Effect of Obesity on Pregnancy, Childbirth and Postpartum Among Moroccan Women

Background: Overweight and obesity among Moroccan adults is continually growing affecting one in three adults from which 63.1% are women. Obesity during pregnancy increases the risk of maternal and fetal complications. The conditions of delivery are also more difficult. Objective: we aimed to describe the complications of obesity occurring in pregnancy, childbirth and postpartum among obese women in Morocco. Material and methods: It is a cross-sectional study conducted, in 2017, in two Hospital maternities in Marrakech. A sample of 200 women, who had just given birth, and have a Body Mass Index more than 30 was recruited. Women sociodemographic conditions and data about complications occurring during pregnancy, childbirth and postpartum, were collected meaning a structured interview and from participants’ birth records. We used The SPSS software to realize descriptive analysis of data. Results: we noticed more than 37% of severe obesity and morbid obesity among participants. Several complications were noticed. Gestational diabetes occurs first (23%), followed by preeclampsia (14%). More than 38% of women gave birth by cesarean section. Almost 33% of participants had postpartum complications, the most common being infection (13%) and hemorrhage (12%). Conclusion: the high incidence of complications in obese women during pregnancy, childbirth and post-partum emphasizes the need of a women nutritional management in preconception and during pregnancy to minimize complications.


Introduction
Changes in diet, habits and lifestyles of human populations (Nutritional Transition), observed over the last decades, have contributed to an increase in overweight, obesity and some chronic diseases associated with nutrition [1]. According to recent WHO global statistics, more than 1.9 million adults were overweight and 600 million were obese, globally 10% of the world's adult population was obese [1]. Generally, female population is more affected, when 15% of obese women versus 11% for men were reported [1]. In Morocco the demographic transition has been accompanied by changes in lifestyles, including food and physical activity (HCP, 2010). This nutritional transition was marked by the transition from a traditional diet based on cereals and vegetables to a diet that includes more animal products and tends to become excessive in relation to the energy needs of a sedentary life [2].
According to national statistics, more than 10 million Moroccan adults are obese or pre-obese, or nearly one in three Moroccans [3]. Among these Moroccan adults, 63.1% are women, including women of childbearing age [4]. Contrariwise, micronutrient deficiencies, such as anemia, vitamin A, iodine and calcium deficiency; still among a public health problem [4]. Obesity is responsible for significant complications among pregnant women and it can put maternal and newborn health at major risk [3,4]. Indeed, during pregnancy, obesity increases the risk of maternal complications (gestational hypertension, gestational diabetes) and fetal complications (malformations, macrosomia). The conditions of delivery are also more difficult, with more caesareans and failures of epidural analgesia [5][6][7]. In this context, the objective of this original study was to describe the complications linked to obesity in pregnancy, childbirth and postpartum among Moroccan women.

Study area
This cross-sectional quantitative descriptive study was conducted in 2017 in Marrakech city. Data were collected in the maternity services of the University Hospital Center, Mohamed VI (CHU, MVI) and at the maternity of Ibn Zohr Hospital.

Population
A sample of 200 women was included in the study according to an accidental probabilistic sampling based on two major inclusion criteria: a) Woman had just given birth, and thus had an experience of pregnancy, childbirth and postpartum.
b) Woman with a Body Mass Index more than 30 (BMI>30).

Data collection
Standardized interviews were used for data collection from eligible participants. The interview questions were tested among 10 women who were excluded from the main study sample. We collected information about women socio-demographic status and complications occurring during pregnancy, childbirth and postpartum experience. Our data were completed and confirmed from official participants' birth records.

Ethical considerations
Before starting our study, we received approval from the local ethics committee of the Ministry of Health. All participants were informed by the objective of the study and gave their free informed consent to participate in this study.

Data analysis
Data were analyzed by the SPSS software (version 10). We calculated the means and standard deviations for the quantitative variables and the frequencies and percentages for the qualitative variables.
Woman Body Mass Index was calculated according to BMI=Weight(kg)/Size2(m) with the weight of women is before pregnancy.

Result
200 women were participated in this study, aged between 17 and 43years with a mean age of 29.75 years (SD=7.6). The demographic origin is rural for 51% (N=103) of participants and more than 75% (N=150) of them were illiterate or did not exceed the level of primary instruction in the moment of the survey. More than 94% of the participants did not have any professional activity. The health insurance was absent for 43% of them and for the insured ones it was the RAMED (Medical Assistance Plan) for more than 90% (Table 1). The BMI of participants ranged from 30 to 48.65 with an average of 34.51 (SD=3.63). The distribution by grades of obesity showed more than 37% of severe obesity and morbid obesity among participants ( Table 1). The majority of participants 75% (N=150) have done, at least, one prenatal consultation at a health center during their pregnancy. However, only 15% (N=30) of them had received dietary advice and without any information about complications they could have during pregnancy or delivery and therefore, did not have any special care for obese women. The majority of participants had complications during pregnancy (Figure 1). Gestational diabetes occurs first with an incidence of 23% (N=46), followed by preeclampsia 14% (N=28). In addition, 11.5% (N=23) of pregnant women had sleep apnea and 11% had gestational hypertension. During childbirth, caesarean delivery was the case for 38.67% (N=78) of women and 10% had obstructed labor (Figure 2). Almost 33% (N=66) of obese women had postpartum complications, the most common being infection (13%) and hemorrhage (12%) (Figure 3).

Discussion
The participants in this study are young, have rural and urban origin, have a very low level of instruction, without professional activity and a modest economic level. Most women were presented complications during pregnancy process and first comes gestational diabetes. Indeed, gestational diabetes is one of the most common complications of pregnancy in obese women, which reflects a rise in maternal blood glucose that occurs during pregnancy from 26 weeks of age and disappears after childbirth. Obesity causes a decrease in insulin sensitivity which is added to the phenomenon of physiological insulin resistance in pregnant women that develops during pregnancy and increasingly. It has been found that obese women are 2.6 times more likely to develop gestational diabetes [7][8][9]. The rate of pre-eclampsy and gravid arterial hypertension was respectively 11% and 14% among participants. In fact, overweight and obese women are respectively 2.5 times and 4 times more likely to develop pregnancy-induced hypertension and which has the serious complication of pre-eclampsy, leading to a high risk of eclampsy attacks that are responsible for maternal and perinatal mortality [9][10][11]. In addition, 11.5% (N=23) of pregnant women had sleep apnea and 11% had gravid arterial hypertension. Sleep apnea syndrome and obesity have a well-established relationship.
Overweight reduces thoracic wall compliance and increases respiratory tract resistance; these repeated periods of nocturnal desaturation have a role in the genesis of pre-eclampsia and in utero growth retardation [11][12][13]. Post-term delivery is also a consequent of obesity. According to the WHO definition, an outdated term is a pregnancy that extends beyond 41 weeks of completed amenorrhea. In fact, the duration of pregnancy increases in proportion to pre-conception BMI [9,11,12]. Similarly, it was showed an increased risk of post-term delivery by grade of obesity at 1.4, 1.5, and 1.8, respectively, for moderate, severe, and morbid obesity. The cesarean delivery rate recorded in this study (38.67%) is well above the national average of 14% [14]. The increase in cesarean delivery and dystocic delivery in obese women has been reported by other authors Djrolo et al. [5], Galtier et al. [6] Deruelle [9] and Mission et al. [13].
Postpartum in overweight and obese women is also a critical period where serious complications occur. In this study, 33% of women had postpartum complications, the most prevalent were infections and hemorrhages. Indeed, several studies have shown that the most common complication of postpartum in obese women is infection (endometritis, wall infections, cesarean or episiotomy scar disruption) [11][12][13]15]. Surgical site infections are two to three times more frequent in overweight patients. These complications lead to a length of stay that increases proportionally with the BMI of patients, regardless of the mode of delivery [6]. In addition, the risk of bleeding from delivery also increases with obesity [11][12][13]15]. The incidence of other complications, such as pulmonary embolism and deep vein thrombosis occur, also increases in obese women [5][6][7]9].

Conclusion
In this study, we report a high incidence of complications in obese women during pregnancy, childbirth and post-partum. Dietary management of women of childbearing age is almost absent in Moroccan health care facilities. Overall, the dietary approach should be integrated with the provision of care at all levels of the health system by scheduling pre-conception consultations, sensitizing women during pregnancy about the complications of obesity and the management of obesity cases. Also, prenatal consultations are very important for the surveillance and early detection of a complication which can occur. These measures would reduce complications such as gestational diabetes, obstructed labor and complications in the newborn.