International Journal of

Environmental Research
and Public Health

Article
Influence of Body Mass Index on Gestation and
Delivery in Nulliparous Women: A Cohort Study
Noemí Rodríguez-Mesa 1 , Paula Robles-Benayas 1 , Yolanda Rodríguez-López 1 ,
Eva María Pérez-Fernández 1 and Ana Isabel Cobo-Cuenca 2, *
1 Hospital Virgen de la Salud de Toledo, Servicio de salud de Castilla la Mancha (SESCAM), 45005 Toledo,
Spain; [email protected] (N.R.-M.); [email protected] (P.R.-B.);
[email protected] (Y.R.-L.); [email protected] (E.M.P.-F.)
2 Department of Nursing and Physiotherapy, Grupo Investigación multidisciplinar en Cuidados (IMCU),
Universidad de Castilla la Mancha, 45004 Toledo, Spain
* Correspondence: [email protected]




Received: 9 April 2019; Accepted: 3 June 2019; Published: 6 June 2019


Abstract: Aims: To assess the influence of obesity on pregnancy and delivery in pregnant nulliparous
women. Methods: A cohort, longitudinal, retrospective study was conducted in Spain with 710
women, of which 109 were obese (BMI > 30) and 601 were normoweight (BMI < 25). Consecutive
nonrandom sampling. Variables: maternal age, BMI, gestational age, fetal position, start of labor,
dilation and expulsion times, type of delivery and newborn weight and height. Results: The dilation
time in obese women (309.81 ± 150.42 min) was longer than that in normoweight women (281.18 ±
136.90 min) (p = 0.05, Student’s t-test). A higher fetal weight was more likely to lead to longer dilation
time (OR = 0.43, 95% CI 0.010–0.075, p < 0.001) and expulsion time (OR = 0.027, 95% CI 0.015–0.039,
p < 0.001). A higher maternal age was more likely to lead to a longer expulsion time (OR = 2.054,
95% CI 1.17–2.99, p < 0.001). Obese women were more likely to have gestational diabetes [relative risk
(RR) = 3.612, 95% CI 2.102–6.207, p < 0.001], preeclampsia (RR = 5.514, 95% CI 1.128–26.96, p = 0.05),
induced birth (RR = 1.26, 95% CI 1.06–1.50, p = 0.017) and cesarean section (RR = 2.16, 95% CI
1.11–4.20, p = 0.022) than normoweight women. Conclusion: Obesity is associated with increased
complications during pregnancy, an increased incidence of a cesarean section and induced birth but it
has no significant effect on the delivery time.

Keywords: obesity; maternal body mass index; labor; nulliparous women

1. Introduction
The prevalence of obesity has increased in recent years worldwide. It is estimated that by 2025,
the global prevalence of obesity in women will be greater than 21% [1]. Obesity affects 17% of the adult
population in Spain. In Castilla-La Mancha, more than 18% of the female population are obese [2].
Obesity is considered a risk factor for several diseases and is related to many pathologies, including
cardiovascular diseases, type 2 diabetes, hypertension, kidney problems and cancer, such as breast,
colon and endometrial cancer [3,4].
Obesity has increased among pregnant women in recent decades, resulting in maternal, perinatal
and neonatal complications. A higher body mass index (BMI) results in a greater risk of gestational
and fetal pathology [5–8]. Obese pregnant women have higher risks of gestational diabetes, pregnancy
hypertension, preeclampsia and HELLP syndrome [9–11]. The fetal risks associated with maternal
obesity are preterm birth, fetal macrosomia, perinatal death and congenital anomalies [5].
Obesity results in an increased duration of delivery, increased rates of instrumental deliveries and
cesarean sections, as wells as in risk of a postpartum hemorrhage, perianal tears, complications from

Int. J. Environ. Res. Public Health 2019, 16, 2015; doi:10.3390/ijerph16112015 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2019, 16, 2015 2 of 8

anesthesia and surgical procedures, surgical wound infections and urinary tract infections [11–13].
The associated pathologies and fetal risks favor the induction of birth [12–14].
Morbidity and mortality associated with excess weight in pregnant women have been studied
extensively in recent years; however, the effects of obesity during childbirth have not been examined.
Currently, delivery rooms in Spain attend to a large number of obese women. These pregnant
women exhibit different characteristics during delivery, which makes it necessary to investigate
the time required for different stages of birth. To our knowledge, in Spain there have been no
studies of nulliparous women with obesity and the relationships between obesity and dilation and
expulsion times.
The aims of this study were: (1) to assess the influence of obesity on pregnancy and childbirth;
(2) to determine the relationship between BMI and dilation and expulsion times in nulliparous women;
and (3) to identify other variables that may influence the duration of childbirth.

2. Materials and Methods

2.1. Study Design and Participants

This was a quantitative, retrospective, longitudinal cohort study conducted in the delivery unit of
a tertiary hospital of reference in Spain.
Through consecutive nonprobabilistic sampling, 710 nulliparous women who went into labor
during 2014–2015 and met the inclusion and exclusion criteria were selected. Two cohorts were created
within this group:

• Group 1 (obese women) [15]: cohort of 601 pregnant women with a BMI > 30 kg/m2 ;
• Group 2 (normoweight women) [15]: cohort of 109 pregnant women with a BMI between 18.5 and
24.9 kg/m2 .

The inclusion criteria were as follows: nulliparous pregnant women with a single term fetus
(37–42 weeks), fetal cephalic presentation and epidural analgesia.
The exclusion criteria were as follows: scheduled cesarean delivery, overweight women,
multiparous women, placenta previa and/or accreta, multiple gestation, noncephalic fetal presentation,
intrauterine fetal death and stained amniotic fluid.
The researchers collected data using the childbirth records belonging to the hospital. This register
contained all information necessary for this study. Maternal weight and height of the women were
recorded at the first prenatal consultation with a midwife. In Spain, prenatal control is free for all
women and the first visit to a midwife is at 8 weeks of gestation.

2.2. Sources and Information

The study variables included: (1) maternal variables: age, weight, height, BMI, gestational diabetes
and preeclampsia; (2) obstetric variables: type of labor (spontaneous or induced), duration of dilation
and expulsion in minutes, type of delivery (vaginal delivery, instrumental (forceps/ventouse) delivery
and cesarean delivery), amniorrhexis (spontaneous or artificial) and the use of oxytocin; and (3) fetal
variables: gestational age, fetal cephalic presentation and newborn weight and height.
The sample size was calculated using the Granmo program (version 7.12) (Barcelona, Spain, 2012),
based on an α risk of 0.05, a relative risk (RR) of 1.7, a β risk of 0.2, an obesity percentage of 18%,
a cesarean rate in the normoweight group of 0.2 and a replacement rate of 10%. These factors indicated
that a population of 610 subjects in the normoweight group and 110 subjects in the obesity group
would be necessary for the study [16].
After approval by the ethics and clinical research committee (Comité de Ética del Complejo
hospitalario de Toledo, dossier number CEIC TO-114/2014) of the institution, data were collected
retrospectively, starting with the most recent cases until the sample needed to conduct the study
was complete.
Int. J. Environ. Res. Public Health 2019, 16, 2015 3 of 8

Statistical analysis was performed with the statistical program SPSS v.19 (IBM, Armonk, NY, USA).
Percentages, means and dispersion measures were obtained for the descriptive analysis. Chi-squared
(χ2 ; qualitative) inferential analysis, Student’s t-test, Fisher’s test (quantitative) and Spearman’s
correlation coefficient analysis (quantitative) were performed. Multivariate linear regression model
was used with quantitative variables. The effect of the BMI category (normoweight or obese) on each
clinical outcome was assessed using a binomial regression model. The results are presented as RR with
a 95% confidence interval (CI), assuming bilateral significance indicated by p < 0.05.

3. Results
The sample consisted of 720 women, of which ten were eliminated for an extreme age (three < 18
years old and seven > 40 years). The definitive sample consisted of 710 women, aged between 18
and 40 years, with an average age of 30.06 ± 5.09 years. Overall, 6.7% (48) of the participants had
gestational diabetes and 0.8% (6) had preeclampsia.
Among the participants, 601 (84.6%) were normoweight (BMI < 25) and were included in group
2. The remaining 109 participants (15.4%) were obese (BMI > 30) and were included in group 1.
Group 1 (obese) included significantly more participants with gestational diabetes (p < 0.001, χ2 ) and
preeclampsia (p = 0.05, Fisher’s test) than did group 2 (normoweight) (Table 1).

Table 1. Maternal and fetal variables in the normoweight and obesity groups.

Group 1 Group 2
Obesity Normoweight
Variables p
(BMI > 30 kg/m2 ) (BMI < 25 kg/m2 )
(n = 109) (n = 601)
Maternal variables
Age 29.84 ± 5.23 30.1 ± 5.06 ns
Age range
18–29 years old 52 (18.1%) 235 (81.9%) ns
30–40 years old 57 (13.5%) 366 (86.5%)
Weight (kg) 88.36 ± 11.07 58.78 ± 6.25 <0.001
Body mass index (BMI; kg/m2 ) 33.6 ± 3.62 22.0 ± 2.14 <0.001
Diabetes 19 (17.4%) 29 (4.8%) <0.001
Preeclampsia 3 (2.8%) 3 (0.5%) 0.05 *
Fetal variables
Fetal age (weeks) 39.53 ± 1.29 39.53 ± 1.95 ns
Fetal weight (g) 3363 ± 523.94 3250 ± 383.9 0.034
Numbers of children with fetal weight ≥4000 g 10 (9.2%) 20 (3.3%) 0.05
Fetal height (cm) 49.96 ± 1.69 49.73 ± 1.87 ns
* Fisher’s test (<5); ns: not significance.

The obese women were 3.61 times more likely to have gestational diabetes (RR 3.61, 95% CI
2.1–6.2, p < 0.001) and 5.5 times more likely to have preeclampsia (RR 5.51, 95% CI 1.13–26.96, p = 0.05)
than were the normoweight women (Table 2).
Group 1 (obese) included more participants who underwent induction (p = 0.017, χ2 ) and a
cesarean section (p = 0.018, χ2 ) than did group 2 (normoweight) (Table 3).
The obese women were 1.26 times more likely to have induced labor (RR 1.26, 95% CI 1.06–1.50,
p = 0.017) and 2.1 times more likely to have a cesarean section (RR 2.16, 95% CI 1.11–4.22, p = 0.022)
than were normoweight women (Table 2).
Int. J. Environ. Res. Public Health 2019, 16, 2015 4 of 8

Table 2. Effects of maternal body mass index on pregnancy outcomes.

Outcome RR * (95% CI † ) p-Value

Diabetes
Obese vs. normoweight [19 (17.4%) vs. 29 (4.8%)] 3.61 (2.1–6.2) <0.001
Preeclampsia
Obese vs. normoweight [3 (2.7%) vs. 3 (0.5%)] 5.51 (1.13–26.96) 0.05
Cesarean delivery
Obese vs. normoweight [11 (10.1%) vs. 28 (4.7%)] 2.16 (1.11–4.20) 0.022
Induction of labor
Obese vs. normoweight [65 (59.6%) vs. 284 (47.3%)] 1.26(1.06–1.50) 0.017
Weight birth ≥4000 g
Obese vs. normoweight [10 (9.2%) vs. 20 (3.3%)] 2.75 (1.33–5.73) 0.005
* Relative risk: the treatment effects were presented as relative risks (95% CI) using a log binomial model that
included the body mass index. † CI: confidence interval. Fisher’s test was used for preeclampsia.

Table 3. Obstetric variables in the normoweight and obesity groups.

Group 1 Group 2
Obstetric Variables Obesity (n = 109) Normoweight (n = 601) p
(BMI * > 30 kg/m2 ) (BMI * < 25 kg/m2 )
Mode of delivery
Spontaneous/vaginal birth 83 (76.1%) 441 (73.4%)
Forceps/ventouse (instrumental) 15 (13.8%) 132 (22%) 0.018
Cesarean 11 (10.1%) 28 (4.7%)
Labor
Spontaneous 44 (40.4%) 17 (52.7%)
Induced 65 (59.6%) 284 (47.3%) 0.017
Rupture of membranes
Spontaneous 48 (44%) 265 (44.2%) ns
Induced 61 (56%) 335 (55.8%)
Oxytocin
No 20 (18.3%) 124(20.6%)
Yes 89(81.7%) 477 (79.4%) ns
M ± DT M ± DT
Length of first stage of labor 309.81 ± 150.42 281.18 ± 136.9 0.05
Length of second stage of labor 109.9 ± 65.05 105.39 ± 65.48 ns
Length of labor 409.75 ± 165.26 384.89 ± 152.8 ns
* BMI, body mass index. ns: not significance.

3.1. First Stage of Labor

The dilation time (first stage of labor) was longer (p = 0.05, Student’s t-test) in group 1 (mean ±
standard deviation: 309.81 ± 150.42 min) than in group 2 (281.18 ± 136.90 min) (Table 3).
The dilation time (first stage of labor) was significantly related to the birth weight (Spearman’s R
= 0.169, p < 0.001) and height (Spearman’s R = 0.160; p < 0.001) of the child. The dilation time (first
stage of labor) was significantly related to the birth weight (p < 0.001, Student’s-t-test) and fetal weight
≥4000 g (375.5 ± 152.99 g) vs. fetal weight <4000 g (281.53 ± 137.45 g). The time of the first stage of
labor with the administration of oxytocin (304.70 ± 142.28 min) was significantly longer (p < 0.001,
Student’s t-test) than that without oxytocin (211.92 ± 94.00 min). No significant relationships were
found among the dilation time, labor onset type and position of the head of the fetus.

3.2. Second Stage of Labor

The expulsion time in older women (30–40 years old; 112.57 ± 64.49 min) was significantly longer
(p < 0.001, Student’s t-test) than that in younger women (18–29 years old; 96.46 ± 65.65 min).
Int. J. Environ. Res. Public Health 2019, 16, 2015 5 of 8

The expulsion time was significantly longer (p = 0.011, Student’s t-test) when the fetal head was
in the occiput posterior position (129.39 ± 64.77 min) than when it was in the occiput anterior position
(105.83 ± 64.60 min).
No differences were found in the expulsion time depending on the administration of oxytocin,
BMI, rupture of membranes and onset of labor.
The weight (Spearman’s R = 0.188, p < 0.001) and height (Spearman’s R = 0.106, p = 0.005) of the
child and the age of the mother (Spearman’s R = 0.159, p < 0.001) exhibited significant weak positive
relationships with the expulsion time.
Table 4 shows factors associated with the dilation and expulsion times.

Table 4. Factors associated with the dilation and expulsion times.

Dilation Time OR * (95% CI† ) p-Value Expulsion Time OR * (95% CI† ) p-Value
Maternal age — ns Maternal age 2.052 (1.16–2.99) <0.001
Fetal Weight 0.43 (0.010–0.075) <0.001 Fetal weight 0.027 (0.015–0.039) <0.001
* OR: odd ratio; † CI: confidence interval. The model was adjusted for maternal age, maternal body mass index, fetal
weight and dilation time.

4. Discussion
The results of our study suggest that obesity in primiparous pregnant women is associated with
the occurrence of complications during pregnancy (diabetes and preeclampsia) and a greater number of
complications during delivery (greater numbers of inductions, cesarean sections or instrument-assisted
births and longer duration of dilation and delivery).
Consistent with the findings of other studies, the obese group had a significantly higher incidence
of gestational diabetes [13,17] and preeclampsia than did the normoweight group [18].
In addition, the incidences of instrumental births and cesarean sections were higher in the obese
group [11,12,18–22]. Obese women were more likely to have induced births [12,13,20,21] and a longer
duration of the first stage of labor than were normoweight women [10,12,21,22]. This increase in
the time of dilation in obese women may be due to uterine dystocia [23,24], such as cephalopelvic
disproportion [25].
A higher fetal weight is associated with a longer duration of the first stage of labor [25]. Among the
factors that are associated with a greater weight and height of the newborn, maternal obesity [11,17],
weight gain and diabetes are noteworthy [17,26,27]. In our study, obese women were 2.7 times more
likely to have children weighing more than 4000 g. Although the obese group included a higher
proportion of diabetic women [11,17], we did not find a relationship between gestational diabetes
and the fetal weight greater than 4000 g. This finding may have been due to the fact that Spain has a
public health system and when gestational diabetes is detected, women undergo health consultations.
The weight and height of the child are also related to the expulsion time.
Controversy exists regarding the relationship between obesity and the expulsion time.
Carhall et al. [11] found a shorter expulsion time in obese women. Other studies found a direct
relationship between the dilation time and expulsion time, in the absence of other factors [25]. In this
study, we did not find differences in the expulsion time, possibly because at our center, the expulsion
time is not allowed to be longer than 3 h, as established by the hospital protocol.
A longer expulsion time is related to the occiput posterior position [28] and an older
maternal age [29].
In this study, the dilation period was longer in women who received oxytocin. This finding
contradicts to the data of other studies [30,31], possibly because the administration of oxytocin is
conducted in a generalized manner. Thus, deliveries with an excessively short or considerably shorter
dilation phase than the average phase in nulliparous women or than that expected by professionals
under different circumstances did not include this intervention.
Int. J. Environ. Res. Public Health 2019, 16, 2015 6 of 8

There are limitations in this study. Because a cohort study design was used, it was not possible to
establish causal relations. Furthermore, the R values were very weak and thus, it could be interesting
to repeat this study, with a larger sample, to evaluate the association between the age and the time of
delivery. The data collected were obtained from the birth register of the hospital. The other limitation
was that we did not collect data about the weight gain during pregnancy.
The strength of this study is that a power calculation was performed, and an appropriate number
of cases was included in each group.
This study did not receive any specific grant from funding agencies in the public, commercial or
not-for-profit sectors.

5. Conclusions
Obesity in pregnant nulliparous women is associated with numerous risks during pregnancy,
such as gestational diabetes and preeclampsia.
In addition, obesity is associated with an increased rate of labor induction, a higher probability of
cesarean section, a longer dilation phase and an increased risk of the birth weight >4000 g.
A higher fetal weight is associated with longer dilation and expulsion times.
An increased expulsion time is associated with an older maternal age.

Implications for Practice

Owing to the influence of excessive weight gain in pregnant women, it is important to focus on
weight control, from gestation to the delivery period, to reduce the occurrence of complications and
prolonged delivery times and to facilitate recovery.

Author Contributions: Conceptualization, N.R.-M., P.R.-B., Y.R.-L., E.M.P.-F. and A.I.C.-C.; methodology, N.R.-M.,
P.R.-B., Y.R.-L., E.M.P.-F. and A.I.C.-C.; software, N.R.-M., P.R.-B., Y.R.-L., E.M.P.-F. and A.I.C.-C.; validation,
N.R.-M., P.R.-B., Y.R.-L., E.M.P.-F. and A.I.C.-C.; formal analysis, N.R.-M., P.R.-B., Y.R.-L., E.M.P.-F. and A.I.C.-C.;
data curation, N.R.-M., P.R.-B., Y.R.-L. and E.M.P.-F.; writing—original draft preparation, N.R.-M., P.R.-B., Y.R.-L.,
E.M.P.-F. and A.I.C.-C.; writing—review and editing, N.R.-M., P.R.-B., Y.R.-L., E.M.P.-F. and A.I.C.-C.; visualization,
N.R.-M., P.R.-B., Y.R.-L., E.M.P.-F. and A.I.C.-C.; supervision, A.I.C.-C.; project administration, E.M.P.-F.
Funding: This research was funded by a grant from the European Regional Development Fund (ERDF) [Fondo
Europeo de Desarrollo Regional (FEDER), (DOCM 24/01/19)].
Conflicts of Interest: The authors declare no conflict of interest.

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