doi:10.1111/jog.13039 J. Obstet. Gynaecol. Res.

2016

Pre-pregnancy body mass index, height and physical activity

are associated with rate of gestational weight gain among
Malaysian mothers

Heng Yaw Yong, Zalilah Mohd Shariff, Shi Jia Koo and Norul Syurafak Binti Sa’ari
1
Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia

Abstract
Aim: Both inadequate and excessive weight gain during pregnancy can have immediate and long-term health
risks for women and infants. This study investigated rate of gestational weight gain (GWG) and its associated fac-
tors in Malaysian pregnant women.
Methods: This cross-sectional study was conducted at maternal and child health clinics in Selangor and Negeri
Sembilan between November 2010 and April 2012. A pre-tested questionnaire was used to obtain
sociodemographic, obstetric, dietary intake and physical activity information. Current weight and height were
measured using standard procedures. GWG rate was calculated as the average weekly weight gain in that partic-
ular trimester of pregnancy and further categorized according to the Institute of Medicine (IOM)
recommendations.
Results: Mean GWG rate for all pre-pregnancy BMI categories in the second and third trimesters was higher than
the IOM recommendations. Overweight women (adjusted OR, 4.26; 95%CI: 1.92–9.44) and women <153 cm tall
(adjusted OR, 1.96; 95%CI: 1.21–3.18) tend to have inadequate GWG rate. Women with high pre-pregnancy body
mass index (BMI; ≥25.0 kg/m2; overweight: adjusted OR, 3.88; 95%CI: 2.12–7.09; obese: adjusted OR, 2.34; 95%CI:
1.28–4.29) and low physical activity (adjusted OR, 1.74; 95%CI: 0.77–3.97) were two–threefold more likely to have
excessive GWG.
Conclusion: Both inadequate and excessive GWG can have detrimental effects on the health of mothers and in-
fants. Pre-pregnancy BMI, height and physical activity should be emphasized in prenatal care to ensure that
women have adequate GWG rate.
Key words: height, physical activity, pre-pregnancy body mass index, rate of gestational weight gain.

Introduction Malaysia, the prevalence of obesity (BMI ≥30 kg/m2)

In both developed and developing countries, over-
weight and obesity are on the rise among women of re-
productive age. In the USA, the prevalence of obesity
(body mass index [BMI] ≥30 kg/m2) in women aged
20–39 years increased from 28.4% in 1999 to 34.0% in
2007.1 The prevalence of obesity (BMI ≥28 kg/m2)
among women aged 18–44 years in China has nearly
doubled from 1992 (3.1%) to 2002 (6.1%).2 Similarly, in
among women aged ≥18 years increased from 5.7% in
1996 to 17.6% in 2011.3,4 Women who are already over-
weight or obese at conception are at an increased risk
of excessive GWG and poor pregnancy outcome.
The rate of GWG in most pregnant women is either
too low or too high based on the recommended range.
In the USA, a retrospective cohort study between 2004
and 2008 reported that 62% of pregnant women have
an excessive rate of GWG, while 17% have an

Received: September 11 2015.

Accepted: April 5 2016.
Correspondence: Professor Zalilah Mohd Shariff, Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, Universiti
Putra Malaysia, Serdang 43400 Selangor, Malaysia. Email: zalilahms@upm.edu.my

© 2016 Japan Society of Obstetrics and Gynecology 1

H. Y. Yong et al.
inadequate rate of GWG.5 In Project Viva, pregnant
women tend to gain more weight than recommended,
with mean GWG rate for normal weight, overweight
and obese pregnant women of 0.39 kg/week, 0.40
kg/week and 0.30 kg/week, respectively.6 A recent
study in China on personalized interventions for GWG
and physical activity among pregnant women found
that the majority of women in both the intervention
(88.7%) and control (91.5%) groups had GWG rate
higher than the recommended range, with mean GWG
rate 0.65 kg/week in the intervention group and 0.71
kg/week in the control group.7
Rate of GWG is associated with both maternal and in-
fant health.8–12 Women with GWG rate 0.50–0.58
kg/week are at higher risk of gestational hypertension,
while those with GWG rate ≥0.59 kg/week are at higher
risk of pre-eclampsia.11 Carnero et al. reported that both
inadequate (<0.04 to <0.10 kg/week) and excessive
(>0.50 to >0.66 kg/week) GWG rates in normal weight
and overweight women may increase the risk of preterm
delivery.12 A systematic review by Han et al. showed that
women with low GWG rate (<0.23–0.40 kg/week) were
at increased risk of preterm delivery. Women with exces-
sive GWG rate (≥0.50 kg/week) tend to have
macrosomic infants.13
Although optimal GWG rate is associated with better
maternal and fetal health outcomes, the precise optimal
rate remains controversial. Given that data on GWG rate
in Malaysian women are limited, the aim of this study
was to describe GWG rate and the associated factors
among pregnant women attending maternal and child
health (MCH) clinics.
Methods
Respondents
This cross-sectional study was conducted at three urban
MCH clinics in the states of Selangor (Bangi and Kajang)
and Negeri Sembilan (Seremban). The respondents were
pregnant women attending these MCH clinics for
routine prenatal check-ups. The selection criteria were
Malaysian female age 20–40 years; gestation 13–36
weeks; singleton pregnancy; and no medical conditions
during pregnancy (e.g. gestational diabetes mellitus
and pre-eclampsia) or chronic diseases (e.g. heart
disease, renal disease and diabetes mellitus). The study
protocol was approved by the Medical Research Ethics
Committee of Universiti Putra Malaysia and the
Ministry of Health Malaysia. A study information sheet
was given to the respondents, and informed consent
2 © 2016 Japan Society of Obstetrics and Gynecology
was obtained from all respondents prior to data
collection.
Measurements
A set of pre-tested interviewer-administered question-
naires was used to obtain sociodemographic (e.g. age,
ethnicity, education level, household income and house-
hold size), obstetric (e.g. gravidity and parity), dietary
intake and physical activity information.
Dietary intake
Dietary intake data were obtained using 2-day 24-h die-
tary recall. The dietary data were analyzed for energy
and macronutrients using Nutritionist Pro Nutrient
Analysis version 1.3 (First Data Bank, 2002) and the Ma-
laysian Food Composition Database.14 Total energy and
macronutrient intake from 2-day 24-h dietary recall were
averaged to derive mean daily dietary energy and mac-
ronutrient values.
Physical activity
The pregnant women completed the Global Physical
Activity Questionnaire.15 The women were asked to
recall the number of days in the last 7 days in which
they engaged in moderate and/or vigorous intensity
activity in three major settings (activities at
work/home, traveling to and from places, recreational
activities), as well as the length of time, in hours and
minutes per day, they performed these activities. The
total hours of physical activity were calculated and
multiplied by metabolic equivalent (MET) hours per
week, and the values were then categorized into low,
moderate and high activity.
Anthropometry
Current weight and height were measured using a
Tanita digital scale (Tanita, USA) and a Seca body meter
(Seca, British Indicators, UK), respectively. All measure-
ments were taken using standard procedures.16 Pre-
pregnancy bodyweight, as well as second and third
trimester weights, were obtained from medical records.
Pre-pregnancy BMI was calculated and classified ac-
cording to the World Health Organization16 cut-off
points: underweight, <18.5 kg/m2; normal weight,
18.5–24.9 kg/m2; overweight, 25.0–29.9 kg/m2; and
obese, ≥30.0 kg/m2. Total current weight gain was de-
fined as the difference between the measured current
weight and the pre-pregnancy weight. GWG rate in the
second and third trimester was defined as the average
weekly gain in that trimester. GWG rate was then
 Gestational weight gain rate

Table 1 Subject characteristics: Second vs third trimester (n = 589)

Second trimester Third trimester
(13–26 weeks) (27–43 weeks) P-value† Total
(n = 285) (n= 304) (n= 589)
Mean ± SD or Mean ± SD or Mean ± SD or
n (%) n (%) n (%)
Age at entry (years) 28.69 ± 4.52 29.05 ± 4.58 0.06 28.87 ± 4.55
Ethnicity 0.24
Malay 182 (63.9) 214 (70.4) 396 (67.2)
Chinese 54 (18.9) 47 (15.5) 101 (17.1)
India and others 49 (17.2) 43 (14.1) 92 (15.7)
Education level 0.75
Secondary and below 150 (52.6) 167 (53.9) 314 (53.3)
Tertiary and above 135 (47.4) 140 (46.1) 275 (46.7)
Monthly household income (RM)‡ 3518.43 ± 2663.01 3356.13 ± 1993.40 0.40 3434.66 ± 2340.82
Low (<2300) 102 (35.8) 105 (34.5) 0.35 207 (35.1)
Middle (2300–5599) 134 (47.0) 158 (52.0) 292 (49.6)
High (≥5600) 49 (17.2) 41 (13.5) 90 (15.3)
Household size 3.68 ± 1.63 3.61 ± 1.80 0.62 3.64 ± 1.72
≤2 78 (27.4) 102 (33.6) 0.26 180 (30.6)
3–4 130 (45.6) 129 (42.2) 259 (44.0)
≥5 77 (27.0) 73 (24.2) 150 (25.4)
Gravidity 2.32 ± 0.08 2.22 ± 0.08 0.42 2.27 ± 1.43
1 103 (36.1) 120 (39.5) 0.58 223 (37.9)
2 81 (28.4) 88 (28.9) 169 (28.7)
≥3 101 (35.5) 96 (31.6) 197 (33.4)
Parity 1.14 ± 0.07 1.06 ± 0.07 0.43 1.10 ± 1.23
0 110 (38.6) 131 (43.1) 0.44 241 (40.9)
1–2 83 (29.2) 88 (28.9) 171 (29.0)
≥3 92 (32.2) 85 (28.0) 177 (30.1)
Height (cm) 156.24 ± 5.94 155.82 ± 5.80 0.39 156.02 ± 5.87
<153 73 (25.6) 81 (26.6) 0.95 154 (26.1)
153–158 120 (42.1) 128 (42.1) 248 (42.1)
>158 92 (32.3) 95 (31.3) 187 (31.8)
Pre-pregnancy weight (kg) 58.43 ± 13.12 58.02 ± 13.61 0.70 58.22 ± 13.36
Current weight (kg) 65.58 ± 12.86 69.17 ± 13.30 0.01 67.43 ± 13.20
GWG rate (kg/week)§ 0.47 ± 0.02 0.45 ± 0.01 0.06 0.45 ± 0.01
Inadequate 76 (26.7) 74 (24.3) 0.04 150 (25.5)
Normal 86 (30.2) 92 (30.3) 178 (30.2)
Excessive 123 (43.1) 138 (45.4) 261 (44.3)
Pre-pregnancy BMI (kg/m2) 23.89 ± 4.99 23.85 ± 5.16 0.91 23.87 ± 5.07
Underweight (<18.5) 31 (10.9) 41 (13.5) 0.81 72 (12.2)
Normal (18.5–24.9) 150 (52.6) 157 (51.6) 307 (52.1)
Overweight (25.0–29.9) 64 (22.5) 65 (21.4) 129 (21.9)
Obese (≥30.0) 40 (14.0) 41 (13.5) 81 (13.8)
Dietary intake
Energy (kcal) 6026 ± 1963.62 6401 ± 2262.95 0.03 6220 ± 2129.85
Percentage energy from carbohydrate 55.90 ± 8.86 54.84 ± 9.41 0.16 55.35 ± 9.16
<55% 126 (44.2) 154 (50.7) 0.23 280 (47.5)
55–70% 143 (50.2) 134 (44.0) 277 (47.0)
>70% 16 (5.6) 16 (5.3) 32 (5.5)
Percentage energy from protein 17.09 ± 3.97 17.20 ± 4.18 0.74 17.15 ± 4.07
<10% 8 (2.8) 5 (1.6) 0.50 13 (2.2)
10–15% 78 (27.4) 92 (30.3) 170 (28.9)
>15% 199 (69.8) 207 (68.1) 406 (68.9)
Percentage energy from fat 27.01 ± 7.89 27.96 ± 8.62 0.17 27.50 ± 8.28
<20% 47 (16.5) 51 (16.8) 0.03 98 (16.6)
20–30% 155 (54.4) 135 (44.4) 290 (49.2)
(Continues)

© 2016 Japan Society of Obstetrics and Gynecology 3

H. Y. Yong et al.
Table 1 (continued)
Second trimester
(13–26 weeks)
(n = 285)
Mean ± SD or
n (%)
>30% 83 (29.1)
Physical activity(MET-min/week) 1186.40 ± 1191.64
Low 31 (10.9)
Moderate 135 (47.5)
High 119 (41.8)
Sedentary activity (min/day) 348.51 ± 11.55
2
†t-test/χ test. ‡10th Malaysia Plan. §Defined as average weekly weight gain in that particular trimester of pregnancy, based on Institute of Med-
icine recommended range for weight gain during pregnancy.19 GWG, gestational weight gain.
categorized as inadequate, adequate or excessive for
each category of pre-pregnancy BMI.17
Statistical analysis
Statistical analysis was performed using IBM SPSS 22.0.
Descriptive statistics (e.g. mean, standard deviation,
frequency) are used to describe the data. Multinomial lo-
gistic regression was used to determine the relationships
between factors and GWG rate. Crude and adjusted
odds ratios (OR) with 95% confidence intervals (CIs)
are presented. The significance level for all statistical
analyses was set at P < 0.05.
Results
A total of 589 pregnant women participated in this study,
with 285 and 304 women in the second and third trimes-
ters, respectively. The demographic, socioeconomic, ob-
stetric, physical activity and dietary intake
characteristics of the women are listed in Table 1. Mean
age was 28.9 ± 4.6 years. Approximately 46.7% of the
women had a tertiary education, and the majority
(84.7%) were in the low–middle income group. Approx-
imately 35.7% of women had pre-pregnancy BMI
categorized as overweight (21.9%) and obese (13.8%),
while 12.2% were underweight. Mean energy intake
(6401 ± 2262.95 KJ/day) in the third trimester was
slightly higher than that in the second trimester (6026 ±
1963.62 KJ/day). The majority of women met the recom-
mended percentages of energy from carbohydrate
(52.5%), protein (97.8%) and fat (83.4%). Moderate and
high levels of physical activity were observed in 49.2%
and 38.9% of women, respectively.
GWG rate vs pre-pregnancy BMI
The overall mean GWG rate in the second trimester
(0.48 ± 0.06 kg/week) was higher than in the third
4 © 2016 Japan Society of Obstetrics and Gynecology
Third trimester
(27–43 weeks) P-value† Total
(n= 304) (n= 589)
Mean ± SD or Mean ± SD or
n (%) n (%)
118 (38.8) 201 (34.2)
1403.29 ± 1511.14 0.05 1298.34 ± 1369.07
39 (12.8) 0.36 70 (11.9)
155 (51.0) 290 (49.2)
110 (36.2) 229 (38.9)
350.30 ± 11.00 0.91 349.43 ± 7.96
trimester (0.40 ± 0.02 kg/week). Underweight women
had the highest mean GWG rate in the second (0.53 ±
0.03 kg/week) and third (0.42 ± 0.04 kg/week) trimes-
ters. In the second trimester, the prevalence of excessive
GWG rate was highest in each BMI category: 38.9% for
underweight, 40.6% for normal weight, 50.4% for over-
weight and 55.6% for obese. In the third trimester, under-
weight (51.2%) and normal weight (37.6%) women had a
higher prevalence of inadequate GWG rate, while >50%
of overweight (56.9%) and obese (65.9%) women had
excessive GWG rate (Table 2).
Factors associated with GWG rate
Bivariate logistic regression analysis was carried out to
explore the relationship between GWG rate and the fac-
tors age; ethnicity; education level; monthly household
income; household size; gravidity; parity; pre-pregnancy
BMI; height; energy intake; percentages of energy from
carbohydrates, protein, and fat; physical activity level;
and sedentary time. Only pre-pregnancy BMI, height
and physical activity level were significantly associated
with GWG rate (data not shown). Thus, they were
entered as independent risk factors into the multivariate
models adjusted for age, ethnicity and parity.
On multivariate logistic modeling, overweight
women (adjusted OR, 4.26; 95%CI: 1.92–9.44) and
women <153 cm tall (adjusted OR, 1.96; 95%CI:
1.21–3.18) tended to have inadequate GWG rate.
Underweight women (adjusted OR, 0.36; 95%CI:
0.18–0.72) were less likely to have excessive GWG rate,
while overweight women (adjusted OR, 3.88; 95%CI:
2.12–7.09) and obese women (adjusted OR, 2.34; 95%
CI: 1.28–4.29) were two–fourfold more likely to have
excessive GWG rate compared with normal weight
women. Pregnant women with low physical activity
level were more likely to have excessive GWG rate
than normal weight women (adjusted OR, 1.74; 95%
CI: 0.77–3.97; Table 3).
 Gestational weight gain rate

Table 2 GWG rate vs pre-pregnancy BMI

GWG rate (kg/week)†
Second trimester Third trimester
(n= 589) (n= 304)
Pre-pregnancy Inadequate Normal Excessive Inadequate
BMI (kg/ IOM
m2)‡ (2009) Mean ± SD n (%) n (%) n (%) Mean ± SD n (%)
Underweight 0.44–0.58 0.53 ± 0.03 21 (29.2) 23 (31.9) 28 (38.9) 0.42 ± 0.04 21 (51.2)
Normal
weight 0.35–0.50 0.55 ± 0.04 79 (25.7) 105 (34.2) 123 (40.1) 0.40 ± 0.04 59 (37.6)
Overweight 0.23–0.33 0.38 ± 0.04 45 (34.9) 19 (14.7) 65 (50.4) 0.38 ± 0.04 23 (35.4)
Obese 0.17–0.27 0.37 ± 0.06 17 (21.0) 19 (23.5) 45 (55.6) 0.40 ± 0.05 8 (19.5)
Total 0.48 ± 0.06 162 (27.5) 166 (28.2) 261 (44.3) 0.40 ± 0.02 111 (36.5)
2
†Based on Institute of Medicine (IOM) recommended range for weight gain during pregnancy (2009).19 ‡Underweight, <18.5 kg/m ; normal
2 2 2
weight, 18.5–24.9 kg/m ; overweight, 25.0–29.9 kg/m ; obese, ≥30.0 kg/m .16 BMI, body mass index; GWG, gestational weight gain; GWG rate,
average weekly weight gain in that particular trimester of pregnancy; total GWG, difference between the measured current weight and the pre-
pregnancy weight.

Discussion women may be explained by higher available fat stores

In the present study the mean GWG rate in the second
trimester was slightly higher than in the third trimes-
ter,17,18 although the IOM proposes similar rates of
GWG in both trimesters. Gaining weight at the recom-
mended rate based on pre-pregnancy BMI reduces the
risk of post-partum weight retention, caesarean delivery
and pregnancy-induced hypertension.19 Drehmer et al.
showed that women with inadequate GWG rate in the
second trimester are at higher risk for small for gesta-
tional age (SGA) babies, while women with excessive
GWG rate are at higher risk for large for gestational
age (LGA) babies and preterm delivery. In the third
trimester, women with excessive GWG rate are at higher
risk for both preterm and caesarean delivery.17 Fetal
growth may be affected by relatively short periods of
poor maternal GWG, even if subsequent GWG is ade-
quate.20 Thus, inconsistent GWG rate over the course
of a pregnancy could put these women at risk for ad-
verse maternal and neonatal outcomes.11,12
Obese women were also found to have higher GWG
rate in the third trimester than in the second trimester.
GWG in the second trimester of pregnancy primarily
represents maternal fat deposition rather than fetal or
placental tissue or amniotic fluid gain.21 The rate of fat
gain was significantly higher in the second trimester
than in the third trimester of pregnancy.22 Lederman
et al. reported that obese women gained less fat during
pregnancy compared with other pre-pregnancy BMI
categories, with mean fat mass gains of 4.8 kg, 3.9 kg,
2.8 kg and 0.2 kg for underweight, normal weight, over-
weight and obese women, respectively.23 Thus, the lower
GWG rate during the second trimester among obese
to support fetal growth, and they may not gain as much
as underweight or normal weight women.24
The present pregnant women tended to have GWG
rates that exceed IOM recommendations for the second
and third trimesters, although GWG rate was higher in
the second than in the third trimester. This is in line with
previous studies reporting that pregnant women tend to
gain more weight than recommended.25,26 Cultural
norms and beliefs may influence GWG. In some cultures,
it is still widely believed that gaining more weight dur-
ing pregnancy is desirable and that pregnant women
need to “eat for two” to ensure healthy infants.27
Moreover, many pregnant women believe that the con-
sumption of protein foods, such as meat, cheese and milk
products, is important for infant growth and develop-
ment. In this study, women consumed higher percent-
ages of energy from protein and fat than from
carbohydrate. Lagiou et al. reported that women con-
suming higher proportions of protein and fat from ani-
mal sources and lower proportions of carbohydrate
were more likely to have increased GWG.28
To date, there are no GWG standards for pregnant
Asian women. In Malaysia, the IOM recommendations
for GWG are used, but IOM recommendations for
GWG based on pre-pregnancy BMI remain controver-
sial. Wolfe et al. found that pre-pregnancy BMI is not a
better predictor of maternal and perinatal morbidity
than bodyweight and height alone.29 Women with simi-
lar pre-pregnancy BMI but different bodyweight and
height can differ significantly in GWG during
pregnancy.30
Having a higher pre-pregnancy BMI is a well-
established determinant of excessive GWG rate.31–33 In

© 2016 Japan Society of Obstetrics and Gynecology 5

H. Y. Yong et al.

Table 2 GWG rate vs pre-pregnancy BMI

GWG rate (kg/week)†
Third trimester Total GWG (kg)†
(n= 304) (n=304)
Normal Excessive Mean ± SD Inadequate Normal Excessive
Pre-pregnancy
BMI (kg/m2)‡ n (%) n (%) n (%) n (%) n (%)
Underweight 12 (29.3) 8 (19.5) 11.90 ± 0.65 24 (58.5) 15 (36.6) 2 (4.9)
Normal weight 40 (25.5) 58 (36.9) 12.04 ± 0.39 80 (1.0) 50 (31.8) 27 (7.2)
Overweight 5 (7.7) 37 (56.9) 9.53 ±0.55 20 (30.8) 26 (40.0) 19 (29.2)
Obese 6 (14.6) 27 (65.9) 8.14 ±0.72 9 (22.0) 16 (39.0) 16 (39.0)
Total 63 (20.7) 130 (42.8) 10.96 ± 0.28 133 (43.8) 107 (35.2) 64 (21.0)

Table 3 Indicators of GWG rate, adjusted for age, ethnicity and parity
GWG rate†
Inadequate Excessive
Adjusted OR (95%CI) Adjusted OR (95%CI)
2
Pre-pregnancy BMI (kg/m )
Underweight (<18.5) 1.26 (0.73–2.17) 0.36 (0.18–0.72)*
Normal (18.5–24.9)‡ 1 1
Overweight (25.0–29.9) 4.26 (1.92–9.44)* 3.88 (2.12–7.09)*
Obese (≥30.0) 0.82 (0.44–1.53) 2.34 (1.28– 4.29)*
Height (cm)
<153 1.96 (1.21–3.18)* 1.29 (0.74–2.24)
153–158 0.99 (0.60–1.65) 1.23 (0.76–1.98)
>158 1 1
Physical activity level
Low 0.76 (0.38–1.51) 1.74 (0.77–3.97)*
Moderate 0.83 (0.54–1.29) 1.13 (0.73–1.76)
High‡ 1 1

*P<0.05. †Reference category is normal weight gain. ‡Reference category. BMI, body mass index; GWG, gestational weight gain.

the present study the overweight and obese women
were two–threefold more likely to have excessive GWG
rate, and the weight of the fetus might contribute to the
excessive GWG rate among overweight and obese
women. Overweight and obese women are more likely
to give birth to LGA or macrosomic infants.34–37 This var-
iation in infant birthweight may be influenced by genetic
factors, particularly maternal genotypes.19,38 The present
study also found that overweight women were signifi-
cantly more likely to have inadequate GWG rate. Wells
et al. reported that women with higher pre-pregnancy
BMI were at increased risk for both inadequate and ex-
cessive GWG.39 The inadequate GWG rate observed for
overweight women in present study may be due to in-
tentional restriction of food intake to prevent excessive
GWG and pregnancy complications, such as gestational
diabetes mellitus, pre-eclampsia and caesarean delivery.
In the present study, women of short stature (<153
cm) were at nearly twofold greater risk of inadequate
GWG rate, in agreement with previous studies.40–42
Short stature is a marker of early life nutritional
deficiency,40 which could extend into adulthood. Thus,
women of short stature may have experienced undernu-
trition during childhood and during the present. Preg-
nancy may aggravate undernutrition or nutrient
deficiency,40 especially if the woman remains
impoverished. The exact underlying mechanisms, how-
ever, remain unclear.
Previous studies have also reported that women with
low physical activity level tend to have excessive
GWG.43–46 Pregnant women are encouraged to stay
physically active or increase their physical activity
during pregnancy; this may reduce the risk of excessive
GWG and promote optimal maternal and fetal health

6 © 2016 Japan Society of Obstetrics and Gynecology


outcomes.46 Most women, however, reduce their
physical activity and have a low physical activity level
during pregnancy.47 This reduction in physical activity
may be due to health reasons, such as the tiredness,
shortness of breath, musculoskeletal problems or physi-
cal restraints experienced by women as pregnancy pro-
gresses.48,49 More than one-half (56.9%) of the present
women had at least one child. Child care activities might
be another possible reason for avoidance of physical ac-
tivity during pregnancy.49,50 In addition, approximately
39.5% of women were in their first pregnancy. It is possi-
ble that these women reduce their physical activity due
to concerns about pregnancy complications, such as pre-
mature labor, or harming the baby by being active.
The limitations of this study should be noted. The
study sample was not representative of pregnant
women in Malaysia, because the study recruited only
pregnant women from urban MCH clinics. In addition,
because these are government clinics, the majority of
women were in the low- and middle-income groups.
Causal relationships between the factors and GWG rate
could not be established due to the cross-sectional design
of the study. Misclassification of bodyweight status may
have occurred if weight at booking (which can be <10
weeks of gestation) was used to calculate pre-pregnancy
BMI. Nevertheless, weight at booking has been used in
other studies to calculate pre-pregnancy BMI.51 Despite
these limitations, this study has provided information
on GWG rates and associated factors in Malaysian
women that were lacking in the literature.
A high proportion of Malaysian mothers did not gain
weight within the recommended range. Gaining weight
at the recommended rate, without dramatically gaining
or losing weight in one trimester, is important to achieve
optimal maternal and child health. This study has
highlighted the need for more effective health promotion
or intervention programs for pregnant women, particu-
larly for those with low and high pre-pregnancy BMI,
short stature and physical inactivity, who are at higher
risk for poor GWG rate. Future studies are needed to
evaluate the effect of GWG rate on both long- and
short-term pregnancy outcomes among Malaysian
women.
Acknowledgments
The author would like to thank the staff and officials of
the MCH clinics in Selangor and Negeri Sembilan for
their assistance during data collection, as well as all the
participants who agreed to be interviewed.
© 2016 Japan Society of Obstetrics and Gynecology
Gestational weight gain rate
Disclosure
The authors declare no conflicts of interest.
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