European Journal of Cardiovascular Medicine

Urbanization in India has accelerated dietary transition, reduced physical activity, and increased overweight/obesity among women of reproductive age. NFHS-5 (2019–21) documents higher overweight/obesity in urban women versus rural, with a continuing upward trend from NFHS-3 through NFHS-5. [1–3] Maternal adiposity is a modifiable risk factor that elevates the likelihood of GDM, HDP (including preeclampsia), CS, postpartum hemorrhage, fetal overgrowth, and NICU admission—findings echoed in Indian cohorts from Pune and Delhi and in multicenter analyses. [4–8,12]

For Asian populations, disease risk appears at lower BMI than in Europids, prompting use of Asia-Pacific cut-offs (overweight ≥23, obesity ≥25 kg/m²) in many Indian obstetric studies. [4,5,9] These thresholds likely classify risk more accurately in Indian women, where metabolic complications occur at comparatively lower BMI. Against this backdrop, we quantified the association of maternal adiposity with obstetric and neonatal outcomes in a large urban tertiary setting and benchmarked results against recent Indian evidence.

Aim and Objectives

Aim: To estimate the effect of maternal overweight and obesity on adverse pregnancy outcomes in urban India.

Objectives:

1. To determine the prevalence of overweight/obesity at booking among women delivering in a metropolitan tertiary hospital.
2. To compare the risk of GDM, HDP, induction, CS, preterm birth, macrosomia, and NICU admission across BMI categories.
3. To compute adjusted odds ratios for key outcomes.
4. To estimate population-attributable fractions (PAFs) using urban adiposity prevalence from NFHS-5.
5. To compare findings with recent Indian studies.

Study Design and Setting

Retrospective cohort study of consecutive singleton deliveries (≥24 weeks) between January 1 and December 31, 2024, at a public tertiary-care hospital serving predominantly urban neighborhoods.

Participants

Inclusion: Singleton gestations with first ANC BMI recorded ≤14 weeks and complete delivery outcomes.

Exclusion: Multifetal gestation, major fetal anomaly, pre-gestational diabetes or chronic hypertension (for primary analyses), and incomplete records.

Exposure

Early-pregnancy BMI (kg/m²) categorized by Asia-Pacific cut-offs: normal (18.5–22.9), overweight (23.0–24.9), obesity (≥25.0); underweight (<18.5) reported descriptively. [4,9]

Outcomes and Definitions

• GDM: 2-h plasma glucose ≥140 mg/dL after 75 g oral glucose in the non-fasted state (DIPSI one-step), the pragmatic approach widely used in India. [9,10]
• HDP/Preeclampsia: Per ISSHP 2021 criteria. [11]
• Mode of delivery: CS vs vaginal (including instrumental).
• Preterm birth:<37+0 weeks.
• Macrosomia:>4.0 kg at birth.
• NICU admission: Any admission within 24 h of birth.

Covariates

Maternal age, parity, prior CS, hemoglobin at booking (anemia <11 g/dL), socioeconomic quintile, and gestational weight gain category (IOM 2009).

Sample Size

Assuming CS risk 30% in normal BMI vs 45% in obesity, α=0.05, power=0.90, 1:2 exposure ratio, minimum n≈930; we analyzed n=1,200 with complete data.

Statistical Analysis

Comparisons used χ² and t-tests/ANOVA as appropriate. Multivariable logistic regression estimated AORs with 95% CIs for overweight and obesity vs normal BMI. [1–3]

Ethics

Institutional approval obtained; de-identified records analyzed; waiver of individual consent consistent with retrospective design.

Participant Flow and Baseline

Of 1,293 eligible deliveries, 1,200 had complete datasets. Mean maternal age 27.1±4.6 y; primigravidae 48.8%; anemia at booking 34.5%; prior CS 16.1%.

Table 1. Baseline Characteristics by BMI

Inference: Higher BMI associated with older age, prior CS, and excessive gestational weight gain.

Table 2. Maternal Complications by BMI

Inference: Stepwise increase in metabolic and hypertensive morbidity with adiposity; CS rate >50% in obesity.

Table 3. Neonatal Outcomes by BMI

Inference: Obesity increases fetal overgrowth and NICU use; modest rise in prematurity.

Table 4. Adjusted Odds Ratios (AOR) for Key Outcomes (ref: Normal BMI)

Inference: Maternal adiposity independently predicts metabolic, hypertensive, operative, and neonatal morbidity.

Table 5. Public Health Burden Estimates (PAF) in Urban Settings

(Using urban OW/OB prevalence ≈31% from NFHS-5 and cohort ORs)

*Pooled approximation from cohort AORs. Inference: Roughly one-quarter of urban GDM/HDP and one-fifth of CS may be attributable to maternal adiposity. [1–3]

Table 6. Summary of Our Findings vs Recent Indian Evidence

Inference: Our magnitude and direction of effects align with recent Indian cohorts, reinforcing external validity.

Principal Findings

In this urban cohort, maternal overweight and obesity were common (≈48% combined) and independently associated with higher odds of GDM, HDP, CS, macrosomia, and NICU admission. The dose–response pattern (normal → overweight → obesity) persisted after adjustment, emphasizing adiposity as a key, modifiable risk factor in urban obstetric care.

Comparison with Recent Indian Studies

Our results are concordant with Pune data among urban slum-dwelling women, where OW/OB categories saw more operative deliveries and adverse neonatal size outcomes, while underweight status tracked with LBW—demonstrating India’s “double burden.” [4] Gandhi et al. in an Indian tertiary setting reported significantly higher preeclampsia, GDM, CS, and NICU with increasing BMI, echoing our gradient. [5] A South Delhi population-based cohort demonstrated that GDM is linked to CS, LGA, and preterm birth, underscoring metabolic pathways by which maternal adiposity worsens outcomes. [7] Arora et al. (2023) examined high pre-pregnancy BMI and found stronger GDM risk and distinctive gestational weight gain patterns in Indian women. [8] Beyond obstetric risk, national analyses show a rising CS prevalence in India with higher rates in urban and private facilities, a pattern potentially intensified by the adiposity shift documented in NFHS-5 and related analyses. [1–3,12]

Biological Plausibility

Insulin resistance, low-grade inflammation, endothelial dysfunction, and altered placentation plausibly connect maternal adiposity to GDM and preeclampsia, while fetal overnutrition explains macrosomia and associated intrapartum complications leading to CS and NICU admissions. These mechanisms have been repeatedly observed in Asian and global literature. [5–6,8,14]

Public Health Implications

Using urban overweight/obesity prevalence from NFHS-5 (~31%), our PAFs imply one in four urban GDM and one in five urban CS could be avoided if maternal adiposity were reduced—large effects at the population level. [1–3] System-level responses include:

• Preconception and interconception weight management per Indian guidance (AIIMS–FOGSI postpartum weight management; scaling to preconception counseling). [13]
• Early ANC booking and universal GDM screening (DIPSI one-step as a feasible first-line), while acknowledging ongoing debates about sensitivity. [9,10]
• Consistent ISSHP-based surveillance for HDP and targeted intrapartum planning for women with high BMI. [11]
• Urban policy measures addressing nutrition and physical activity for reproductive-age women.

Strengths and Limitations

Strengths: Large urban cohort; Asia-Pacific BMI categorization suitable for Indian risk profiles; adjustment for key confounders; triangulation with recent Indian evidence.

Limitations: Single-center retrospective design; residual confounding (dietary quality, physical activity) possible; macrosomia defined at >4.0 kg may under-capture risk in Indian newborns where >3.5 kg is sometimes used; DIPSI’s debated sensitivity may underestimate GDM prevalence.

Future Research

Prospective multicenter cohorts using standardized Asian BMI cut-offs, harmonized GDM criteria (e.g., parallel IADPSG), longitudinal maternal-child cardiometabolic follow-up, and economic evaluations of preconception weight-management programs in urban India.

Maternal overweight and obesity substantially elevate risks of GDM, HDP, CS, fetal overgrowth, and NICU admissions in urban India. Given the rising urban adiposity documented by NFHS-5 and other recent analyses, integrated strategies—preconception counseling, early ANC, universal and pragmatic GDM screening, and tailored intrapartum care—are urgently needed to curb preventable obstetric and neonatal morbidity and reduce health-system costs. [1–3,5,7–9,12–13]

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