CHAPTER ONE (INTRODUCTION)

1.1 INTRODUCTION

BACKGROUND OF THE STUDY

Gestational weight is defined as the total weight gain during pregnancy (Cedegren, 2007).

Over the past several decades, it has been proved that gestational weight gain (GWG) is

crucial for both maternal and fetal pregnancy outcomes. According to Cedegren (2007),

inadequate weight gain during pregnancy is associated with maternal and fetal health

problems.

Overweight in pregnancy on the other hand is one of the risk factors for a large number

of health problems. The total health and economic consequences of excessive weight gain

in pregnancy are significant, as the prevalence of overweight is high and increasing

steadily worldwide (World Health Organization, 2004). According to a study conducted

from 2002-2004 in Scotland, 20% of women who received antenatal care were

overweight representing a twofold increase over the past ten years. Choi, Park and Shin

(2011) also noted a 40% increase in the number of pregnant women who gained weight

more than the recommended. A similar study in Nigeria reported overweight in pregnant

women (Chigbu &Aja, 2012)

Excessive gestational weight gain has been associated with several pregnancy

complications (Johnson, 2006). Specifically, gaining excessive weight during pregnancy

results in gestational diabetes, hypertensive disorders, cephalopelvic disproportion,

prolonged labour, birth trauma, asphyxia, macrocosomic baby which can result in

caesarean section (Zhang, Decker, Platt & Kramer, 2010). Gaudet, Andree and Magee

(2011) also noted that, it is associated with increased rates of congenital anomalies, rising
rates of childhood obesity, miscarriage, preterm delivery, thromboembolism. Not only is

excessive gestational weight gain responsible for complications who gain more weight

than recommended retain twice as much complications in women in later life

Many risk factors have been associated with excessive gestational weight gain such as,

educational level of pregnant women (Wells, Schwalberg & Noonan, 2006), higher parity

(Walker, Hoke & Brown, 2009). A Study of women who had two consecutive births

showed that 11% of normal weight women who gained excessive weight during their

first pregnancy were overweight by the second pregnancy (Ruchat, Davenport, Giroux,

Hillier et .al. 2012). Other associated risk factors include, higher-pre-pregnancy body

mass index (Brawarskky, Stotland, Jackson, Fuentes et.al. 2005; Wells et.al, 2006;

Deierlein, Siega- Ritz& Herring, 2008);age; occupation; positive family history of

overweight in pregnancy (Bhattadiarya, Campbell, Liston & Bhattacharya,2007).

Poor nutrition or dietary habit during pregnancy is also risk factor in gaining excess

weight. It has been noted that eating less fruit and vegetables than recommended

predispose pregnant women to excessive weight gain (Wen, Flood, Simpson, Rissel

&Baur, 2010). Observational studies have found an association between higher intake of

calories and higher gestational weight gain (Dierlein, et.al. 2008). This is more so in

pregnant women who believe in eating for two instead of eating twice as healthy as

possible (Ruchatt, Davenport, Giroux,Hillier et.al. 2010).

Reduction in physical activity or remaining physically inactive during pregnancy has

equally been associated with increased risk of excessive gestational weight gain (Jiang,

Quan, Li, Lynn et .al. 2012). Research reports indicate that pregnant women who remain
inactive and consequently develop excessive gestational weight gain had an increased

negative pregnancy outcome of pregnancy (Jiang et.al, 2012).

Though, pregnancy is a critical stage of life cycle when a woman is at higher risk of

developing overweight, many pregnant mothers have the potential to improve their

dietary and physical activity levels (Watson & McDonald, 2007). Therefore, in an effort

to encourage appropriate weight gain during pregnancy, the United States Institute of

Medicine (IOM, 2009) developed a new weight gain recommendations. This guideline

ensures that the amount of weight a woman gains during pregnancy be guided by her pre-

pregnancy body mass index. That is, those with a higher body mass index prior to

pregnancy are to gain less weight during pregnancy than those with a lower body mass

index (Schmid & Lau, 2009).

Despite this effort being made by IOM, to guide weight gain in pregnancy, women tend

to exceed beyond the appropriate weight gain recommended for their BMI (Deierlan et.

al., 2008). It has also been noted that the actual knowledge of the associated risk factors

and complications of overweight in pregnancy are deficient among women, hence the

increase in negative outcomes of pregnancy (Smith, Husley, & Goodnight, 2008).

Therefore, in order for this recommended guidelines to become evident among pregnant

mothers and for the prevention of the associated complications of excessive gestational

weight to be achieved, it becomes necessary to determine their knowledge of and the

associated risk factors that can predispose these women to gaining more weight than

recommended.

This would help in creating awareness needed in controlling this health related risk factor

in pregnancy. Thus, this study on the knowledge of and associated risk factors for
 excessive gestational weight gain among pregnant mothers that utilize maternal services

in federal staff hospital, Gwarimpa.

1.2 RATIONAL/THEORETICAL FRAME WORK

In this work, the researcher applied the Health Believe Model (HBM) to explain the risk

factors for excessive gestational weight gain among pregnant women.

Health Belief Model

Health Belief Model (HBM) was one of the first and the best known social cognition

model (Ogden, 2007). The HBM was developed in the 1950s by Hochbaum, Rosenstock

and Kegels who worked for the United States Public Health Service. It was furthered by

Becker in the 1970s and was subsequently amended in 1988 to accommodate the role

that knowledge and perceptions play in personal responsibility. The core assumption of

HBM is based on ones belief in a personal threat together with ones belief in the

effectiveness of the proposed behavior will predict the likelihood of that behavior. This

suggests that a pregnant woman will take a health related action (example knowing the

recommended weight guidelines and demographic characteristics, avoiding unhealthy

dietary habits or sedentary lifestyle) if that person feels that the complications of

excessive gestational weight gain can be avoided. That is, a woman can avoid excessive

gestational weight gain and its consequences if she can successfully avoid its risk factors.

The HBM was spelled out in four constructs: perceived susceptibility, perceived

severity, perceived barriers and perceived benefits. Each of these perceptions can be used

to explain health behavior. Later, constructs of mediating factors to connect the various

types of perceptions with the predicted health behavior include: cues to action;

demographic variables, motivating factors and self-efficiency

1. Perceived susceptibility (an individuals assessment of her risk of getting the condition, that

is, gaining excess eight). It is a powerful perception in prompting people. This suggests that

the greater the risk of getting a certain medical condition, the more a person will engage in

behaviors to decrease the risk. This is what prompts the pregnant women to engage in

physical activity, eat diets that are of less saturated fat and calories in order to reduce the

gaining of excess weight in pregnancy.

2. Perceived severity (an individuals assessment of the seriousness of the condition and its

potential consequences) ones opinion on how serious a condition is and its consequences,

determines the person action. That means, the pregnant womans correct knowledge about

excessive gestational weight gain and its complications to her and her fetus/baby determine

how she will perceive the seriousness and this perceived seriousness in turn will influence

her behavior. That is, she will avoid engaging in predispositions for excessive weight gain.

3. Perceived Barriers (an individuals assessment of the influence that facilitate or discourage

adoption of the promoted behavior). This is the womans own thought about the obstacles in

the way of adopting a new behavior and also the consequences of continuing an old behavior.

This could be due to lack of money that prevents the woman from buying enough fruits and

vegetables, thus adopting risk behavior like eating much calories and saturated fats. It could

also be from family which believes in eating for two instead of eating twice as healthy before

pregnancy.

4. Perceived Benefit (an individuals assessment of the positive consequences of adopting the

behavior). The construct to perceived benefit is the womans opinion of the usefulness of a

new behavior in decreasing risk of developing a disease. That is, a woman tends to adopt a

healthier behavior (seeking for information on recommended weight gain, avoiding

 unhealthy eating habit, sedentary lifestyle when she believes the new behavior will decrease

her chance of gaining excess weight. Therefore, those who found that avoiding risk factors

are beneficial to preventing excess weight gain often avoid them. This explains the

relationship between knowledge and associated risk for excessive gestational weight gain

5. Cues to Action: in addition to the four perceptions, the HBM suggests behavior mediating

factors which include cues to action. Cues to action are external influences promoting the

desired behavior which may include; information provided or sought, reminder by others,

persuasive communications and personal experience (Ogden, 2007). Example, knowing a

woman who died as a result of complications of pregnancy owing to overweight in

pregnancy. Also, hearing about the negative outcomes of pregnancy due to unhealthy dietary

habits and physical inactivity.

6. Demographic Variables (age, occupation, ethnicity, parity, past experience etc.) these are

individual characteristics that influence personal perceptions. The womans past experience

or age could influence her decisions to avoid excessive gestational weight gain risk behavior.

7. Self-efficiency: this construct deals with the womans self-assessment of ability to

successfully adopt the desired behavior. If someone believes new behavior is beneficial

(perceived benefit) but does not think she has the ability to do it (perceived barrier), there is

the tendency that she will not try the new behavior. For example, the pregnant woman will

not seek for information on recommended weight guidelines, demographic characteristic she

has that could predispose her to overweight and avoid sedentary lifestyle and unhealthy

dietary habits unless she thinks she can do them.

This suggests the reason why some women even when they identify the risky behaviors that

will predispose them to gaining excess weight in pregnancy will still engage in those

activities.

Empirical Review

Abenhaim, kinch, Morin and Usher (2007) carried out a study to assess the effect of

prepregnancy body mass index (BMI) on obstetric and neonatal outcomes among women in

Australia. The study was an experimental study that consisted of 4,312 underweight women,

10021 normal weight women, 3069 overweight and 1,137 obesed women. The result found

out that overweight, and obesed women had an increased risk of preeclampsia, gestational

hypertension, preterm birth, ceaarean section, shoulder dytocia, birth injuries and

macrosomia as compared to women with normal body mass.

In another study by de Jersey, Nicholson, Callaway and Daniels (2012) on knowledge of

weight gain recommendation in Australia. The study was a prospective study of 664 women

from a tertiary obstetric hospital between 2010 and 2011. The result found out that 47% of

the women were unsure of the weight gain recommendation. 36% gained according to

guidelines and 56% of overweight women gained in excess of IOM guidelines compared

with 30% of those who started with a healthy weight.

Another study was carried out by Nitert, Foxcroft, Lust, Fagermo et.al (2011) to assess

knowledge regarding the risks of overweight and obesity in pregnancy in Brisbane, Australia.

It was a cross sectional study of 412 unselected women, 255 public women and 157 women

at a private maternity. The result found out that 75% of the women identified that overweight

women have an increased risk of overall complications including gestational diabetes,

hypertensive disorders compared with normal weight women. More than 60% of women
asserted that obesity would increase the risk of ceasarean section, and less than 50%

identified an increased risk of adverse neonatal outcomes while 19% did not know about

effect of obesity on neonatal outcomes and 7.4% lack knowledge of maternal outcomes.

Knowledge of risk of obesity was similar among women recruited at the public hospital and

those recruited as unselected.

Another study was conducted by Wen, Flood, Simpson, Rissel and Baur (2010) on dietary

behavior during pregnancy in South Western Sydney, Australia. The consumption of milk,

soft drinks, processed meat products, fast foods take away and chips were assessed using

questionnaire through face to face interviews of 409 primiparas. The results found out that

one fifth of mothers (21%) drank 2 cups or more of soft drink per day, 125 consume more

than 2 meals or snacks from fast food or take away outlets per week. Soft drink consumption

was also found to be positively correlated with fast food/take away consumption, and

significant inverse association between intake of water and soft drinks and between fruit

consumption and eating fast food/take away, processed meat or chips.

Jiang, Qian, Li, Lynn et. al. (2012) conducted a study at Changzhou in China on association

between physical activity during pregnancy and gestational weight gain between 2005 and

2007. The physical activity levels of the pregnant mothers were assessed using pedometer.

The study categorized the women into four activity level according to the daily step counts;

sedentary (<5000) daily steps) low Active (5000-7500 daily steps) somewhat active (7500-

10,000 daily steps), Active (> 10000 daily steps). The results found out that the active group

had 1.45kg less gestational weight gain than the sedentary group and excessive gestational

weight gain decreased with the increase level of physical activity.

Another study was conducted by Kinnunen, Pasanen, Aittasalo, Fogeholm Clarke and Luoto

(2007) in Finland using 105 pregnant primparas with the aim of preventing excessive weight

gain during pregnancy. It was found out that the control group who consumed more high

sugar, snacks, low fiber bread gained weight in excess of IOMs recommendations.

A descriptive study was carried out by Laura, Gaudet, Gruslin and Magee (2010) on the

knowledge of target gestational weight gain and obesity related pregnancy complications in

British Columbia Womens Hospital using 117 respondents. The study utilized an

anonymous questionnaire for pregnant women to ascertain their calculation of pre-pregnancy

BMl and whether the women could correctly classify their BM1. The results showed that the

knowledge of the women regarding classification of their BMl, appropriate gestational

weight gain was deficient. Most women were unable to identify complications of overweight

in pregnancy for themselves or their baby. Their major sources of information were maternity

care providers (86%), the internet (59.8%) and printed materials (60.7%).

A study was conducted by Carreno, Clifton. Hauth and Myatt et. al. (2012) in United States

to determine if there was an association between excess early gestational weight gain and

development of gestational diabetes and macrosomia, using 7,985 pregnant women. The

results found out that the rates of gestational diabetes, large for age and birth weight greater

than 4kg were higher in women with excess gestational weight gain.

In another study, Tovar, Taber, Bermudez, Hyatt and Musi (2010) assessed the knowledge,

attitudes and beliefs regarding weight gain during pregnancy among Hispanic women at

Baystate Medical Centre in the United States using 29 women. The study utilized focus

groups with open ended questions to address the different dimensions from Health Belief

Model. The result found out that majority of the women did not consider weight gain
guidelines to be important and had not received any information on recommendations for

weight gain during pregnancy from physicians. The women reported to receive weight gain

advice largely from nutritionist and family members rather than from physicians. Knowledge

about weight gain recommendation was more among normal weight women and overweight

women mentioned that they had not received any weight gain recommendations. It was found

out that the women believed that eating larger amount of food and snacking throughout the

day were contributors to pregnancy weight gain. The result also revealed that the women

identified more consumption of fruits and vegetables as major contributor of less weight gain

in pregnancy. The result also reported that most women felt that walking was the best and

safest way to exercise and many women also felt that they did not have time to exercise due

to childcare and family responsibilities.

Phelan, Phipps, Abrams, Darroch, Schaffner and Wing (2011) carried out a study in the

United States to assess the receipt of gestational weight gain advice in prenatal care and ideal

and expected gestational weight gain outcomes for normal and overweight women. It was a

cross sectional study of 203 normal weight women and 198 overweight women. The result

showed that less than half of the participants (41.7%) reported receiving weight gain advice

from practitioner.

Phelan, Hart, Phipps, Abrams et. al (2011) conducted a study in Califonia in United States

with the aim to assess the maternal behaviours during pregnancy and its impact on offspring

obesity risk. The study used 132 overweight women and 153 normal weight women. The

result found out that higher intake of sweets and refined sugar by the overweight women was

related to higher offspring weight status at birth while higher intake of soft drinks was the

strongest predictor of higher offspring birth weight in normal weight women. It was also
found out that Low levels of physical activity and sedentary lifestyle are known contributing

factors to obesity and weight gain in the general population. Also, increasing physical

activity during pregnancy has been related to lower GWG in some women.

Ruchat, Davenport, Giroux, Hillier et.al (2012) conducted an experimental study in the

United States of America with the aim to evaluate the effect of an exercise program of two

different intensities with nutritional control on gestational weight gain. The exercise

program consisted of walking sessions 3 to 4 times per week from 25 to 40 minute per

session and 45 women who did not participate in any structured exercise program were used

as a control group. The result found out that total gestational weight gain was higher in the

control group compared with the intervention groups. The study also found out that excessive

gestational weight gain during the intervention was prevented in 70% of women in low

intensity group and 77% of those in the moderate intensity group.

Another study by Chigbu and Aja (2011) in South East Nigeria assessed obesity in pregnancy

between April 2009 and January 2010 using 3,167 recruited pregnant women. The result

found out that only 478 (15.1%) women knew their prepregnancy weight and that overweight

was more in urban women than in rural women. The study found out that it was because

women in urban areas ate more of processed commercial foodstuff, snacks and are engaged

in more sedentary occupations than women in rural areas who ate more of fibers and engaged

in manual work and subsistence farming.

Isreal, Nyeche, Akani and Akani (2011) carried out a study on pregnancy outcome among

obese parturient at Port Harcourt Teaching Hospital in Nigeria. The prospective study was

conducted between May 2006 and April 2007 using 150 obese pregnant women and 150 non

obese pregnant women used as control. The result found out that obese pregnant women
 were more likely to have hypertensive disorder of pregnancy (14%), gestational diabetes

(2%) prolonged pregnancies (24%), ceasaran section (30%). The study also found out that

fetal macrosomia was higher among obese subjects (22%), birth asphyxia (6.6%), perinatal

mortality (3.3%).

1.3 STATEMENT OF PROBLEM

Excessive gestational weight gain is a public health issue which has drawn the attention

of various organizations in the world. The Centre for Disease Control and Prevention

(CDC) reported that between 1990 and 2005, the number of pregnant women who gained

18.1kg or more during pregnancy rose from 15-20% in the United States (Clatfelter,

2010). In Nigeria, 22% of women aged 25-49 years are overweight (National Population

Commission, 2009), thus predisposing them to gaining excess weight in pregnancy. This

has been associated with increased risk of maternal and perinatal complications,

including pre-eclampsia, gestational diabetes, ceasarean section, stillbirth, prolonged

labour, increased blood loss, wound infection and neonatal admissions (Isreal, Nyeche,

Akani, &Akani, 2011). Furthermore, 14% of pregnant women in a study in Nigeria were

found to be overweight during the course of their pregnancy (Chigbu &Aja, 2011).

Ezeanochie, Ande and Olagbuji ( 2012) in Nigerian Tribune (17 May, 2012) also

revealed that pregnancy induced hypertension, hospital admissions during pregnancy,

ceaserean section, stillbirths were significantly higher in pregnant women that were

overweight compared to women that gained according to the recommended weight gain

guidelines.

The researcher during clinical experiences equally observed the increase in the rates of

hypertensive disorders, gestational diabetes mellitus, preterm labour or birth,

 macrosomia, birth trauma just to mention a few among pregnant mothers. Also, observed

at Poly clinic was a woman with severe pre eclampsia that was referred to Enugu state

Teaching Hospital, who later underwent emergency ceaserean section.

Most of these complications were attributed to excessive gestational weight gain more

than recommended among these mothers. One wonders if these pregnant mothers were

aware of pregnancy weight gain guidelines which are explicitly based on their pre-

pregnancy body mass index and if they actually know these complications/ risks of

gaining more weight than recommended. Moreover, the researcher wonders if there are

demographic characteristic, physical in activities or dietary habits that could predispose

these pregnant mothers to excessive pregnancy weight gain.

The answer to this speculation motivated the researcher to empirically ascertain the

knowledge of and associated risk factors for excessive gestational weight gain among

pregnant mothers who utilize maternal health care services in federal staff hospital

gwarimpa

1.4 PURPOSE OF THE STUDY

The purpose of this study is to determine the knowledge of and associated risk factors for

excessive gestational weight gain among pregnant mothers that utilize maternal health

care services in federal staff hospital gwarimpa.

OBJECTIVES OF THE STUDY

Based on the above purpose of the study the following objective ware set to:

1. Determine what the pregnant mothers know about body mass index and pregnancy weight

gain guidelines.
2. Determine whether the mothers know about complications of excessive gestational weight

gain.

3. Determine if the pregnant women have demographic characteristic that predispose them to

excessive gestational weight gain.

4. Determine if the pregnant mothers are predisposed to excessive gestational weight gain due

to physical inactivity

5. Assess the pregnant mothers dietary habits that may predispose them to excessive weight

gain

1.5 RESEARCH QUESTIONS AND/OR HYPOTHESES

Based on the objectives, the following research questions were asked:

1. What do pregnant mothers know about body mass index and pregnancy weight guidelines?

2. What knowledge do the mothers have about the complications of excessive gestational

weight gain?

3. What are the demographic characteristics of the pregnant women that are associated with

excessive gestational weight gain?

4. How predisposed are pregnant women to excessive gestational weight due to physical

inactivity

5. What are dietary habits that predispose the mothers to excessive weight gain?

1.6 SIGNIFICANCE OF THE STUDY

The findings of this study may reveal gap in the knowledge of recommended pregnancy

weight and associated risks of excessive gestational weight gain. This will provide useful

information for Nigeria health ministries, obstetricians, Midwives, community health

workers etc to improve the education of pregnant mother on these issues in order to
 reduce maternal and child morbidity and mortality rates caused by excessive gestational

weight gain. The study may also reveal the characteristics of the mothers that predispose

them to excessive weight gain. This will assist the above bodies to channel their

resources to the most vulnerable group of pregnant mothers.

The study may also reveal the pregnant mothers unhealthy dietary habits and lack of

physical activity thus may help in re-directing their antenatal counseling towards

behavioral modifications in pregnancy which when adopted by pregnant mothers will

reduce the associated complications of excessive weight gain in pregnancy. This will

evidently contribute to the achievement of Millennium Development Goals 4 and 5 which

are aimed at reducing infant mortality and improving maternal health.

The finding of this study may also increase the existing knowledge in the area and serve

as a reference for future researchers who would want to work further in this field of

study.

1.7 LIMITATION OF THE STUDY

The major constraint of this study might be Time, Finance, Language Barrier, difficulty

in data collection.

The study is restricted to hundred. The researcher would have study larger population of

pregnant mothers in FCT (both Urban and Rural areas). To access the knowledge of

associated risk factors for excessive gestational weight gain among them.

1.8 SCOPE/DELIMINATION OF THE STUDY

This study is delimited to pregnant mothers who utilize maternal health care service in

Federal Staff Hospital Gwarimpa. It is also delimited to knowledge of and associated risk

factors of excessive gestational weight gain. The study is specifically delimited to their
 knowledge of, body mass index, pregnancy weight gain guidelines, complications of

excessive weight gain and associated risk of excessive weight gain, demographic

characteristic, dietary habits and extent of physical in activities that predispose the

pregnant mothers to excessive weight gain.

1.9 OPERATIONAL DEFINITION OF TERMS

Knowledge of gestational weight gain: In this study refers to accurate information that

pregnant mothers have about body mass index, pregnancy weight gain guidelines, and

complications of excessive gestational weight gain.

- Body mass index: refers to quotient of weight in kilogram and the square of height in

metres expressed in kilogram per square metre (kg /m2).

- Pregnancy weight gain guidelines: refers to the gain of; 12-18ky by pregnant mothers

with low body mass index (< 19.8kg 1m2), 11.5-16kg by normal weight women (19.8-

25kg/m2), 7-11.5kg by women with pre-pregnancy body mass index of 26 to 29kg by

obesed women (>29kg/m2). In this study, it is also the gain of 1-3kg in the first trimester

and 0.5kg per week, 0.4kg per week and 0.3kg per week by underweight women, normal

and overweight women respectively in the second and third trimesters.

- Complications of excessive gestational weight gain: they are those negative outcomes

of overweight in pregnancy that put the mother and foetus/baby at risk for

morbidity/mortality. In this study, they include; gestational diabetes, thromboembolim,

hypertensive disorders, caesarean section, operative vaginal deliveries, postpartum

hemorrhage, macrosomia and others.

 Associated Risk factors: these are those modifiable (example, dietary habits and physical

inactivity) and non-modifiable (example, age, positive family history) factors that can

predispose pregnant mothers to excessive gestational weight gain.

Demographic characteristics: In this study refers to the pregnant mothers age (greater than

25 years), parity (greater than two children), positive family history of overweight and

sedentary or very sedentary occupation that may serve as risk factor for gaining excess

weight in pregnancy. Sedentary occupation style in this study refers to one in which the

woman sits down a lot but can move around occasionally. Very sedentary occupation style is

one in which the woman sits down throughout the working hours.

Extent of physical inactivity: refers to a period of walking, jogging, swimming etc. for less

than 3-5 times per week and less than 30 minutes to one hour per activity time. It also refers

to a period when a pregnant mother watches television, sleeps and uses computer at leisure

time more than 3-4 hours per day.

Dietary habits: are those eating behaviors that may predispose pregnant women to excessive

weight gain. They refer to the consumption of snacks (eg meat pie, bons, cakes, puffpuff

etc.), refined sugar and high calories food (table sugar, rice, foo-foo, packaged juice etc),

foods made of animal milk (yogurt, cheese, viju etc), indomie, spaghetti and fast foods. It

also refers to consuming these foods more than three (3) times per week. It also refers to

eating/drinking from fast foods joints more than once per week.