days health has wide scope and health (SDH) Social determinants are known as the most complexed and controversial issue for health sector (Marmot, Allen, Bell, Bloomer, & Goldblatt, 2012).
The factors which effect health are: (a) Socio-economic and political factors, successful culture and social structure, (b) systematic factors which contribute in social and economic inequalities like schooling, earnings, gender, ethnicity and job status, (c) the intermediate factors like psychosocial factors: social support, self‐esteem, couples’ relationship; Behavioral Factors: negative behaviors (Sharifi, Dolatian, Kazemi Fath Nezhad, Pakzad, & Yadegari, 2018).
The two major factors which effect the wellbeing of the systematic determinants of inequality in health and psychosocial issues structural determining factors of inequalities at the level of health and psychosocial conditions, while the economic and social variables which effect the psychosocial, and biological elements which consequently effecting the health status (Marmot et al., 2012).
While more thorough focus on health factors which change many variables dependent on problems related to increase in weight during pregnancy (Garza, 2006). The chance of obesity are also increased due to improvement in lifestyle, dietary habits, which decreases physical activities. (Chu, Kim, & Bish, 2009; Fathnezhad‐Kazemi & Hajian, 2019).
The chronic stress lead to change the biological habits which are followed by imbalance diet plan, heavy increase in weight during pregnancy and postnatal obesity (Davis, Stange, & Horwitz, 2012). The physical elements like stress, anxiety, depression, past psychological issues and social support are correlated with overweight during gestational period (Mehta, Siega‐Riz, & Herring, 2011; de Rooij, Schene, Phillips, & Roseboom, 2010).
Many researches proposed that there is link between household and food insecurity for overweight particularly in females (Holben & Pheley, 2006; Martin & Ferris, 2007). While identifying the risk for pregnant women, plan a successful treatment for them and recognize the relative strength of each group of factors which lead to risk for excessive and insufficient weight gain in pregnancy.
While describing the importance of weight gain during pregnancy the undefined factors which are related to the lack of proper knowledge of Ilam province, the latest research was done to define the gestational weight gain status and interaction elements with the consideration of Social Determinants of Health and WHO, so the major factors were acknowledged on the basis of literature review and the conceptual framework.
METHODS AND RESOURCES
1 Research design and criteria for sampling:
From August 2016 to June 2017 a systematic research was performed with sample of 734 women in Ilam province. Mostly Iranian national are participating as they are capable of reading, and writing, for singleton pregnancy, 24–28 weeks of gestational age, lack of medical conditions and they are satisfied and comfortable in participating for the research. In absence of coordination in this research analysis with questionnaires. During pregnancy the 2nd trimester are better than other two trimesters as per the questionnaires filled by women go to health care centers and deliver test results. All the health reports like test results, weight gain from start to the end of pregnancy are considered.
2 Sample size
In Ilam province of southwest of Iran has 10 cities where this research was performed by using group of random sample. All 10 cities of this province are divided into 5 geographical areas such as Central, North, South, East and West, each zone have group of 3 to 4 health care centers. By using Randomizer software, researcher select one urban health system for each group. Then family health record of the individual is checked.
Found womens who are pregnant and had 24-28weeks of pregnancy, initially these women are invited to participate in this research. In this research if any participant didn’t attend the first session of research they can join this research as per the list so that the researcher finalize their sample size. All the participant are informed about the reason of this study and they ensure their participant that their information are highly confidential which they give in questionnaire. All the participant fill their questionnaires in conference room of respective health care center, questionnaire are very lengthy so researcher gave them 20 to 35mins so they can easily answer all the parts.
3 Measurement tools
All the data was collected through questionnaires filled by longitudinal and midwifery, systematic health centers, the measurement by middle health factors questionnaires that include food insecurity, stress, anxiety and depression, pregnancy‐specific stress and many others. In current research the researcher can develop the socio demographic and questionnaire of obstetrics features. Remaining questionnaires are examine in Iran for validity and reliability, those that are valid in Persian.
4 Questionnaire on Socio‐Demographic and obstetrics
The survey was develop by the researcher in which he include questions related to age of pregnant women, age of her husband, age of gestation, race, pregnancy number, gap between pregnancies, and any serious disease etc. the socioeconomic status portion include education of pregnant women, education of husband, occupation of women, occupation of husband, number of person in home, income etc. the face and content validity approach was use to evaluate reliability of questions.
5 Normal questionnaire on stress, anxiety and depression from DASS‐21
In 1995 Mr. Lovibond developed a questionnaires each area have 7 questions to calculate the symptoms anxiety, stress, and depression. The questionnaire consist of highest and lowest score respectively from zero to 3 and this study is used within and outside the country. The validity and reliability of questions are verified in the depression domain 0.95, domain in anxiety are 0.91 and the domain in stress are 0.93 whereas the overall results was 0.97 (Sahebi, Asghari, & Salari, 2005).
6 Questionnaire on stress specified to pregnancy
The questionnaire for this research include 25 sentences which covers infant, childbirth, mother‘s personal and family question and question about occupation, ambitions in 6 subgroups. Survey was built on the basis of 5-options Likert scale of high and low scores respectively of 0 to 5. The scores of question explain the level of problems face by pregnant women. The validity and reliability of these score are verified by Navidpour in Iran (Navidpour, Dolatian, Yaghmaei, Majd, & Hashemi, 2015).
7 Questionnaire on domestic abuse
Questionnaire were develop by WHO to evaluate the level of violence of spouse when she is expecting, the scoring was based on Likert scale with 10, 5 and 11 questions each. This survey also calculate the sexual, physical, and emotional aggression level. If any person give at least one positive answer that mean she is aggressive. The three segments of questionnaire are physical, sexual, and psychological abuse whereas the alpha coefficient of Cronbach report 0.92, 0.89, 0.88 respectively in Iran ( Hajian, Vakilian, Najm‐abadi, Hajian, & Jalalian, 2014).
In 1988 Zimatt and other develop MSPSS so that they can measure the perceived social support to women from their family, friends and other individuals in their lives, this scale scores minimum 12 and maximum 84. The scores results from 12 to 48 show that there is low level of social support while the score between 69- 84 shows that there is high level of social support. The reliability was measured with alpha coefficient of Cronbach which was between 0.86 and 0.9 for subgroups and 0.86 for total instrument whereas validity was determine by content analysis in Iran (Bagherian‐Sararoudi, Hajian, Ehsan, Sarafraz, & Zimet, 2013).
9 Household food insecurity access scale (HFIAS)
HFIAS include 9questions with 4 options (most often, occasionally, rarely and never) providing information related to food insecurity in terms of availability of food at the level of household. The score for each question is minimum 0 and maximum 3. The validity of question is checked by utilizing face material and structure by Mohammadi and others, the alpha coefficient of Cronbach was 0.86 which show that internal stability level is high (Mohammadi et al., 2012).
Whereas the reliability of questions are determine by using test-retest method, and this method is applied on 30 pregnant women the internal stability is explain by Cronbach’s alpha coefficient was 0.89, 0.92 and 0.88 for domain of depression, anxiety and stress respectively which explain the DASS‐21 standard questionnaire, on other side the Cronbach’s alpha coefficient was 0.88, 0.86, 0.88, 0.89 respectively for pregnancy‐specific stress questionnaire, domestic violence questionnaire, multidimensional perceived social support scale and household food insecurity access scale.
Computational model was develop in latest studies to measure the factors that are linked with increase in weight during pregnancy such as social factors, socioeconomic status, food insecurity, perceived social support, domestic abuse, stress and anxiety and depression and traumatic life and pregnancy care shown in Figure 1. The method of Path analysis are used to analyze the good fit model and percentage variance range.
10 Statistical analysis
After collecting all the data researcher analyze the data through various software like SPSS19 software (IBM© SPSS© Statistics version 19 IBM© Corp.) and Lisrel 8.8. To measure the frequency, mean, median, standard deviation and percentage descriptive statistics are used. When the relation between factors and weight gain are defined by Chi‐square and Fisher’s analytical statistics are used. If the predicted number is less than 5 then Fisher statistical was used. The Path analysis is used to measure the more significant element which influence the increase of weight during pregnancy and it identifies the direct and indirect effect of variables.
RESULTS:
The average age of sample was 28.7 years (SD 4.4), and average age of the spouses was 33.4 years (SD 5.5). 81.6% of participants were Kurdish origin, 46.3% of participants had their first pregnancy, 86.6% of them wish for their pregnancy and 13.4% of pregnancies are unplanned. Half of pregnant women 50.7% and their husband 48.2% completed their university education. 86.2% of women are housewives, 64% of husbands were self-employed, 86.8% of household are single employed member of home, 57.4% of household income was 10–20 million Rials shown in table 1.
Table 1. The demographic and socio‐economic features of the participants
| # | Variable | Mean (SD) |
|---|---|---|
| Women’s age | 28.73 ± 4.41 | |
| Husband’s age | 33.41 ± 5.47 | |
| Type of pregnancy | Wanted pregnancy | 636 (86.6) |
| Unwanted pregnancy | 98 (13.4) | |
| Number of pregnancy | One | 340 (46.3) |
| Two | 238 (32.4) | |
| Three and more | 156 (21.3) | |
| Ethnicity | Kurdish | 599 (81.6) |
| Lor | 77 (10.5) | |
| Lak | 39 (5.3) | |
| Others | 19 (2.6) | |
| Women’s education | Elementary | 29 (4) |
| Secondary | 49 (6.7) | |
| High school | 284 (38.7) | |
| University | 372 (50.7) | |
| Husband’s education | Elementary | 22 (3) |
| Secondary | 51 (6.9) | |
| High school | 307 (41.8) | |
| University | 354 (48.2) | |
| Women’s jobs | Housewives | 633 (86.2) |
| Employees | 82 (11.2) | |
| self‐employed | 19 (2.6) | |
| Husband’s jobs | Unemployed | 12 (1.6) |
| Employees | 470 (64) | |
| self‐employed | 252 (34.3) | |
| Household income | Less than 10 million Rials | 125 (17) |
| 10–20 million Rials | 421 (57.4) | |
| More than 20 million Rials | 88 (25.6) | |
| Number of family members | 1–3 | 566 (77.2) |
| 4 and above | 168 (21.9) |
The 2.8% women are completely healthy, 57.7% women have normal BMI, and 39.6% of women are overweight, 28.7% women are under weight, 49.6% women have normal weight, and 21.7% of women have excess weight in our research. The mean of women weight gain during pregnancy are 11.27 ± 3.23. According to this research there is no significant difference in education of pregnant women and their husbands, household income, occupation of women and their husband, household cost, and their household size in respective group which determine the relationship between structural factors and weight (p > .05) shown in table 2.
In following investigation the intermediary factors and weight gain during pregnancy show that there are 3 groups of inadequate weight gain, excess weight gain and normal weight gain in which there are significant difference in between food security, support from society and prenatal care (p < .05).
Table 2. The relationship between socioeconomic status of pregnant women and weight gain during pregnancy.
| Variable | Low rate of weight gain (%) | Normal weight gain (%) | Excessive weight gain (%) | p‐value |
|---|---|---|---|---|
| Individual education | 0.182 | |||
| Secondary school and lower | 27 (36.5) | 34 (45.9) | 13 (17.6) | |
| High school education | 76 (28.0) | 126 (46.5) | 69 (25.5) | |
| University | 99 (27.5) | 190 (52.8) | 71 (19.7) | |
| Husband’s education | 0.583 | |||
| Secondary school and lower | 23 (33.3) | 31 (44.9) | 15 (21.7) | |
| High school education | 88 (30.2) | 146 (50.2) | 57 (19.6) | |
| University | 91 (26.4) | 173 (50.1) | 81 (23.5) | |
| Individual’s occupation | ||||
| Housewife | 179 (29.4) | 294 (48.4) | 135 (22.2) | 0.389 |
| Employee | 20 (25.6) | 45 (57.7) | 13 (26.7) | |
| Self‐employed | 3 (15.8) | 11 (57.9) | 5 (26.3) | |
| Husband’s occupation | 0.151 | |||
| Unemployed | 4 (33.3) | 8 (66.7) | 0 (0.0) | |
| Self‐employed | 138 (30.9) | 213 (47.7) | 96 (21.5) | |
| Employee | 60 (24.4) | 129 (52.4) | 57 (23.2) | |
| Household income | 0.082 | |||
| Less than 10 million Rials | 38 (31.9) | 57 (47.9) | 24 (20.2) | |
| 10–20 million Rials | 126 (31.3) | 196 (48.6) | 81 (20.1) | |
| Above 20 million Rials | 38 (20.8) | 97 (53.0) | 48 (26.2) | |
| Average household cost | 0.574 | |||
| Less than 10 million Rials | 101 (29.0) | 174 (50.0) | 73 (21.0) | |
| 10–20 million Rials | 96 (28.7) | 167 (49.9) | 72 (21.5) | |
| Above 20 million Rials | 5 (22.7) | 9 (40.9) | 8 (36.4) | |
| Household size | 0.233 | |||
| 1–3 people | 159 (29.3) | 274 (50.5) | 110 (20.3) | |
| 4 people and more | 43 (26.5) | 76 (46.9) | 43 (26.5) |
The research show that the pregnant women have too much weight who have food insecurity whereas the women who have high and adequate social support have normal and high level of weight gain during pregnancy, in all three groups there are no significant difference for general violence for women who are high, low and normal weight gain during pregnancy (p = .99) shown in table 3.
Table 3. Relationship between intermediate health’s factors in pregnant women and weight gain during pregnancy
| Intermediate determinants | Low rate of weight gain (%) | Normal weight gain (%) | Excessive weight gain (%) | p‐value |
|---|---|---|---|---|
| Food security | 0.008 | |||
| Has it | 114 (24.9) | 243 (53.1) | 101 (22.1) | |
| Does not have | 88 (35.6) | 107 (43.3) | 52 (21.1) | |
| Social support | 0.007 | |||
| Low | 29 (26.9) | 59 (54.6) | 20 (18.5) | |
| Average | 108 (30.3) | 154 (43.3) | 94 (26.4) | |
| High | 65 (27.0) | 137 (56.8) | 39 (16.2) | |
| Stress symptoms | 0.822 | |||
| Does not have | 150 (28.1) | 268 (50.3) | 115 (21.6) | |
| Has it | 52 (30.2) | 82 (47.7) | 38 (22.1) | |
| Anxiety symptoms | 0.854 | |||
| Does not have | 169 (28.3) | 298 (49.8) | 131 (21.9) | |
| Has it | 33 (30.8) | 52 (48.6) | 22 (20.6) | |
| Depression symptoms | 0.406 | |||
| Does not have | 170 (28.2) | 305 (50.7) | 127 (21.1) | |
| Has it | 32 (31.1) | 45 (43.7) | 26 (25.2) | |
| Pregnancy‐specific tension and worry | 0.093 | |||
| Does not have | 148 (28.4) | 270 (51.7) | 104 (19.9) | |
| Has it | 54 (29.5) | 80 (43.7) | 49 (26.8) | |
| Domestic violence | 0.099 | |||
| Does not have | 101 (26.2) | 190 (49.4) | 94 (24.4) | |
| Has it | 101 (31.6) | 160 (50.0) | 59 (18.4) | |
| Unwanted pregnancy | 0.178 | |||
| No | 183 (29.8) | 302 (49.2) | 129 (21.0) | |
| Yes | 19 (20.9) | 48 (52.7) | 24 (26.4) | |
| Pregnancy care | <.001 | |||
| Adequate | 111 (21.5) | 270 (52.3) | 135 (26.2) |
In all the factors of research structure such as mother age, education of husband and women, household size variables had influence on weight gain during pregnancy. In all above factors only age of mother had impact on weight gain during pregnancy in direct and indirect ways. If the age of pregnant women is greater they had low weight gain from direct line (β = 0.08) and in indirect path, because of BMI effect of mother’s (β = 0.12), BMI have a negative impact on the rate of increase in weight during pregnancy (β = −0.08). The education of female and her husband has negative and decreasing effect on excessive overweight as rate of overweight decrease when level of education increases (Figure 2 and Table 4).
The expected (standardized) coefficients correlated between structural and intermediary determinants effect the weight gain in social determinants of health.
Table 4. Direct and indirect effects of structural and intermediary determinants of health on weight gain during pregnancy
| Variable | Direct effect | Indirect effect | Total effect |
|---|---|---|---|
| Individual’s age | −0.08 | −0.010 | −0.90 |
| Individual’s education | ‐ | −0.003 | −0.003 |
| Education of spouse | ‐ | −0.002 | −0.002 |
| Household size | ‐ | 0.002 | 0.002 |
| Food insecurity | ‐ | 1.087 | 1.087 |
| social support | ‐ | −0.002 | −0.002 |
| Stress symptoms | ‐ | 0.025 | 0.025 |
| Anxiety symptoms | ‐ | 0.011 | 0.011 |
| Depression symptoms | ‐ | 0.031 | 0.031 |
| Domestic violence | ‐ | 0.006 | 0.006 |
| pregnancy‐specific stress | ‐ | 0.02 | 0.02 |
| BMI | −0.08 | ‐ | −0.08 |
| Status of prenatal care | 0.7 | −0.003 | 0.697 |
The two factors of prenatal BMI and during of maternity care had direct effect on increase in weight between intermediary health determinants. The research show that the women who gets more care during pregnancy can have more increase in weight during pregnancy (Table 4).
The food insecurity factor had great influence on excessive weight gain in indirect direction and had growing and positive impact on weight gain (β = 1.087) and excessive food insecurity increase the massive weight gain during pregnancy. The three indirect ways of food insecurity had impact on depression’s symptoms, tensions, stress, pregnancy related issues, weight of pregnant women, and BMI leads to severe obesity of pregnant women (Table 4). The weight gain during pregnancy indirectly effect the other intermediate factors like symptoms of stress, anxiety, depression, stress specified for pregnancy and violence that are as following:
- Anxiety had a positive impact on weight gain (β = 0.011)
- Stress had positive effect (β = 0.46)
- Stress specified for pregnancy (β = 1.23)
- Worry on weight gain (β = 0.02).
- Violence have symptoms of depression (β = 0.17)
- Symptoms of severe depression lead to increase in stress (β = 0.56)
- Anxiety specified to pregnancy (β = 0.87) (Fig 2)
According to this research all the intermediate health factors and structural factors in the model such as age of mother, prenatal BMI, quality of care for pregnant women directly influences the weight of pregnant women, whereas insecurity of food, size of household, stress, anxiety related symptoms to pregnancy, and violence have increased and positive impact as shown in table 4. The consistency of both fit index, normalize fit index, comparative fit index and error in root mean square which use in metrics fit in model, these standard are acceptable in this model and this model was good as shown in table 5.
Table 5. Comparison of assessment model’s fitness indicators
| Index | Value |
| Chi‐squared index | 181.14 |
| Df | 36 |
| Root‐mean‐square error (RMSEA) | 0.01 |
| Fit goodness index (GFI) | 1 |
| Normalized fit index (NFI) | 1 |
| Comparative fit index (CFI) | 0.93 |
DISCUSSION:
In the sample of this study 2.8% of women were lean, 57.7% have normal BMI and 39.6% had prenatal overweight, 13.2% of women are overweight, 3.6% women are fat and 15.8% are lean before gestation (Chen et al., 2010). The mean of increase in weight during pregnancy was 11.27 ± 3.23. Women with insufficient weight 28.7%, sufficient weight 49.6%, and 21.7% of women are excessive weight during pregnancy. According to Deputy and other research 20.9% women have insufficient weight, 32% of women have sufficient and 47.2% of women have excessive overweight during pregnancy (Deputy, Sharma, Kim, & Hinkle, 2015).
The findings of current study show that SDH structural factors like mother’s education, occupation of women and her husband, household size, and household income have important relation with increase in weight, but path analysis stated that above factors affect the intermediate health determinant and it also effect the increase in weight (Finney Rutten, Yaroch, Colón‐Ramos, Johnson‐Askew, & Story, 2010). The factors which effect the increase of weight during pregnancy is identified by biological, metabolic, socioeconomic and psychological aspects (Davis et al., 2012).
The level of weight gain was high when age of pregnant women increases and the BMI before delivery was consistent as per current study (Mohammadi et al., 2011); if the pregnant women is underweight than the women may increase insufficient weight during pregnancy and with rural housing society, low level of education, excessive weight and smoking also effect the weight gain of pregnant women, on other hand if women is obese and had higher or less education have excessive overweight during pregnancy (Wells, Schwalberg, Noonan, & Gabor, 2006).
According to researcher Delaram and Akbari the outcomes of path analysis indicate that the age of mother, husband, education of pregnant women and husband, size of household can affect the overweight in gestational period by structural determinants. As per these factors through indirect and direct ways only age of pregnant women can affect the increase of weight, whereas the education of husband and pregnant women have negative and excessive results, when the level of education increases the rate of excessive increase of weight during pregnancy will decreased.
According to Delaram and Akbari there is no connection between occupation of pregnant women and overweight during pregnancy, but education had substantial relation with overweight, higher the education higher the level of average weight gain (Delaram & Akbari, 2008). The different outcomes of research are due to different samples, different techniques, different questionnaires, different classification of variables used in model.
In current research there is important and negative relationship among age of pregnant women, size of household, stress related to pregnancy, and BMI in prepartum, and have important and positive relation between husband educations, prenatal care and weight increase during pregnancy. The social factors of health and intermediate factors in social and structural model includes: stress, depression, anxiety, and support from society. The insecurity of food, maternal care are linked with increase in weight during pregnancy.
According to Davis model genetics, medical care, socioeconomic status, ethnicity are included in factors of maternal stress. The chronic stress leads to change in the biological behavior which is followed by balance disruption, massive increase in weight and prenatal obesity (Davis et al., 2012). Other researchers conclude that increase in weight are linked with other psychological factors like depression, social support, anxiety, and negative body image (Bovier, Chamot, & Perneger, 2004; de Rooij et al., 2010).
The outcomes in other research indicate that some maternal factors affect the weight gain during pregnancy that include self-esteem, anxiety, depression and any past psychological issues (Herring et al., 2008; Mehta et al., 2011). The relationship between weight gain during pregnancy and depression, social support are very important but there is no significant relation was noticed between weight gain during pregnancy and stress, anxiety, self‐confidence (Herring et al., 2008).
Furthermore the outcomes of path analysis shows that BMI of prenatal of pregnant women and pregnancy status directly affect the increase in weight by intermediate health factors, health care has greater effect on pregnancy care so those women wo have more care gain more weight during pregnancy, whereas the indirect ways like food insecurity had greater effect on weight of pregnant women are also effected by other factors. The finding of this study was similar to the results of Laraia et al studies and the women with food insecurity have high BMI before pregnancy and weight gain during pregnancy is also high pregnancy (Laraia, Siega‐Riz, & Gundersen, 2010).
The relation between household insecurity specially in women and excessive weight was confirmed by Martin et al study (Holben & Pheley, 2006; Martin & Ferris, 2007) and, the obesity is due to the food insecurity in people, with low consumption of food, energy food with high energy density but there is low micro nutritional values are more important (Hill et al., 2013). The aim of current study is to find the relation evaluation, one of the strength of this study is to consider the multiple variables of social health. Insecurity of food is one of the most significant reason that this research have been done in all this period of pregnancy. The outcome of this research can also use in framework of other researches.
Recommendations
The current research shows that every 1/3 women increases 32% of their weight as per recommendation during their pregnancy, 21% women gains below average weight during their pregnancy, and 48% women gains too much increase in their weights during pregnancy.
During pregnancy if the weight increases less than the recommended guideline it mean that the baby will be weak, some babies came into this world too early i.e. premature birth, which creates problems in beginning like breastfeeding, this increases the risk of diseases and the growth of the baby could also be slow as compare to babies of his or her age. While if the pregnant women increase her weight more than the recommended weight that means that the baby is too fat which causes complication during delivery, childhood obesity, and cesarean delivery. If the weight increase during pregnancy period above then the recommended weight that lead towards obesity.
Here are some recommendation related to weight gain during pregnancy:
- Properly check the weight of pregnant women from health care provider from start of gestational period till the end of delivery whether the women meet weight goals properly or not.
- From the beginning of women’s pregnancy and onwards pregnancy period women have to monitor her weight and she has to compare her weight progress with the recommended range of increase in weight which is heathy for her as well as for the baby.
- The pregnant women have to take healthy diet full of proteins and vitamins like whole grains, vegetables, fruits, and low fat dairy etc. Helpful social applications like My Plate can be used by pregnant women on daily basis and check the list of food which she can add in her daily routine and complete the targets of her pregnancy stages. Mostly every food is healthy for pregnant women but some caution have to be taken by her regarding unhealthy food like junk food. The pregnant women have to visit health care center and get all the information related to food which she has to take during pregnancy and make her pregnancy safe.
- Pregnant women have to add limited amount of sugar and fats in her food like soft drinks, desserts, whole milk, fried items, and fatty meat etc.
- The pregnant women have to know that how much calories she can absorb. Generally in first trimester pregnant women didn’t require any extra calories, in second trimester pregnant women requires 340 extra calories per day, and in third trimester pregnant women have to take 450 extra calories per day.
- The pregnant women have to work out of aerobic exercise for at-lest 150 minutes at moderate level per week, 150 minutes sounds difficult but she have to reach the target by splitting her physical activity into 10mins at a time. For pregnant women physical activities are very beneficial and also at the time of delivery. She also have to visit health care center to get information about her and infant’s health.
CONCLUSION
As per the results shown in above research half of pregnant women have normal increase in weight, which indicate that there is adequate availability of food, high level of social support, improve prenatal care which is associated with normal increase of weight during pregnancy. Other determinants like stress, depression, abuse, anxiety, stress specified with pregnancy have indirect impact on weight gain during pregnancy. Hence there is a need to provide proper information to pregnant women about her weight increase during pregnancy. Besides mental well-being of a pregnant women other related factors like nutritional status of pregnant women, physical, social, behavioral and other factors are also examined.
According to this research it is found that if pregnant women get proper nutrition and positive environment the weight of pregnant women could properly increase or some time it increases too much, on other hand if pregnant women get negative environment and food insecurity, stress, depression it effect the health of child and women both and many problems occur during pregnancy period or at the time of delivery. Hence for health of women and child environmental or social support is very important and she have to follow all the recommended guidelines which lead to safe pregnancy.
Limitations
The drawback of this research can be attributed towards a large number of questionnaires that were filled by pregnant women, lengthy questionnaires require long time to be filled and hence the survey take long time to complete, and also the information like increase in weight of each women during her pregnancy the maternity care which she get was provider by health care centers.
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