Received date: October 24, 2016; Accepted date: December 26, 2016; Published date: December 30, 2016
Citation: Al-Ani ZR, Al-Dulaimy WZ, Al-Dulaimy KM, Al-Haj SA, Al-Nuaimi YAR, et al. (2016) Postpartum Weight: A Guide for Calculation of the Expected Prepregnancy Weight to Study the Risk of Maternal Overweight and Obesity on Congenital Anomalies. J Obes Weight Loss Ther 6: 330. doi:10.4172/2165-7904.1000330
Copyright: © 2016 Zaid R Al-Ani, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Objectives: To study the risk of maternal overweight and obesity on congenital anomalies (CAs) using the expected prepregnancy body mass index (EPPBMI) calculated from the postpartum weight.
Methods: By deciding four difference factors, one for low, normal, overweight, and obese mothers as 60% of the pregnancy weight gain, then subtracting each factor from the corresponding postpartum weight to calculate the EPPBMI, to study the risk of overweight and obesity on CAs, applied retrospectively on mothers examined in the birth defect center of Al-Ramadi city, Iraq. For every mother delivered CA-affected baby, two mothers delivered healthy neonates were selected randomly as controls. Calculated EPPBMI of the cases compared with controls to study the risk of maternal obesity on CAs using the Odd's ratio and 95% confidence interval as a measure of the risk significance.
Results: Enrolled mothers were 184 delivered 184 CA-affected neonates, 115 male and 69 female. Mother's age was 16-44 years (mean 28.3 years), their postpartum weight was 52-108 kg (mean 74.6 kg). Both postpartum BMI and EPPBMI in cases showed higher overweight and obesity than in controls. Obesity and overweight found risk factors for studied CAs. Obesity found a risk factor for development of VSD, ASD, congenital hip dislocation, hydrocephalus, meningomyelocele, lip & palate defects, and down's syndrome, while overweight found a risk factor for ASD.
Conclusion: EPPBMI calculation from the postpartum weight is easy and will make the study of the risk of maternal obesity on CAs simple, especially in areas with poor antenatal care. Overweight and obesity found risk factors for certain CAs. Social education about the early antenatal care and control of obesity before pregnancy are important to reduce the prevalence of CAs.
Obesity; Postpartum weight; Expected prepregnancy BMI
Obesity is a major public health and economic problem. According to the WHO, obesity defined as the excessive accumulation of body fat that presents a risk factor to the health and life. The crude population measure of obesity is the body mass index (BMI) . BMI is calculated as the weight in kilograms divided by the square of the height in meters . The WHO classifies BMI into four main groups and other subgroups . The four main groups are
• BMI<18.5 kg/m2-Underweight
• BMI 18.5-24.9 kg/m2-Normal
• BMI 25-29.9 kg/m2-Overweight
• BMI ≥ 30 kg/m2-Obese
About 30-40% of the causes of obesity are genetic in origin and the remaining 60-70% is environmental as the high energy foods and sedentary lifestyle . In Iraq, the prevalence of obesity in childbearing age women is 32.1% . This prevalence is higher in the Arabic Gulf Countries as Kuwait (53%), Saudi Arabia (50.4%), and Bahrain (40.3%). In Oman, although it is one of the Gulf Countries, the prevalence of obesity is 22.3%. The prevalence in the other near countries is 25.2% in Iran, 15.2% in Lebanon, and 10.9% in Palestine. In the far Arabic countries, it is 7.1% in Libya, 13.3 in Tunisia and 18.3% in Morocco . In the United States, about one third of women aged 15 years and above was obese . Overweight and obesity in the childbearing age females compose a more public health concern . It has been shown that women with a prepregnancy overweight or obesity has a more risk for the development of maternal and child health complications , and the more she is overweight, the more she will have pregnancy complications and her baby will develop health complications such as congenital anomalies (CAs) . For the mother, obesity during pregnancy increases her incidence for gestational diabetes, hypertensive disorders, preeclampsia, thromboembolic disorders, cesarean section, and wound infections [11-16]. For the baby, maternal obesity increase his risk for the macrosomia, birth difficulties, birth injuries, perinatal death, stillbirth, preterm birth and the CAs such as the spina bifida, anencephaly, orofacial clefts, and congenital heart diseases [17-20]. The future predisposition to obesity in children will increase about 40% if one of the parents is obese and over 70% if both parents were affected . If a mother is overweight and planned to be pregnant, starting weight loss before her pregnancy can reduce her risk of pregnancy complications and complications in her neonate such as the CAs .
Congenital anomalies may start at the time of conception due to chromosomal abnormalities such as Down's syndrome, or in the embryonic stage (first eight weeks of gestation) as spina bifida, or in the early fetal life (eight to sixteenth weeks of gestation) as the eye and external genitalia anomalies . The effects of teratogens are also different according to the stages of pregnancy. In the zygotic stage and before implantation, teratogens rarely have any impact on the fetus and if they do, the tiny mass of cells is usually so completely damaged that unlikely to survive. During the embryonic stage, most of the serious and major defects are likely to occur in this period. After the embryonic stage, the teratogenic damage is usually less serious and results in minor anomalies but still some organs such as the brain, ears, eyes, teeth, and genitals can be strongly affected when exposed to teratogens during this stage .
Several potential mechanisms explain the relation of obesity with CAs. These include, the more liability of obese mothers to develop gestational diabetes that shares with obesity a similar teratogenic metabolic abnormality such as the insulin resistance and hyperglycemia. The more liability of obese mothers to the nutritional deficiencies specifically folate deficiency due to the increased metabolic requirements . The more liability for chronic hypoxia and hypercapnia which are considered fetal teratogenic factors . The obesity associated macrosomia that increase the intrinsic mechanical forces and constrains the fetus in the uterine cavity. This will lead to different malformations such as the flattened facies, craniostenosis, congenital hip dislocation, hyperextended knee joints and the club foots . Also, the ultrasound scanning during obesity is more difficult and of lower detection rates specially the soft tissue anomalies. This will result in a fewer prenatal diagnosis and less terminations of the pregnancies due to these anomalies .
To study the risk of maternal overweight and obesity on CAs, maternal BMI should be calculated during the prepregnancy period and maximum up to the first 10 weeks of pregnancy . During our study of the risk factors for development of congenital anomalies in the "Western Iraq Center for Congenital Anomalies Registry and Surveillance" (WICCARS) in Al-Ramadi city in 2010-2011 , the vast majority of examined the mothers after delivery were found not knowing their prepregnancy weight, and their first antenatal care visits were either absent or late during pregnancy. Accordingly, studying the risk of overweight and obesity on the development CAs was impossible.
The aim of this study is to use the expected maternal prepregnancy weight calculated from the recorded postpartum weight to study the risk of maternal overweight and obesity on CAs, and to study the types of the CAs according to the maternal BMI types. This is the first study that uses the EPPBMI calculated from the postpartum weight. The study was applied retrospectively on mothers examined in 2010-2011 in the WICCARS  center of Al-Ramadi Maternity and Children's Teaching Hospital (MCTH), in Al-Ramadi city, Western Iraq.
This is a retrospective hospital based study applied in Al-Ramadi MCTH, in Al-Ramadi city (the capital of Al-Anbar governorate, 550,000 populations, 110 km west to Baghdad, of urban center surrounded by a tribal suburban and rural peripheries), during the period from the 1st of February to the 1st of October 2015, to study the risk of maternal prepregnancy overweight and obesity on the development of CAs using the expected prepregnancy body mass index (EPPBMI) calculated from the recorded maternal postpartum weight, and to study the types of CAs according to the maternal BMI types. All enrolled mothers and their neonates were previously examined and monitored in the (WICCARS) of Al-Ramadi MCTH in 2010-2011  WICCARS is a hospital based center located in Al- Ramadi MCTH to study the CAs of all neonates delivered in the hospital. The center was planned to be in the future as the main center of Al-Anbar Governorate to study CAs of all neonates delivered in the Governorate (the largest governorate of Iraq, about 1/3 of the country, land area: 138,500 Km2). Birth certificates were not delivered unless both the mother and her neonate examined in the center within the 7th postpartum day or more after delivery. Data were collected from the datasheets of the center and include the mother's age, height, date of delivery, date of examination after delivery, postpartum weight at the time of examination, types of the delivery product (premature, full term, LBW), and the types of maternal illnesses during the pregnancy. Baby's data include his weight, gender, gestational age, and types of the associated structural CAs. Maternal weight and height were measured in the center after delivery using the weight and height scale type TZ120 (Yuyao Balance Instrument Factory, China) with a minimum error of 50 g for weight and 0.5 cm for height, and accordingly the BMI was calculated. Shoes, coats, external heavy clothes, hand bags or accessories were taken off before the weight measure. For the retained clothes, a 2.5 kg in winter, 2 kg in temperate months, and 1.5 kg in the summer months were subtracted from the total weight to approximate the actual body weight. For every mother with a CA-affected neonate, two age matched mothers delivered sex matched CA-free neonates were selected randomly as controls from the same group of mothers in the center. Mothers with no height and/or weight measurement, those examined after two weeks of delivery, those with stillbirth delivery, twin delivery, premature delivery, preeclampsia, pathological edema, abortion, and hyperemesis gravidarum were excluded from the study. According to the Institute of Medicine Recommendations , when a mother completes her full term pregnancy, she will gain an average gestational weight gain (GWG) as follows:
• 12.5 kg ± 4.2 SD for low BMI mothers.
• 11.6 kg ± 4.1 SD for normal BMI mothers.
• 10.5 kg ± 5.5 SD for overweight mothers.
• 9.1 kg ± 7.3 SD for obese mothers.
The average values of the pregnancy components in normal mothers at different stages of pregnancy are shown as follows: (Table 1) .
|Pregnancy component||10 weeks||20 weeks||30 weeks||40 weeks|
|Baby||5 g||300 g||1500 g||3500 g|
|Placenta||20 g||170 g||430 g||650 g|
|Amniotic fluid||30 g||350 g||750 g||800 g|
|Uterus||140 g||320 g||600 g||970 g|
|Breast||45 g||180 g||360 g||415 g|
|Blood volume||100 g||600 g||1300 g||1250 g|
|Fluid retention||100 g||500 g||800 g||1300 g|
|Body fat||210 g||1580 g||2760 g||3200 g|
|Total||650 g||4000 g||8.5 kg||12.5 kg|
Table 1: The average values of the pregnancy components in normal mothers at different stages of pregnancy.
At delivery, the mother will lose the weight of the conception products (fetus, amniotic fluid and placenta) and retain the excess weights of retained pregnancy components (breast, uterus, fat, fluid and blood volumes) which are lost gradually in the next months after delivery. The percent of the conception products lost after delivery in normal BMI pregnancy is different from one study to another. Hytten  reported the percent about 38.2% of the total GWG, UTAH Department of Health  reported the percent 36.6%, Macones in the UpToDate  reported the percent 40.8%, and in the Web MD [34,35], the percent was about 43.3% of the GWG. This variation is expected because of the different characteristics and racial origins of mothers and their pregnancy products used in these studies. The average percent of these reports is 39.7%. So, the average percent of the retained pregnancy components after delivery will be 100% - 39.73% = 60.3% approximated to 60% (the difference factor). Accordingly, the weight of the conception product (fetus, placenta and amniotic fluid) will be 40% of the GWG, and the excess weight of the retained pregnancy component (breast, uterus, fat, fluid and blood volumes) will be 60% of the GWG according to the maternal BMI types.
When the difference factors applied as 60% of GWG for low, normal, overweight, and obese BMI mothers according to the Institute of Medicine Recommendations, the types of the difference factors will be:
- Difference factor for underweight mothers = 7.5 kg ± 2.52 SD.
- Difference factor for normal weight mother = 7 kg ± 2.46 SD.
- Difference factor overweight mother = 6.3 kg ± 3.33 SD.
- Difference factor obese mother = 5.5 kg ± 4.38 SD.
After delivery, the mother will gradually lose the excess weight of the retained pregnancy components (the difference factor, the 60%) and will takes about 6 to 12 months to reach about her original weight before her pregnancy with a maximum average weight loss of 0.5 kg/ week during the first 6 weeks after delivery, then decreased gradually . Since all enrolled mothers in this study examined between 7 to 14 days after delivery, the mother will lose weight during this period from 500 g to 1000 g. The average = 750 g because:
The average postnatal weight loss for mothers examined at 7 days = 500 g
The average weight loss for mothers examined at 14 days = 1000 g.
The average weight loss at 7 to 14 days will be 1000 + 500/2 = 750 g.
So, the expected weight after delivery (after loss of the conception products) = Postnatal weight at 7 to 14 days – 750 g.
The Expected Prepregnancy Weight = Maternal weight after delivery − the corresponding difference factor according to the postpartum BMI type.
The Expected Prepregnancy BMI (EPPBMI) of cases and controls = The Expected Prepregnancy Weight (kg)/Height (m2).
The EPPBMI of the cases are compared with controls.
Baseline characteristics were assessed as potential risk factors for CAs using the odds ratio and P value using the Minitab system version 16. Data were presented as frequency and percentages with the relevant Odd's ratio and 95% confidence intervals. A P?value<0.05 was considered as statistically significant. The study was approved by the Research Scientific Committee of the College of Medicine, Al-Anbar University, Western Iraq.
The total number of mothers examined in the WICCARS center during the 2010-2011 was 5864. After exclusion of mothers with stillbirth, premature, and the twin deliveries, the number of enrolled mothers who delivered full term live birth babies were 5578. From those, the number of mothers delivered CA-affected neonates were 231. In this study, 47 (20.3%) of the mothers were exclude, and the rest 184 mothers were the study sample, delivered 184 CA-affected neonates composed of 115 males and 69 females with a m/f ratio of 1.6/1. The age of mothers was 16-44 years (mean 28.3 years), and their postpartum weight at 7-14 days after delivery was 52-108 kg (mean 74.6 kg). The parity of the studied mothers was 49 mothers with one live birth and 135 mothers with multiple live birth deliveries. The excluded 47 mothers composed of 38 mothers without weight and/or height measure, 2 mothers with preeclampsia, 3 mothers with pathological edema, and 4 mothers with incomplete or missing data.
Selected controls were 368 age matched mothers delivered 368 sex matched CA-free neonates. All controls were selected from mothers examined in the same center.
The recorded types of CAs in the affected neonates were composed of 156 (84.8%) isolated CAs and 28 (15.2%) multiple CAs. According to the severity, the number of CAs was 126 (68.4%) major and 58 (31.5%) minor anomalies. Because of the multiple CAs, the total recorded CAs were 232, exceeded the number of the affected neonates.
Table 2 shows the calculated postpartum BMI values in the cases and controls and their changing profile to the EPPBMI after subtraction of the corresponding difference factors. In the mother cases, the majority (85.7%) of recorded postpartum BMI found of overweight and obese types. After subtraction of the difference factors, the percent of overweight and obesity dropped to 72.3% as EPPBMI. This process converted 15 obese mothers to the overweight EPPBMI level, and 25 overweight mothers to the normal EPPBMI level.
|Postpartum BMI||Changes||EPPBMI||Postpartum BMI||Changes||EPPBMI|
Table 2: The changing profile of the postpartum body mass index (BMI) and expected prepregnancy BMI (EPPBMI) after subtraction of the difference factor in cases and controls.
In the control mothers, the recorded postpartum overweight and obese BMI types were found in 69.2%. After subtraction of the difference factors, the percent of overweight and obese mothers dropped down to 35.8% as EPPBMI. This process converted 38 obese mothers to the overweight EPPBMI level, 123 overweight mothers to the normal EPPBMI level, and 16 normal mothers to the low EPPBMI level which indicate the higher obesity and overweight values in both postpartum BMI and calculated EPPBMI in the cases than controls, and their distribution in the cases was toward the upper borderline of overweight and obesity EPPBMI levels, making them less liable to drop to a down-level EPPBMI after subtraction of the corresponding difference factors than in controls.
Table (3) shows the maternal variables of the studied 184 mothers. Gestational diabetes mellitus was recorded only in 2 (1.08%) of the studied mothers. Maternal ages between 20-30 years were the most common recorded age groups (58.1%). The same common records were noticed in the primary school education (52.1%), urban residence (51.6%), parity of 3 or less live births (83.1%), and mothers of unbooked antenatal care (77.2%). Smoking during pregnancy (active + passive) was recorded in 45.2% of the studied mothers, and caesarean section recorded in 60 (32.6%) of mothers. More than 78% of caesarean sections were elective in type while the rest 17.7% were of the emergency caesarean section types.
|Maternal Variables||No. (%)|
|Gender of neonate|
|≤ 20||35 (19.0)|
|High education||12 (6.52)|
|Breast feeding||113 (61.4)|
|Bottle feeding||33 (17.9)|
|Passive+active smoking||84 (45.6)|
|No smoking||100 (54.4)|
|≤ 3||153 (83.1)|
|Gestational diabetes||2 (1.08)|
Table 3: Maternal variables of the studied 184 mothers.
Table 4 shows the distribution of the recorded CAs according to the body systems and the types of EPPBMI. According to the body systems, the most recorded common CAs were the cardiovascular system anomalies, followed by genitourinary system anomalies, musculoskeletal system anomalies, and CNS system anomalies. According to the types of EPPBMI, the most common CAs associated with maternal overweight and obesity EPPBMI types were ventricular septal defects (VSD), atrial septal defects (ASD) and common AVcanal cardiac anomalies, the undescended testis, hydrocele and hypospadias genitourinary anomalies, the congenital hip dislocation, polydactyly and club-foot musculoskeletal anomalies. The CNS anomalies were the hydrocephalus, microcephaly and meningomyelocele CAs. Down's syndrome was the most common syndrome recorded in the syndromic anomalies, and hemangioma the most common in the skin anomalies. With low EPPBMI type, only one microcephaly case was recorded. The net result was 41% of the total CAs found associated with obese EPPBMI mothers, 32.3% with overweight EPPBMI mothers, 26.3% with normal weight EPPBMI mothers, and less than 1% with the underweight EPPBMI mothers.
|Congenital anomalies||EPPBMI Types|
|Common A.V. Canal||6||8.1||-||-||1||1.3||2||2.7||3||4|
|Tricuspid valve incompetence||2||2.7||-||-||1||1.3||-||-||1||1.3|
|Mitral valve regurgitation||1||1.3||-||-||-||-||-||-||1||1.3|
|Bartholin gland cyst||1||2.7||-||-||1||2.7||-||-||-||-|
|Congenital Hip Dislocation||9||28.1||-||-||1||3.1||4||12.5||4||12.5|
|Absent distal phalanges||1||3.1||-||-||-||-||1||3.1||-||-|
|Single hand creases||1||3.1||-||-||-||-||1||3.1||-||-|
|Hyperextension of hip & knee joint||2||6.2||-||-||1||3.1||-||-||1||3.1|
|Central Nervous System||30||12.9||1||3.3||6||20||8||26.6||15||50|
|Spina bifida occulta||1||3.3||-||-||-||-||1||3.3||-||-|
|Cleft palate+Cleft lip||3||15.7||-||-||1||5.2||2||10.2|
|Congenital skin nevus||1||7.6||-||-||1||7.6|
|Small palpebral fissure||1||14.2||-||-||-||-||-||-||1||14.2|
|Absent left eye||1||14.2||-||-||-||-||1||14.2||-||-|
|Low set ears||2||28.5||-||-||1||14.2||1||14.2|
|Bilateral choanal atresia||1||33.3||-||-||1||33.3||-||-||-||-|
Table 4: Distribution of congenital anomalies according to the systems and to types of expected pre-pregnancy body mass index (EPPBMI).
Table 5 shows the risk of the EPPBMI types on the development of CAs when cases compared with controls.
When obese, overweight, and low EPPBMI mothers were compared with the normal EPPBMI mothers, overweight and obesity EPPBMI found risk factors significantly associated with the development of CAs, while no relation was found between the low EPPBMI type and development of CAs.
Table 6 shows the risk of the EPPBMI types on the development of a selected most common recorded CAs when the cases compared with controls. When obese, overweight and low EPPBMI mothers were compared with normal EPPBMI mothers, obesity found a risk factor associated with the development of VSD, ASD, congenital hip dislocation, hydrocephalus, meningomyelocele, Down's syndrome, and all the cleft lip and cleft lip-cleft palate anomalies, while overweight found a risk factor for the development of the ASD cardiac anomaly only.
|EPPBMI types||Cases(184)||Controls (368)||OR (95% CI)†||P value|
|No (%)||No (% )|
|Low||1 (0.54)||18 (4.89)||0.242 (0.24-1.85)||0.0683|
|Normal||50 (27.1)||218 (59.2)||-||-|
|Overweight||55 (29.9)||86 (23.3)||2.79 (1.76-4.40)||0.0001|
|Obese||78 (42.4)||46 (12.5)||7.39 (4.54-11.9)||0.0001|
†OR: odd's ratio
Table 5: Risk of expected prepregnancy body mass index (EPPBMI) types on congenital abnormalities.
|Systems and its CAs||Types of EPPBMI|
|Cardiovascular||cases||cases||OR (95% CI)†||cases||OR (95% CI)|
|VSD||27||5||-||-||5||2.53 (0.71-8.97)||17||16.1 (5.65-45.89)*|
|ASD||25||5||-||-||10||5.06 (1.68-15.2)*||10||9.47 (3.09-29.03)*|
|Undescended testis||15||7||-||-||5||1.81 (0.55-5.86)||3||2.03 (0.50-8.14)|
|Hydrocele||7||2||-||-||3||3.80 (0.62-23.1)||2||4.73 (0.65-34.5)|
|Hypospadias||8||4||-||-||1||0.63 (0.63-0.06)||3||3.55 (0.76-16.4)|
|Cong. Hip dislocation||9||1||-||-||4||7.60 (0.78-74.1)||4||14.2 (1.44-139.7)*|
|Club foot||3||1||-||-||1||2.53 (0.56-40.9)||1||4.73 (0.291-77.1)|
|Central nervous system|
|Hydrocephalus||9||2||-||-||3||3.80 (0.62-23.1)||4||9.74 (1.68-53.3)*|
|Microcephaly||6||1||-||-||3||7.60 (0.78-74.1)||2||9.47 (0.84-106.7)|
|Cleft lip+cleft palate||3||-||1||0.333||2||0.666|
|Down's syndrome||9||3||-||-||-||-||6||9.47 (2.28-39.2)*|
†OR: odd's ratio; CI: confidence interval; *P value: significant
Table 6: Risk of expected prepregnancy body mass index (EPPBMI) types on selected congenital anomalies (CAs) between cases and control.
Obesity present at conception is certainly found associated with the development of some CAs as the spina bifida and congenital heart defects [20,36]. Obesity is a modifiable risk factor ideally addressed the prepregnancy period and between the pregnancies [37,38]. A high BMI before the start of pregnancy is a greater determinant of the healthy outcomes for the woman and her newborn than the increased GWG. The higher the pre-pregnancy BMI, the greater will be the associated risk and complications for the woman and her neonate [37,39]. Obesity before conception is associated with increased rate of congenital defects and the pregnancy complications [37,40]. The in utero environment may program the fetus for the elevated risk of the future obesity . Attempts should be made to prevent the maternal obesity prior to the pregnancy . One of the methods to prevent complications is through the prepregnancy health care. Antenatal care started when the mother become pregnant while obesity present before the first pregnancy or between the pregnancies. The WHO stated that a gap exists in the continuum of the maternal care . Accordingly, since 2012, the WHO adopted the prepregnancy care program for the sake of the baby and mother health . The pre-pregnancy care can increase the health and well-being of women and couples and improve the subsequent pregnancy and child health outcomes before the mother start her pregnancy . If a mother is obese, she must encourage weight reduction programs including the proper diet, physical activity and behavior modification before attempting the first pregnancy and between the subsequent pregnancies . Obese mother must start the antenatal care booking as soon as she feels pregnant . A schedule of antenatal care visit frequency must be put according to her level of obesity with more frequent visits in the 3rd trimester. In each antenatal care visit, the GWG must be monitored. Maternal GWG must be limited according to her prepregnancy BMI to avoid the excessive fat gain during pregnancy. Folic acid 5 mg/day must be supplanted one month before pregnancy and continue to the end of the 1st trimester to prevent the CAs in neonates . Vitamin D 10 microgram/day is supplemented during the pregnancy and breast feeding because vitamin D level in obese mothers is inversely related with the degree of obesity . If the mothers is of grade II obesity (BMI above 40), she must be monitored more frequently for the hypertension, gestational diabetes, and preeclampsia. Also coordination with the gynecologist and anesthetist must be done if the mother has excessive obesity since overweight and obese mothers have a higher risk for delivery complications and caesarean section .
To study of the relation of the maternal obesity with CAs, nine months follow up of mothers is required from conception till delivery. The BMI of the mother must be checked in the prepregnancy period or early during pregnancy, and after delivery, the neonate must be checked for the presence or absence of CAs. In areas with availability of the health provider, prepregnancy health care, family medicine system, and high social health education, mothers usually started their antenatal care early and the access to mothers early in the prepregnancy period and the follow up of their pregnancy until delivery will be more easy. Also the access to a tailored previous medical records including the prepregnancy or early pregnancy weight, height, and BMI will be more simple, and a large sample of mothers can be collected in short period for a prospective, retrospective [13,15,18,19,26,28] or meta-analysis studies [9,12,14,20,23]. In areas with poor social health education, no prepregnancy care system, and no family doctor system, the first antenatal care visits may be late or absent, and the mother may be lost during the 9 months of the pregnancy follow up. In these conditions, collection of adequate sample of mothers for prospective studies will take a long period, and the retrospective or meta-analysis studies will be not possible because of the poor or absence of the electronic medical records.
During the review of the literatures of this study, the majority of the studies that determine the relation of maternal obesity with CAs were either retrospective or meta-analysis studies depended on data analysis of previous studies, or collection of thousands of mother cases in the prepregnancy period or early after conception from the previous medical records was easier. Accordingly, the method of the present study is not required in areas with easy access to mothers early during the pregnancy, in areas with high early antenatal care rate, areas with tailored digital medical records and with high socio-maternal health education.
During the 1970s and 1980s, the Iraqi health care system and the medical education were the best in the region. The country boasted a free health care facility in 172 hospitals and 1200 primary health care clinics. Also the Iraqi medical graduates were often sent to UK and Germany to receive their specialty training and health certification . As a result of the chronic different wars, internal conflicts, international sanctions, and political instability during the last few decades, the Iraqi health care system had been seriously affected [45,46] These successive events resulted in a substantial fall in the major health indices and left the country complaining of a crippled health system struggling to meet the population needs [46-48]. The primary health care system and the maternity care services in particular did not escape these damaging effects and continue to suffer from problems common throughout the health care systems [46,49]. The antenatal care services also suffer the same problems of the primary health care system. The primary, secondary and the tertiary health services had never developed in Iraq over the recent years. One of the important health services that were ignored in Iraq is the electronic health record . The country is still deficient of the electronic medical records, and the old archived case sheets and papers for data storage is still the only method used in all hospitals and health centers of the country.
As a part of Iraq, Al-Anbar governorate was seriously affected by these health deteriorations. In the antenatal care systems, there is no available systematic and tailored medical record, and no record of the weekly number of mothers visiting the health centers. The prospective follow up of mothers for 9 months until delivery is more difficult in these conditions. As a trial to check the early antenatal care visit trend in two of the health centers of the governorate, we studied the antenatal visit cards of mothers visiting the health centers in one month of 2014. We found the average number of mothers who started the first visit antenatal care was 24% at the 1st trimester, 64% at the 2nd trimester, and 12% at the 3rd trimester. An interview with two doctors working in the health centers explained the causes due to the absence of the gynecology specialist, ultrasound specialist, and family medicine doctors in the health centers of the governorate in spite of equipping of the centers by the Ministry of Health with most of appliances, equipment, and drugs in the last 4 years. Causes related to the mothers include the tendency of most mothers to start their first antenatal care visit in the second trimester for taking the tetanus vaccine immunization, the preference of some mothers to hide and not expose their early pregnancy, the use of the cheap pregnancy test-kit for home diagnosis of pregnancy, the preference of most women for the private gynecology clinic follow up, and the scorning idea of some mothers about the health centers as they are for poor and low standard peoples. Accordingly, the number of the booked antenatal care mothers will be low, and the number of mothers who can be seen near conception or during the first weeks of pregnancy is limited in these conditions, and collection of adequate sample of mothers for the study is difficult and takes a long time. Maternal postpartum weight is easier to access in these conditions and when a prospective multicenter study is used in high delivery rate hospitals or health centers, a large number of mothers can be collected after delivery in short period, and a uniform perfect well-adjusted postpartum weight, height and EPPBMI can be done and will result in a rapid, easy, and practical method.
In this study, the calculation of the EPPBMI involve in addition to the excessive weight of the normal components of pregnancy, the weight of the fat gain secondary to the excessive food intake during the pregnancy that may give a false high overestimated results in some of the calculated EPPBMI. Food intake and fat gain during pregnancy must be limited according to the prepregnancy BMI to avoid the excessive fat gain and obesity during pregnancy . Women who start their prepregnancy weight as underweight should gain more total pregnancy weight than obese mothers and their total weight gain must be 13-18 kg. That start at normal weight should gain 11-16 kg, the overweight mothers should gain 7-11 kg, and obese mothers should gain 5-9 kg during their full term singleton pregnancy . A study in the United States  involving 44000 pregnant mothers in 18 states showed that increased appetite and excessive fat gain during pregnancy with increased gestational weight gain more than recommended occurred mostly in those who were already overweight or obese before conception than in those who were underweight or normal mothers. This may reduce the overestimation effect of this study since the low and normal BMI mothers are less liable for excessive weight gain and will be less overestimated during the calculation of the EPPBMI, and when an overweight mother had additional fat gain and estimated as obese EPPBMI, or an obese mother had additional fat gain and estimated as an excessive obesity EPPBMI, this will minimally affect the net result since both these types are known risk factors for CAs.
In this study, the difference factors calculated as 60% of the average pregnancy weight gain represent the excess weights of the uterus, breast, fat, fluid and blood volumes during pregnancy that is retained after delivery. The calculated percent of the conception products and accordingly the percent of the retained pregnancy components after delivery may be different according to the maternal BMI types. In spite of the extensive review literatures search, we couldn't find any record of neither the percent of the conception product nor the percent of the excess weight of retained pregnancy components after delivery according to the maternal BMI types. Normally, a normal BMI mother gains an average of 0.5-2.0 kg weight during her 1st trimester  if the excess fat gain due to the excessive food intake is excluded. Studies that depended the maternal BMI measure at 10 weeks of pregnancy or on the self-record  of the pre-pregnancy weight and BMI may carry a weight differences possibly not less than what we resulted in this study. The unmeasured excess body fat secondary to the excessive food intake during the first 10 weeks of pregnancy, or the use of the nonstandardized or different weighing scales or the poor maternal weighing-experience that will give different results than the actual weights. The 60% which is depended for all difference factor types in this study will be changed soon if we find any study that prove a different percent than what we used in this study.
In this study, the prevalence of the overweight and obesity in the controls which represent the normal population of this study was 35.8%. This was approximate to the national Iraqi percent were the percent of is 36.3% for overweight and 33.1% for obese females, and to the international percent (36.9%), but lower than the United States which was 61.9% of females . The poor activity and athletic habits, the genetic tendency, the tendency for the increased parity, and the high calorie diets in most of the Iraqi meals will make those women more prone for the obesity and gestational complications than the other childbearing age groups.
The present study recorded overweight and obesity a significant risk factor for the recorded CAs. The same results was recorded in Florida , Spain , Cuba  and the U.K studies , while other study in United States  showed maternal obesity not associated with the development of CAs unless the obesity is associated with gestational diabetes mellitus. The unknown factors, the increased body requirement for folate and vitamin D, the increased liability for gestational diabetes and the mechanical pressure forces during the fetal life will make obese mothers more prone for CAs than the normal BMI mothers. Spina bifida, congenital heart diseases and congenital diaphragmatic hernia are well known associated with maternal obesity while gastroschisis more associated with low BMI mothers.
Regarding the risk of obesity according to the system involved, the study showed maternal obesity a risk factor for the development of certain cardiac anomalies as the VSD and ASD. The same result was noticed by a study in Sweden . In United States, Brite et al.  recorded obesity a risk factor for cono-truncal defect in addition to the ASD and VSD anomalies, while in Iran , no relation was recorded between high BMI and the congenital heart defects. This variation may be related to the different racial, genetic, and environmental causes and to the sample size and type of the study. Hospital based study usually gives more incidence of congenital heart diseases than population based studies.
Genitourinary system anomalies was the second recorded CAs following the cardiovascular anomalies, and the most common recorded anomalies were the hypospadias, undescended testis and the hydrocele. The relation of the maternal obesity with the development of genitourinary anomalies explained by the altered maternal hormones, blood sugar metabolism, and the nutritional deficiencies associated with obesity during the pregnancy . Although these three genitourinary anomalies were more recorded in the obese mothers, obesity found not a risk factor for the development of these anomalies. The same result was recorded by Adams et al in the United States . In Qatar, Abbas et al.  recorded maternal obesity not a risk factor for hypospadias.
Obesity during pregnancy found a risk factor for the development of congenital Hip dislocation. Saxena et al.  recorded obesity a risk factor for both congenital hip dislocation and club foot, while Werler et al.  recorded obesity is a risk factor for club foot. The obesityassociated macrosomia and the gestational diabetes mellitus-associated macrosomia will increase the constrictive mechanical forces inside the uterine cavity and explain the development of these skeletal CAs in obese mothers .
Rasmussen et al.  reported maternal obesity a risk factor for most of the neural tube defects. Block et al.  reported maternal obesity a risk factor for hydrocephalus. In this study, maternal obesity found a risk factor for both hydrocephalus and the meningomyelocele CNS anomalies. Hydrocephalus as the most common CNS anomaly associated with neural tube defects was also recorded in 2010 in the same hospital of this study (Al-Ramadi MCTH) .
This study recorded all cases of cleft lip and cleft lip+cleft palate produced by overweight and obese mothers. This was consistent with the results recorded by Blanco in Chile  and Cedergren in Sweden . Also, obesity found a risk factor for Down's syndrome. This was consistent with the result noticed by Hildebrand et al in Sweden .
Exclusion of 47 (23.3%) mothers with full term delivery, all mothers with premature, still birth and twin deliveries from the study caused exclusion of a sample of different BMI types of mothers with their CAaffected neonates that would affect the study of both the BMI types in the mothers and the CAs types in the neonates.
The EPPBMI is an easy and good tool for studying the risk of maternal obesity on CAs. Calculation of the EPPBMI from the postpartum weight is simple and practical and can be used in both the retrospective and prospective studies.
Overweight and obesity type BMI were recorded in the majority of postpartum BMI and calculated EPPBMI in mothers delivered CAaffected neonates than in controls.
Maternal overweight and obesity were found risk factors for the development of the studied CAs.
The poor facilities in the health centers and low maternal and social health education made the first visit antenatal care late with more preference for private clinic pregnancy follow up and the access to mothers in the prepregnancy stage not easy in Al-Anbar governorate and possibly in the other Iraqi governorates, and accordingly the study of the risk of obesity on CAs will become more easy if we use the method of this study.
Mothers in Al-Ramadi city were not aware about the importance of the early antenatal care visit for their pregnancy and neonate's health.
• Social education is recommended to alert people about the relation of maternal obesity with CAs using social media, TV, magazines or group discussion with mothers in health centers about the importance of the prepregnancy weight measure before conception and the early antenatal care visit for the general checkup and the BMI measurement.
• Overweight and obese mothers must apply a nutritional, activity and behavioral changes to reduce their weights early before the first pregnancy and between pregnancies, and must limit their gestational weight gain according to their prepregnancy BMI to prevent excessive fat gain during the pregnancy and the obesity between pregnancies.
• The application of the prepregnancy health care system with the antenatal care system will prepare the mother's physical, nutritional, weight reduction, health condition and disease-control before the start of conception to reduce the risk and complications of obesity on the mother and her outcome.
• To prove the accuracy of this study method, another study is required to follow up the gestational weight gain of four groups of mothers according to their BMI type (low, normal, overweight and high BMI type) from conception till delivery and calculate the GWG, the conception product percent, and the difference factors according to the BMI types. Our method will be accurate if the calculated difference factors were found equal or near to 60% of the GWG according to the maternal BMI types.