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R E S E A R C H A R T I C L E Open Access
Secular trends in pregnancy weight gain in
German women and their influences on foetal
outcome: a hospital-based study
Nina Ferrari
1*
, Peter Mallmann
2
, Konrad Brockmeier
1,3
, Heiko Klaus Strüder
4
and Christine Graf
1,5
Abstract
Background: Increasing rates of overweight have been reported. In Germany, women of childbearing age are
especially affected. Those women are at increased risks of several peri- and postnatal complications. The purpose of
this study was to carry out Germany’s first study in terms of secular trends of overweight and weight gain during
pregnancy related to foetal clinical outcomes (birth weight, Apgar score and umbilical blood pH).
Methods: A database maintained by a large regional university hospital in Cologne, Germany was used to evaluate
clinical routine data from 1996 to 2012. 11771 women (23.5 ± 5.4 years; 18–48 years), who gave birth to a live singleton
child (>2000 gram) were included. Recommended weight gain during pregnancy was based on IOM guidelines: Total
weight gain range for underweight (initial BMI < 18.5 kg/m
2
) is 12.5 - 18 kg/ 28–40 lbs respectively, for normal-weight
(initial BMI 18.5 -24.9 kg/m
2
) is 11.5 - 16 kg/ 25–35 lbs respectively, for overweight (initial BMI 25.0-29.9 kg/m
2
)is
7–11.5 kg/ 15–25 lbs respectively and for obese (initial BMI ≥30.0 kg/m
2
)is5–9kg/11–20 lbs respectively.
A one-way variance analysis was employed to test for differences in particular factors in various groups. Multiple linear
regression analysis was used to model impact factors.
Results: Over the second analysed period (2005–2012), the number of women with high weight gain increased from
33.8% to 42.9% (p <0.001). 54.5% overweight and 57.7% obese women were affected (p <0.001). Women with high
weight gain were 54.5% significantly more likely to give birth to an infant ≥4000 grams than women with normal
(31.7%) or low weight gain (13.8%, p < 0.001). Women with normal weight gain had significantly better foetal
outcomes in terms of the Apgar score at 5 min and umbilical cord blood pH.
Conclusion: These data confirm an increase in maternal weight gain before and during pregnancy. An excessive
weight gain is accompanied by macrosomia, lower Apgar scores and pH-value. Women should therefore be advised
about the risks of obesity before and during pregnancy as well as excessive maternal weight gain during pregnancy.
Keywords: Pregnancy, Gestational weight gain, Birth weight, Apgar, Obesity, Umbilical cord blood pH
Background
Findings from the largest nationally and internationally
representative studies have shown that the number of
overweight and obese adults is increasing [1-3]. Over the
past two decades, in particular, the number of obese
German women in younger age groups (up to 35) has
increased [2]. Currently, 30% of 18 to 29 year old fe-
males show a BMI ≥25 kg/m
2
, 20.4% of these have been
classified as pre-obese (25 to < 30 kg/m
2
) and 9.6% as
obese (≥30 kg/m
2
). In the age group, 30–39 year olds,
the prevalence reached 38% for overweight (BMI ≥
25 kg/m
2
); 20.1% of these women have been classified as
pre-obese and 17.9% as obese.
Evidence has been presented for links between over-
weight/obesity and a variety of co-morbidities during
pregnancy. Overweight women seem to be twice as likely
and obese women 3.3 times as likely to develop pre-
eclampsia than normal-weight women (BMI < 25.0 kg/m
2
)
[4]. Similarly, the risk of developing gestational diabetes is
increased by 2.4% in overweight women and by 5.2% in
* Correspondence: n.ferrari@dshs-koeln.de
1
Cologne Centre for Prevention in Childhood and Youth/ Heart Centre
Cologne, University Hospital of Cologne, Kerpener Str. 62, 50937 Cologne,
Germany
Full list of author information is available at the end of the article
© 2014 Ferrari et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Ferrari et al. BMC Pregnancy and Childbirth 2014, 14:228
http://www.biomedcentral.com/1471-2393/14/228
obese women when compared to normal-weight women
[4]. It is particularly noticeable that overweight and obese
women gain much more weight during pregnancy than
normal-weight women [5,6]. Excessive weight gain during
pregnancy is associated with multiple maternal and neo-
natal complications like gestational hypertension, macro-
somia, birth complications, caesarean delivery, stillbirth,
low Apgar score at 5 minutes, hypoglycaemia or cardio-
vascular risk factors [7-11]. Women who gained more
than the recommended amount of weight during preg-
nancy according to [12] were more likely to have offspring
with greater BMI, waist, fat mass, lipid and inflammatory
profiles [11]. In addition, studies have found excessive ma-
ternal weight gain [12] in overweight women to be associ-
ated with a higher percentage of fat mass in their children
compared to children of normal-weight women [13].
Macrosomic new-borns are more at risk of developing
metabolic disorders over the long term [14,15]. Adverse
effects on foetal and neonatal parameters, described in
terms of the Apgar score, are also more likely [16-21]. The
children of overweight or obese women, for instance,
more commonly achieve lower Apgar scores at five mi-
nutes than the children of normal-weight mothers [22,23].
Although the Apgar score is a reasonable parameter to
evaluate the physical condition of new-born infants, it has
some limitations. Therefore, the measurement of umbil-
ical cord blood pH has been adopted as an addition to the
Apgar score for assessing the condition of the new-borns
[24]. A lower Apgar score is associated with lower levels
of umbilical cord pH, especially in morbidly obese women
(BMI >50 kg/m
2
)[25].
The objective of this analysis was therefore to carry
out Germany’s first study into the secular trends of over-
weight, obesity and weight gain during pregnancy in re-
lationship to foetal clinical outcomes (birth weight,
Apgar, pH-value). In addition, it aimed to contribute to
the improvement of very early prevention by identifying
groups at risk for excessive weight gain and targeting
them for preventive interventions.
Methods
Cohorts
Routine data from 18976 pregnant women registered at the
Clinic for Gynaecology at the University Hospital of
Cologne between 1996 and the summer of 2012 was retro-
spectively analysed by the Cologne Centre for Prevention in
Childhood and Adolescence at the Heart Centre of the
University Hospital of Cologne. Therefore, the study was
exempt from ethical approval from the Ethics Committee
of the University Hospital of Cologne.
Women who met the following criteria were included in
the study’s analysis: women were 18–48 years of age when
they gave birth, women possessed a minimum body height
of one meter (3.28 feet), they were not experiencing a
multiple pregnancy, and the child’s birth weight was at
least 2000 grams. The study population was limited to
children’s birth weight of at least 2000 grams, as there
were many incomplete and/or implausible datasets in chil-
dren weighing less than 2000 grams. Only data from
2000–2012 were used, because only this data had all ex-
posure and outcome data available. Therefore, a total of
11771 pregnant women were included in the study. Metric
measures are mainly presented in kilogram, gram and
meter for better reading. Imperial measures are cited in
tables as well.
Pre-pregnancy body weight as well as socioeconomic
data were queried during the routine prenatal care visits
in the Women’s Clinic. Anthropometric maternal data
including age, height, pre-pregnancy weight, weight at
the end of pregnancy and the resulting (relative) weight
gain were assessed. BMI was calculated and classified ac-
cording to the reference values issued by the World
Health Organization (WHO); thus, a BMI ≥25 kg/m
2
was considered overweight and ≥30 kg/m
2
obese. The
perinatal weight gain was defined as the difference be-
tween the weight before entering pregnancy and the
weight determined just before delivery. The recom-
mended weight gain during pregnancy was based on a
function of the initial BMI (Table 1; [12]).
Biometric data of the new-born (birth weight, umbil-
ical blood pH, Apgar) were measured right after delivery.
The Apgar scores at one and five minutes after birth
serve as a surrogate parameter for the child’s health/the
status of the new-born infant [26]. The Apgar score
ranges from 0 to 10 and comprises a series of five indi-
vidual tests performed on the new-borns: heart rate, re-
spiratory effort, muscle tone, reflex irritability and
colour. The umbilical artery blood pH at birth is com-
monly used to measure perinatal asphyxia and its meas-
urement has been used as an adjunct to the Apgar score
for assessing the new-borns condition [27].
This article considers the influence of pre-pregnancy
BMI and maternal (relative) weight gain over the past
12 years on neonatal outcomes including birth weight
(normal-weight 2000–3999 gram vs. ≥4000 gram),
Table 1 Weight gain recommendations during pregnancy
according to the Institute of Medicine 2009 [12]
Pre-pregnancy BMI Total weight gain
Range in kg Range in lbs
Underweight (BMI < 18.5 kg/m
2
) 12.5 –18 28 - 40
Normal-weight (BMI 18.5 –24.9 kg/m
2
) 11.5 –16 25 - 35
Overweight (BMI 25.0 –29.9 kg/m
2
)7–11.5 15 - 25
Obese (BMI > 30 kg/m
2
) 5-9 11-20
Source: Institute of Medicine (IOM) 2009; [12].
kg = kilogram; lbs = pounds.
Ferrari et al. BMC Pregnancy and Childbirth 2014, 14:228 Page 2 of 8
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umbilical blood pH and (low) Apgar scores at one and five
minutes after birth.
Statistical analysis
The statistical analysis of the data set was performed
using the SPSS 21.0 data-analysis software (Statistical
Product and Service Solutions 21.0) for Windows™.
Mean values and standard deviations (SD) were calcu-
lated using descriptive statistics for anthropometric
data. The chi-square test was also conducted to deter-
mine the indirect association between two categorical
variables. A one-way analysis of variance (ANOVA) was
employed to test for differences in particular factors in
various groups. A p-value less than 0.05 was considered
to be significant. All confidence intervals (CIs) were es-
timated at the 95% level. Multiple linear regression ana-
lysis was used to model impact factors.
Results
Maternal parameters and general weight gain
Pre-pregnancy maternal anthropometric data is shown
in Table 2.
5.0% of the women (n = 584) were considered under-
weight, 65.8% (n= 7681) normal-weight, 19.1% (n= 2225)
overweight and 10.2% (n = 1188) obese before pregnancy.
Table 3 shows the development of weight gain while tak-
ing the prenatal weight classification into account.
Gestational weight gain averaged 13.3 ± 5.6 kg and,
when the different years were taken into account, it be-
came evident that women gained less weight in 2000
(12.3 kg; 95% Cl: 11.9, 12.7), in 2001 (12.3 kg; 95% Cl:
11.9, 12.6) and in 2002 (12.5 kg; 95% Cl: 12.0, 12.9) than
women in 2010 (13.7 kg; 95%Cl: 13.4, 14.1), 2011 (13.9 kg;
95% Cl: 13.5, 14.2) and 2012 (13.7 kg; 95% Cl: 13.2, 14.2)
(p <0.05).
Relative weight gain
Depending on weight before pregnancy [12], 27.4% of
the women (n = 2514) gained less weight than the rec-
ommended amounts, 36.5% (n = 3347) were within the
range and 36.0% (n = 3303) gained more than the recom-
mended amount (p <0.001; see Figure 1). 54.5% of the
overweight and 57.7% of the obese pregnant women
gained more than the recommended amount, than
underweight and normal-weight women (13.2% and
29.3% respectively).
From 2000 to 2012, the values show a trend towards
excessive weight gain (p <0.001). Especially over the sec-
ond period (2005 to 2012), the number of women who
experienced excessive gestational weight gain increased
markedly from 33.8% to 42.9% (Figure 2).
Birth weight
The new-borns’weight at birth averaged 3280.9 ±
552.4 g. No significant differences in birth weight were
observed during the period from 2000 to 2012.
On average, the children born to underweight women
weighed 3081.8 g (95% Cl: 3037.2, 3126.4), those born to
normal-weight women weighed 3261.0 g (95% Cl: 3248.8,
3273.0), those born to overweight women weighed 3336.0 g
(95% Cl: 3313.2, 3358.9) and those born to obese women
weighed 3382.0 g (95% Cl: 3350.0, 3413.3). A significant dif-
ference between all groups was found (p <0.05) (Figure 3).
Birth weight depending on relative weight gain
At 3412.4 ± 552.8 grams, infants were significantly heavier
from women who had higher weight gain than those who
had normal or low weight gain during pregnancy (each
p <0.001; see Table 4). This finding was confirmed when
birth weights ≥4000 grams were examined. Women who
gained more than the recommended weight were signifi-
cantly more likely to give birth to an infant ≥4000 g
Table 2 Pre-pregnancy maternal anthropometric data
N Mean SD Range
Maternal age 11771 32.5 5.4 18.0-48.1
Maternal height in cm (in) 11771 167.2 (65.8) 6.7 (26.4) 108.0-192.0 (42.5-75.6)
Maternal weight in kg (lbs) 11684 66.7 (147.0) 14.3 (31.5) 37.0-174.8 (81.6-385.4)
Maternal BMI
+
11678 24.0 5.0 13.1-86.8
Maternal BMI classification (n;%)
$
: underweight (BMI < 18.5 kg/m
2
) 584 (5.0)
Normal-weight (BMI 18.5 –24.9 kg/m
2
) 7681 (65.8)
Overweight (BMI 25.0 –29.9 kg/m
2
) 2225 (19.1)
Obese (BMI > 30 kg/m
2
) 1188 (10.2)
Parity 11601 1.7 1.0 0-12
Pre-pregnancy maternal data of women who born a live singleton new-born between 2000 and 2012 at the Clinic for Gynaecology at the University Hospital
of Cologne/Germany.
+
Body Mass Index was calculated as bodyweight (kg) divided by height squared (m
2
);
$
Body Mass Index classification according to WHO guidelines;
cm = centimetre; in = inch; kg = kilogram; lbs = pounds; BMI = Body Mass Index; SD = standard deviation; Range = minimum and maximum.
Ferrari et al. BMC Pregnancy and Childbirth 2014, 14:228 Page 3 of 8
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(54.5%, n = 458) than women who were within (31.7%,
n = 267) or below the recommendations (13.8% n = 116,
p<0.001).
Regression analysis
Multiple linear regression analysis was carried out to ana-
lyse the individual factors that had an impact on the chil-
dren’s weight at birth. The initial model included parity,
country of origin (Germany or others), maternal age, pre-
pregnancy weight, weight gain, marital status (single,
married, widowed, divorced) as well as the mother’sem-
ployment status (employed or unemployed). In the final
model, the variables of weight gain (β-coefficient: 0.228;
p<0.001),parity(β-coefficient: 0.092; p <0.001), maternal
age (β-coefficient: 0.029; p= 0.008), pre-pregnancy weight
(β-coefficient: 0.169; p <0.001), mother’s employment
(β-coefficient: −0.063; p <0.001), marital status (β-coeffi-
cient: 0.032; p = 0.002), and country of origin (β-coeffi-
cient: 0.027; p = 0.010) explained 8.4% of the variance.
Foetal parameters
The average Apgar index at one minute after birth was
8.3 ± 1.7 and 9.4 ± 1.3 after five minutes. The average
umbilical blood pH-value was 7.3 ± 0.2. There was a sig-
nificant correlation between Apgar score at one and five
minutes and the pH-value (r = 0.085, p <0.001; r = 0.065,
p <0.001). No differences were found between pH-value
and BMI-classification, whereas there was a significant
difference in weight classes to Apgar values at one and
five minutes after birth between all groups (each p
<0.001). The new-born infants of obese and overweight
women showed significantly lower Apgar values at one
(p <0.001; p = 0.003) and at five minutes (p <0.001; p =
0.020) compared with the children of normal-weight
women (Figure 4).
There was a significant difference between recom-
mended weight gain during pregnancy and Apgar score
at 5 min (p = 0.013 adjusted by mode of delivery and
umbilical cord blood pH) as well as recommended
weight gain during pregnancy and umbilical cord blood
pH (p = 0.036 adjusted by mode of delivery and Apgar
score at 5 min).
Multiple linear regression analysis was used to identify
possible impact factors on the Apgar score at five mi-
nutes. Birth weight, marital status, pre-pregnancy
weight, mother’s age, gestational weight gain during
pregnancy, parity, umbilical blood pH and mode of de-
livery were included in the model. In the final model,
the variables of birth weight (β-coefficient: 0.224;
p <0.001), pre-pregnancy weight (β-coefficient: −0.075; p
<0.001), mother’sage(β-coefficient: 0.023; p = 0.031), par-
ity (β-coefficient: −0.036; p = 0.001), pH value (β-coeffi-
cient: −0.067; p <0.001), delivery mode vaginal operative
(β-coefficient: 0.099; p <0.001), delivery mode elective
Table 3 Total weight gain during pregnancy (mean) and 95% confidence intervals according to the pre-pregnancy
body mass index
BMI classification
+
n Mean ±SD in kg Mean ±SD in lbs 95% Cl in kg (lbs)
underweight (BMI < 18.5 kg/m
2
) 478 13.6 ± 5.0 30.0 ± 11.0 13.1-14.1 (28.9-31.1)
normal-weight (BMI 18.5 –24.9 kg/m
2
) 6058 13.8 ± 5.2 30.4 ± 11.5 13.7-13.9 (30.2-30.6)
overweight (BMI 25.0 –29.9 kg/m
2
) 1740 12.6 ± 5.9 27.8 ± 13.0 12.3-12.8 (27.1-28.2)
obese (BMI > 30 kg/m
2
) 917 10.7 ± 6.9 23.6 ± 15.2 10.3-11.0 (22.7-24.3)
+
Body Mass Index classification according to WHO guidelines; BMI = Body Mass Index; SD = standard deviation; kg = kilogram; lbs = pounds; 95% Cl: 95%
confidence intervals in kilogram and (pound).
Figure 1 Weight gain according to IOM guidelines [12] depending on weight classification. *Chi
2
-test.
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caesarean section (β-coefficient: 0.087; p <0.001) and de-
livery mode emergency caesarean section explained 9.0%
of the variance.
Discussion
Excess weight and obesity during pregnancy result in
major adverse effects on both mother and child later in
life [19,28,29]. The Avon Longitudinal Study of Parents
and Children (ALSPAC), for instance, revealed that chil-
dren born to women who experienced excessive gesta-
tional weight gain will be at risk of becoming obese and
suffering elevated blood pressure as well as elevated
blood parameters significantly more often than their
normal weight gain counterparts [11]. The weight gain
during pregnancy was correlated to the baseline BMI of
the mothers [6,9]. Many findings to date have described
possible long-term effects [30,31] but there are relatively
few studies into such short-term effects as congenital
malformations and mortality. The five-minute Apgar
score is used as a potential surrogate parameter for
physical condition, even if it has some limitations [26].
Experts recommend combining the Apgar score with
other more objective neonatal outcomes like umbilical
cord blood pH. No data related to secular trends in
Germany have yet been published. The presented study,
therefore, investigated the data from a regional database
for the Cologne area to establish (relative) weight gain
during pregnancy and possible associations with foetal
parameters (birth weight, Apgar score and umbilical
blood pH). Especially over the second analysed period
(2005 to 2012), the number of women who experienced
excessive gestational weight gain increased markedly
from 33.8% to 42.9%. Predominantly the overweight and
obese women gained more weight than recommended.
DeVader et al. [32] indicated that women experiencing
excessive weight gain during pregnancy but who were
classified as being of normal weight prior to conception
and before putting on too much weight, were at higher
Figure 2 Total weight gain during pregnancy according to IOM guidelines [12] depending on the year. *Chi
2
-test.
Figure 3 Birth weight in gram by pre-pregnancy weight classification. *one-way ANOVA.
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risk of preeclampsia, were more likely to require induced
labour and caesarean delivery, and had a higher ratio of
infants who were large for their gestational age.
In our study, multiple linear regression analysis showed
that weight gain during pregnancy had the highest impact
on birth weight, although the total variance explained only
8.4%. We were able to assess and adjust our results for
confounding bias. We acknowledge that our results may be
influenced by other important confounders, including
gestational age or dietary habits of the women in our study
population.
Nevertheless, in our study, foetal outcomes attributed to
high maternal weight gains are reflected in increased birth
weight, lower Apgar scores at one and five minutes after
birth, and lower umbilical cord blood pH compared with
women who gained weight within the recommended
range. Consistent with our study, Stotland et al. [9] also
provided evidence that underlined a relationship between
excessive weight gain, large size for gestational age, lower
Apgar scores (<7) at five minutes, and lower umbilical
cord blood pH. This may influence the development of in-
fants. Macrosomic new-borns are more likely than other
infants to be obese in childhood, adolescents and early
adulthood [33] and are at risk of cardiovascular and meta-
bolic risk factors later in life [15,34]. In addition, low
Apgar scores and lower umbilical cord blood pH are asso-
ciated with neonatal mortality and morbidity, spasticity
and long term outcomes like cerebral palsy [27,35,36].
Table 4 Mean and 95% confidence intervals (CIs) for birth
weight in gram by total maternal weight gain
Total maternal weight gain n Mean SD 95% Cl
Low weight gain 2514 3107.7 527.4 3086.5 - 3128.9
Normal weight gain 3347 3258.2 541.0 3239.8 –3276.5
High weight gain 3303 3412.4 552.8 3394.0 –3430.9
+
The recommended weight gain during pregnancy was based on a function of
the initial BMI according to IOM [12]; SD = standard deviation; 95% Cl: 95%
confidence intervals.
Figure 4 Apgar score at 1 and 5 minutes depending on weight classification. a. Apgar score at 1 min: depending on weight classification;
One way Anova p <0.001;
+
Apgar score at 1 min between underweight vs overweight women p = 0.014;
++
Apgar score at 1 min between
underweight vs. obese women p <0.001;
*
Apgar score at 1 min between normal-weight vs overweight women p = 0.003;
**
Apgar score at 1 min
between normal-weight vs. obese women p <0.001. b. Apgar score at 5 min; One way Anova p <0.001
+
Apgar score at 5 min between
underweight vs overweight women p = 0.014;
++
Apgar score at 5 min between underweight vs. obese women p = 0.001;
*
Apgar score at 5 min
between normal-weight vs overweight women p = 0.020;
**
Apgar score at 5 min between normal-weight vs. obese women p <0.001.
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Our data showed, that birth weight had the highest impact
on Apgar score at five minutes, although the total variance
is very small and findings must be interpreted with cau-
tion. Nevertheless, our findings demonstrate that preven-
tion of maternal excessive weight gain is important.
It should be noted that the presented study is limited to
theextentthatitonlyrecordedanthropometricdatabefore
pregnancy; smoking was not recorded as well as gestational
age, and that it only considered a regional situation. It was
possible to adjust our results for some confounding bias,
but not all. Although studies have often reported outcomes
in terms of birth weight, it should be noted that gestational
age has an important impact on foetal parameters. Gesta-
tional age is strongly associated with birth weight [37]. In
addition, the Apgar score at one and five minutes after birth
are directly related to gestational age [38]. Nevertheless,
Kitlinski et al. 2003 [39] found that within the interval of
37–41 weeks no association between gestational age and a
low Apgar score was demonstrated, but a statistically sig-
nificant positive association between a gestational age of 41
3/7 weeks or more and Apgar score less than 7 at 5 minutes
was found. Furthermore, the authors demonstrated that the
mean umbilical artery pH decreased with increasing gesta-
tional age. Therefore, a substantial limitation of our retro-
spective study might be that data of gestational age was not
available. Another limitation might be the Apgar score. The
Apgar score, as a relatively subjective parameter, is an ex-
pression of the infants’physiological condition. Therefore,
we used birth weight and umbilical blood pH as well, to de-
fine foetal outcome and neonatal condition [9,24,27,40].
Conclusion
In conclusion, the presented study demonstrated that the
prevalence of excessive weight gain during pregnancy has
increased markedly in the Cologne area over recent years
and that these results are closely associated with birth
weight, low Apgar score and umbilical blood pH. The main
strengths of the study are its consistent method, dataset
over 12 years, and the size of the examined collective.
Despite the mentioned limitations, our results confirm
the importance and contribute to the improvement of
early preventive measures by identifying women at risk
for excessive weight gain. The prevention of maternal
excessive weight gain is likely to benefit women’s health
as well as that of their infants. Women should therefore
be advised about the risks of obesity during pregnancy
prior to conception and should be motivated by gynae-
cologists and midwives to take initial steps to avoid ex-
cessive weight gain during pregnancy.
Abbreviations
ANOVA: Analysis of variance; BMI: Body mass index; HDL: High density lipid;
i.e.: In example; in: Inch; IOM: Institute of Medicine; Lbs: Pound; SD: Standard
deviation; WHO: World Health Organization.
Competing interests
The authors declared that they have no conflict of interests.
Authors’contribution
Study concept: NF, PM, KB, CG; Data collection: PM; Data handling: NF, PM,
CG; Analysis: NF; Interpretation of data: NF, CG; Critical revision of the
manuscript: PM, KB, HKS, CG. All authors read and approved the final
manuscript.
Acknowledgements
We gratefully appreciate the Förderverein des Herzzentrums Köln and the
staff at the Clinic and Polyclinic for Gynaecology and Obstetrics, University
Hospital of Cologne, for their support. We would also like to thank Erica
Wineland-Thomson, Peter Wright, David Gordon Tansey and Christiane Klose
for critically reviewing the manuscript.
Author details
1
Cologne Centre for Prevention in Childhood and Youth/ Heart Centre
Cologne, University Hospital of Cologne, Kerpener Str. 62, 50937 Cologne,
Germany.
2
Clinic and Polyclinic for Gynaecology and Obstetrics, University
Hospital of Cologne, Kerpener Str. 34, 50931 Cologne, Germany.
3
Department
of Paediatric Cardiology, Heart Centre Cologne, University Hospital of
Cologne, Kerpener Str. 62, 50937 Cologne, Germany.
4
Institute of Movement
and Neurosciences, Am Sportpark Müngersdorf 6, German Sport University
Cologne, 50933 Cologne, Germany.
5
Department for physical activity in
public health, Institute of Movement and Neurosciences, Am Sportpark
Müngersdorf 6, German Sport University Cologne, 50933 Cologne, Germany.
Received: 13 November 2013 Accepted: 9 July 2014
Published: 15 July 2014
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doi:10.1186/1471-2393-14-228
Cite this article as: Ferrari et al.:Secular trends in pregnancy weight gain
in German women and their influences on foetal outcome: a hospital-
based study. BMC Pregnancy and Childbirth 2014 14:228.
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