Counseling and Behavioral Interventions for Healthy Weight and Weight Gain in Pregnancy: Evidence Report and Systematic Review for the US Preventive Services Task Force | Guidelines | JAMA | JAMA Network
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Figure 1.  Analytic Framework: Counseling and Behavioral Interventions for Healthy Weight and Weight Gain in Pregnancy
Analytic Framework: Counseling and Behavioral Interventions for Healthy Weight and Weight Gain in Pregnancy

Evidence reviews for the US Preventive Services Task Force (USPSTF) use an analytic framework to visually display the key questions that the review will address to allow the USPSTF to evaluate the effectiveness and safety of a preventive service. The questions are depicted by linkages that relate interventions and outcomes. A dashed line indicates a health outcome that immediately follows an intermediate outcome. For additional information see the USPSTF Procedure Manual.16 BMI indicates body mass index; GWG, gestational weight gain.

Figure 2.  Literature Search Flow Diagram: Counseling and Behavioral Interventions for Healthy Weight and Weight Gain in Pregnancy
Literature Search Flow Diagram: Counseling and Behavioral Interventions for Healthy Weight and Weight Gain in Pregnancy

Targeted searches for the contextual questions are not included in diagram. HDI indicates Human Development Index; KQ, key question.

aSome included publications are counted in multiple sections.

Figure 3.  Healthy Weight and Weight Gain During Pregnancy Meta-analysis of Trials: Mean Gestational Weight Gain
Healthy Weight and Weight Gain During Pregnancy Meta-analysis of Trials: Mean Gestational Weight Gain

Dashed line indicates the overall effect. NR indicates not reported; PP, postpartum.

aAdjusted mean difference.

Table 1.  Summary of Pooled Findings: Maternal Health Outcomes (Key Question 1)
Summary of Pooled Findings: Maternal Health Outcomes (Key Question 1)
Table 2.  Summary of Pooled Findings: Infant Health Outcomes (Key Question 1)
Summary of Pooled Findings: Infant Health Outcomes (Key Question 1)
Table 3.  Summary of Pooled Findings: Weight Outcomes (Key Question 2)
Summary of Pooled Findings: Weight Outcomes (Key Question 2)
Table 4.  Summary of Evidence
Summary of Evidence
Supplement.

eMethods 1. Literature Search Strategies

eMethods 2. Quality Assessment Criteria

eTable 1. Healthy Weight and Weight Gain During Pregnancy Interventions: Eligibility Criteria

eTable 2. Healthy Weight and Weight Gain During Pregnancy Interventions: Study and Population Characteristics

eTable 3. Healthy Weight and Weight Gain During Pregnancy Interventions: Intervention Characteristics

eTable 4. Healthy Weight and Weight Gain During Pregnancy Interventions: Outcomes and Harms

eTable 5. Healthy Weight and Weight Gain During Pregnancy: Quality Assessment of Randomized Clinical Trials

eTable 6. Healthy Weight and Weight Gain During Pregnancy: Quality Assessment of Controlled Intervention Studies

eTable 7. Behavioral and Counseling Intervention Implementation Table: Summary and Examples of Included Interventions for Healthy Weight and Weight Gain During Pregnancy

eFigure 1. Healthy Weight and Weight Gain During Pregnancy Meta-analysis of Trials: Gestational Diabetes Mellitus

eFigure 2. Healthy Weight and Weight Gain During Pregnancy Meta-analysis of Trials: Gestational Hypertension

eFigure 3. Healthy Weight and Weight Gain During Pregnancy Meta-analysis of Trials: Cesarean Delivery

eFigure 4. Healthy Weight and Weight Gain During Pregnancy Meta-analysis of Trials: Preeclampsia

eFigure 5. Healthy Weight and Weight Gain During Pregnancy Meta-analysis of Trials: Macrosomia

eFigure 6. Healthy Weight and Weight Gain During Pregnancy Meta-analysis of Trials: Large for Gestational Age

eFigure 7. Healthy Weight and Weight Gain During Pregnancy Meta-analysis of Trials: Preterm Birth

eFigure 8. Healthy Weight and Weight Gain During Pregnancy Meta-analysis of Trials: Exceeding NAM Recommendations for Gestational Weight Gain

eFigure 9. Healthy Weight and Weight Gain During Pregnancy Meta-analysis of Trials: Adherence to NAM Recommendations for Gestational Weight Gain

eFigure 10. Healthy Weight and Weight Gain During Pregnancy Meta-analysis of Trials: Postpartum Weight Retention

eReferences

US Preventive Services Task Force
Evidence Report
May 25, 2021

Counseling and Behavioral Interventions for Healthy Weight and Weight Gain in Pregnancy: Evidence Report and Systematic Review for the US Preventive Services Task Force

Author Affiliations
  • 1Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
  • 2Department of Family Medicine, Oregon Health & Science University, Portland
  • 3Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
  • 4School of Public Health, Oregon Health & Science University–Portland State University
  • 5Kaiser Permanente, Center for Health Research, Portland, Oregon
JAMA. 2021;325(20):2094-2109. doi:10.1001/jama.2021.4230
Abstract

Importance  Counseling and active behavioral interventions to limit excess gestational weight gain (GWG) during pregnancy may improve health outcomes for women and infants. The 2009 National Academy of Medicine (NAM; formerly the Institute of Medicine) recommendations for healthy GWG vary according to prepregnancy weight category.

Objective  To review and synthesize the evidence on benefits and harms of behavioral interventions to promote healthy weight gain during pregnancy to inform the US Preventive Services Task Force recommendation.

Data Sources  Ovid MEDLINE and the Cochrane Library to March 2020, with surveillance through February 2021.

Study Selection  Randomized clinical trials and nonrandomized controlled intervention studies focused on diet, exercise, and/or behavioral counseling interventions on GWG.

Data Extraction and Synthesis  Independent data abstraction and study quality rating with dual review.

Main Outcomes and Measures  Gestational weight–related outcomes; maternal and infant morbidity and mortality; harms.

Results  Sixty-eight studies (N = 25 789) were included. Sixty-seven studies evaluated interventions during pregnancy, and 1 evaluated an intervention prior to pregnancy. GWG interventions were associated with reductions in risk of gestational diabetes (43 trials, n = 19 752; relative risk [RR], 0.87 [95% CI, 0.79 to 0.95]; absolute risk difference [ARD], −1.6%) and emergency cesarean delivery (14 trials, n = 7520; RR, 0.85 [95% CI, 0.74 to 0.96]; ARD, −2.4%). There was no significant association between GWG interventions and risk of gestational hypertension, cesarean delivery, or preeclampsia. GWG interventions were associated with decreased risk of macrosomia (25 trials, n = 13 990; RR, 0.77 [95% CI, 0.65 to 0.92]; ARD, −1.9%) and large for gestational age (26 trials, n = 13 000; RR, 0.89 [95% CI, 0.80 to 0.99]; ARD, −1.3%) but were not associated with preterm birth. Intervention participants experienced reduced weight gain across all prepregnancy weight categories (55 trials, n = 20 090; pooled mean difference, −1.02 kg [95% CI, −1.30 to −0.75]) and demonstrated lower likelihood of GWG in excess of NAM recommendations (39 trials, n = 14 271; RR, 0.83 [95% CI, 0.77 to 0.89]; ARD, −7.6%). GWG interventions were associated with reduced postpartum weight retention at 12 months (10 trials, n = 3957; mean difference, −0.63 kg [95% CI, −1.44 to −0.01]). Data on harms were limited.

Conclusions and Relevance  Counseling and active behavioral interventions to limit GWG were associated with decreased risk of gestational diabetes, emergency cesarean delivery, macrosomia, and large for gestational age. GWG interventions were also associated with modest reductions in mean GWG and decreased likelihood of exceeding NAM recommendations for GWG.

Introduction

The prevalence of overweight and obesity is increasing among women of childbearing age and pregnant women in the US, similar to trends observed in nonpregnant populations. Data suggest that obesity rates during pregnancy in the US increased from 13% in 1993 to 24% in 2015, and in the same year, nearly half of all women entered pregnancy with a body mass index (BMI) category of overweight (24%) or obese (24%).1,2

Gestational weight gain is usually defined as change in weight measured before pregnancy (prepregnancy) or during the first trimester to weight measured at the end of pregnancy (eg, prior to delivery). Prepregnancy BMI is independently associated with many adverse pregnancy outcomes. Many observational studies report strong associations between elevated prepregnancy BMI and adverse pregnancy outcomes.3-11 In 2009, the National Academy of Medicine (NAM; formerly the Institute of Medicine) recommended that women begin pregnancy with a normal BMI and made recommendations for healthy gestational weight gain (GWG), which varied according to prepregnancy weight category (25-35 lb for normal weight, or BMI 18.5-24.9 [calculated as weight in kilograms divided by height in meters squared]; 15-25 lb for overweight, or BMI 25.0-29.9; and 11-20 lb for obese, or BMI ≥30.0).12 Approaches to achieving recommended GWG include preconception counseling and weight loss for women with overweight or obesity; counseling about healthy weight gain during pregnancy; adherence to NAM recommendations for GWG; and/or providing women at risk of excess GWG with lifestyle interventions.13 Guidelines also note that abnormally high or low BMI and excessive GWG is associated with pregnancy complications. In response to NAM and other recommendations on GWG, there has been a proliferation of randomized clinical trials on the effect of interventions on GWG published in the last decade.14,15

The US Preventive Services Task Force (USPSTF) has not previously made a recommendation on healthy weight gain during pregnancy. This review synthesizes current evidence to inform a USPSTF recommendation on this topic.

Methods
Scope of the Review

This review addressed 3 key questions (KQs) (Figure 1) examining the effectiveness of counseling and active behavioral interventions to promote healthy weight gain during pregnancy on health-related outcomes (KQ1), weight-related outcomes (KQ2); and potential harms of interventions (KQ3). Full methods, including data analysis methods, are available in the full evidence report.17

Data Sources and Searches

Searches of Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews through February 2021 (eMethods 1 in the Supplement). Reference list review of relevant systematic reviews supplemented the searches. Ongoing surveillance was conducted to identify major studies published since March 2020 that may affect the conclusions or understanding of the evidence and related USPSTF recommendation. The last surveillance, conducted on February 5, 2021, identified no additional studies. All searches were limited to articles published in English.

Study Selection

Two investigators independently reviewed titles, abstracts, and full-text articles using predefined eligibility criteria (eTable 1 in the Supplement). Populations included adolescent and adult women who were pregnant or planning a pregnancy, with normal weight (BMI of 18.5-24.9), overweight (BMI of 25-29.9) or obesity (BMI ≥30), based on prepregnancy weight categories as defined by the World Health Organization. Women with low prepregnancy BMI (underweight) were outside the scope of this review. Studies of interventions vs controls (eg, usual care, attention control, minimal intervention) were included (eTable 7 in the Supplement). Interventions were categorized as active (consisting of a structured, physical element that could include a counseling component [eg, supervised exercise programs, prescribed exercise or dietary programs, or intensive weight management] or counseling only. Intervention intensity was categorized as low (<2 contacts during the intervention period), moderate (3-11 contacts), or high (≥12 contacts). Outcomes were classified as weight-related intermediate outcomes (GWG, exceeding or adhering to NAM GWG recommendations, and postpartum weight loss or retention) or health outcomes (maternal morbidity or mortality, infant morbidity or mortality). Harms were anxiety, depression, maternal musculoskeletal injuries, stigma, and those related to insufficient weight gain, including infants small for gestational age. Randomized clinical trials (RCTs) and nonrandomized controlled intervention studies were considered for harms; only RCTs were eligible for analysis in all other outcomes.

Data Abstraction and Quality Rating

One investigator abstracted details about each study’s design, patient population, setting, interventions, analysis, follow-up, and results. A second investigator reviewed abstracted data for accuracy. Two investigators independently assessed the quality of each study as good, fair, or poor using predefined criteria developed by the USPSTF (eMethods 2 in the Supplement).16 Discrepancies were resolved through consensus. In accordance with the USPSTF Procedure Manual, poor-quality studies with critical methodological limitations were excluded.16

Data Synthesis

Data were synthesized separately for each KQ by outcome. Only RCTs were considered for meta-analysis. Nonrandomized controlled intervention studies were not pooled; these studies did not affect the findings that are described in the full report. For both continuous and dichotomous outcomes, random-effects meta-analyses were conducted using the profile likelihood method using Stata version 14 (StataCorp).

For continuous data, meta-analysis of RCTs was conducted to combine the mean difference between the intervention and the control groups. For mean GWG, the mean difference adjusted for baseline characteristics was used in the meta-analysis when available; otherwise, the mean difference in weight change from baseline to follow-up was used. Because imbalance in baseline weight was generally not observed, sensitivity analysis was not conducted using the difference in follow-up weights. If necessary, mean weight change was calculated based on reported baseline and follow-up weights; when not reported, the correlation between baseline and follow-up weights was assumed to be the average correlation calculated from studies that reported this information. Missing standard deviations were imputed, if necessary, by assuming the same coefficient of variation at baseline and follow-up; the standard deviations at baseline and follow-up were similar in studies that reported both. For dichotomous outcomes with at least 5 trials, sufficient sample size, and comparable outcomes, risk ratios were combined across eligible studies.

Stratified analyses were conducted when sufficient data were available on BMI category (normal, overweight, obese, overweight or obese combined, or mixed BMI populations), GWG assessment time point (28 weeks, 34-36 weeks, 36 weeks up to delivery, and at delivery), intervention type (counseling-only or active), intervention intensity (low, moderate, or high), and study quality (good or fair). Statistical heterogeneity was assessed with the Cochran Q-test and the I2 statistic to detect the proportion of total variability in point estimates.18 The P value for subgroup interaction was calculated to test for subgroup differences. Interactions between interventions and sociodemographic characteristics could not be assessed because of sparse data. Results were considered statistically significant if the P value was less than .05, based on 2-sided testing.

Results

A total of 8511 unique citations and 845 full-text articles were reviewed. Across all KQs, 64 RCTs (N = 24 829)19-82 and 4 nonrandomized controlled intervention studies (N = 960)83-86 met criteria for this systematic review (Figure 2).

Across all studies, sample sizes ranged from 50 to 2261 (N = 25 789; median n = 230). Mean sample ages ranged from 18.6 years to 33.8 years (median, 30.4 [SD, 2.8] years), with study eligibility criteria ranging from 14 to 49 years (eTable 2 in the Supplement). Twenty-eight of 68 included studies (41%) enrolled more than 20% of patients from diverse backgrounds, including those who were socioeconomically disadvantaged, racial or ethnic minorities, rural populations, or others defined by the National Institute on Minority Health and Health Disparities as populations adversely affected by disparities.87 There were no studies exclusively of pregnant adolescents or women with advanced maternal age. Studies enrolled women in 3 prepregnancy BMI categories: mixed (all BMI categories), overweight and obesity only, and obesity only.

All studies evaluated pregnancy interventions except for 1 study of a prepregnancy intervention; 1 study included a preconception component.70,88 The majority of interventions were counseling-only (45 studies),20-24,31-36,38-40,46-48,51-58,60,62,64-70,74-79,81,82,84-86,89-99 and were rated as moderate-intensity (23 studies)20,22,31,33,38,39,46,47,51-54,57,58,62,69,70,74-76,82,84,85,89,91,93-96 or high-intensity (34 studies)19,21,25-30,34,37,40-45,48-50,56,59,61,63,66,67,71-73,77-81,83,86,90,92,98-105 (eTable 3 in the Supplement). The remaining 22 studies19,25-30,37,41-45,49,50,59,61,63,71-73,80,83,100-105 used active interventions (eTable 3 in the Supplement).

The duration of follow-up ranged from 14 weeks to 12 months postpartum; the majority (77%) of studies enrolled pregnant women early in their second trimester and followed them up until at least 36 weeks’ gestation (eTable 4 in the Supplement). Fifteen RCTs and 1 nonrandomized controlled intervention study were rated good-quality, and 49 RCTs and 3 nonrandomized controlled intervention studies were rated fair-quality (eTables 5 and 6 in the Supplement). Given the nature of the interventions and comparisons, many participants and clinicians could not be blinded. Methodological limitations included unclear reporting of randomization and allocation concealment (eMethods 2 in the Supplement).

Benefits for Health Outcomes

Key Question 1a. Do interventions to limit excess gestational weight gain improve health outcomes among pregnant women and their infants?

Key Question 1b. Do interventions to reduce prepregnancy weight in women who are overweight or obese improve health outcomes among women who become pregnant and their infants?

Key Question 1c. Does the effectiveness of these interventions differ by age, race/ethnicity, socioeconomic status, parity, smoking status, or BMI category?

Maternal Health Outcomes
Gestational Diabetes

Forty-three trials (n = 19 752) of counseling-only and active interventions vs controls reported on gestational diabetes (Table 1; eFigure 1 in the Supplement).20,24,26,28-34,36-39,41,44,46,48-53,55-60,62-65,67,69-74,78-80,82 Gestational diabetes criteria varied among studies and included criteria based on country-specific guidelines (15 trials)29,31,39,44,49-51,53,55,59,65,67,72,80,82; International Association of Diabetes and Pregnancy Study Groups criteria using the 1-step approach to diagnosis with a 75-g glucose load (18 trials)20,24,30,33,34,37,38,41,46,52,56,60,63,69,70,73,74,78; and review of medical records (8 trials).28,36,57,58,62,64,71,79 Two trials used unclear criteria to define gestational diabetes.26,32

Gestational weight gain interventions were associated with decreased risk of gestational diabetes vs control (43 trials; relative risk [RR], 0.87 [95% CI, 0.79 to 0.95]; I2 = 16.4%; absolute risk difference [ARD], −1.6% [95% CI, −2.5% to −0.7%]) (Table 1; eFigure 1 in the Supplement). In stratified analyses, there were no statistically significant interactions between effects of GWG interventions on likelihood of gestational diabetes and BMI category, intervention type, or intensity.

Gestational Hypertension

Twenty-eight RCTs (n = 14 875) reported rates of gestational hypertension (Table 1; eFigure 2 in the Supplement).24,28,31-34,38,39,41,51,52,55-58,60,62-64,67,69-71,73,77,79,80,82 Gestational hypertension was defined as persistent or repeated measures of blood pressure greater than or equal to 140/90 mm Hg after 20 weeks’ gestation (a definition generally consistent with the US guideline).106

Gestational weight gain interventions were not associated with reduced likelihood of gestational hypertension compared with controls (28 trials; RR, 0.87 [95% CI, 0.70 to 1.04]; I2 = 32.5%; ARD, −0.8% [95% CI, −1.9% to 0.2%]) (Table 1; eFigure 2 in the Supplement). However, stratified analysis showed statistically significant interactions between effects of GWG interventions on risk of gestational hypertension and intervention type and intensity (P<.001 for interactions) but not BMI category. There were statistically significant effects in the active (7 trials; RR, 0.60 [95% CI, 0.41 to 0.82]; I2 = 0%; P < .001) and high-intensity (12 trials; RR, 0.69 [95% CI, 0.50 to 0.91]; I2 = 23.5%; P = .006) intervention subgroups.

Cesarean Delivery

Forty-six RCTs (n = 19 573) reported effects of GWG interventions on rates of cesarean delivery (Table 1; eFigure 3 in the Supplement).20,22-24,26,28-34,36-40,44,49-52,55-59,61-65,67,69,71-73,75,77-80,82,100 Thirty-four trials20,22,26,28-30,33,34,36,38-41,44,49-52,56-59,61-65,67,69,71,73,78,79,82 reported on the outcome of cesarean delivery not specified as emergency or elective (n = 15 908); 12 trials24,31,32,37,44,52,55,72,75,77,80 specified elective cesarean delivery (n = 6222); and 14 trials24,31,32,37,38,44,52,55,56,67,72,75,77,80 reported emergency cesarean delivery (n = 7520), though only 1 trial78 reported indications for emergency cesarean delivery (eTable 4 in the Supplement).

Gestational weight gain interventions were not associated with decreased likelihood of cesarean delivery (not specified as emergency or elective) vs controls (34 trials; RR, 0.98 [95% CI, 0.91 to 1.04]; I2 = 10.8%; ARD, −0.7% [95% CI, −2.4% to 0.8%]) (Table 1; eFigure 3 in the Supplement). However, GWG interventions were associated with reduced risk of emergency cesarean delivery (14 trials; RR, 0.85 [95% CI, 0.74 to 0.96]; I2 = 0%; ARD, −2.4% [95% CI, −4.2% to −0.3%]) (Table 1). A separate analysis was not conducted for elective cesarean delivery alone because of lack of reporting on indication. In stratified analyses, there were no statistically significant interactions between associations of GWG interventions with likelihood of cesarean delivery and BMI category, intervention type, or intensity.

Preeclampsia

Twenty-seven RCTs (n = 17 538) reported effects of GWG interventions on rates of preeclampsia (Table 1; eFigure 4 in the Supplement).20,24,28,31,36,38,39,44,51-53,55,57,58,62-64,67,69,70,72,73,77,79,80,82 Most studies defined preeclampsia as gestational hypertension accompanied by proteinuria (greater than 300 mg/24 h). The remaining 6 trials57,58,62-64,82 reported preeclampsia as clinically distinct from gestational hypertension but did not provide a formal definition.

Interventions for GWG were not associated with reduced risk of preeclampsia vs controls (27 trials; RR, 0.98 [95% CI, 0.84 to 1.13]; I2 = 0%; ARD, 0.1% [95% CI, −0.6% to 0.5%]) (Table 1; eFigure 4 in the Supplement). In stratified analyses, there were no statistically significant interactions between effects of GWG interventions on likelihood of preeclampsia and BMI category, intervention type, or intensity.

There were no effects of GWG interventions on the remaining maternal outcomes (postpartum hemorrhage, perineal trauma, or maternal death); events were uncommon and estimates were imprecise. See the full report for details.17

Infant Health Outcomes
Macrosomia

Twenty-five trials (n = 13 990) evaluated effects of GWG interventions on risk of macrosomia. Macrosomia was defined as term infants weighing more than 4 kg (21 RCTs22,25,27,28,30,33,38,53,57,59,62-64,67,71-73,77,79,80,107) or 4.5 kg (6 RCTs),24,37,38,51-53 with 2 trials38,53 reporting outcomes using both definitions (eTable 4 in the Supplement).

Gestational weight gain interventions were associated with decreased risk of macrosomia vs controls (25 trials; RR, 0.77 [95% CI, 0.65 to 0.92]; I2 = 38.3%; ARD, −1.9% [95% CI, −3.3% to −0.7%]) (Table 2; eFigure 5 in the Supplement). Stratified analyses showed statistically significant interactions between effect of GWG interventions on risk of macrosomia and intervention intensity (P = .03 for interaction) but not BMI category or intervention type. Statistically significant effects were demonstrated in the high-intensity intervention subgroup (14 trials; RR, 0.65 [95% CI, 0.49 to 0.84]; I2 = 37%).

Large for Gestational Age

Twenty-six RCTs (n = 13 000) reported the outcome of large for gestational age (LGA) infants, defined as birth weight greater than the 90th percentile for gestational age (Table 2; eFigure 6 in the Supplement).20,24,32-34,37-40,44,49,50,52,53,56,58,65,67,69,72-74,77-80 Gestational weight gain interventions were associated with decreased risk of LGA (26 trials; RR, 0.89 [95% CI, 0.80 to 0.99]; I2 = 0%; ARD, −1.3% [95% CI, −2.3% to −0.3%]) (Table 2; eFigure 6 in the Supplement). In stratified analyses, effect estimates of GWG interventions on likelihood of LGA did not differ by BMI category, intervention type, or intensity.

Preterm Birth

Thirty-three RCTs (n = 16 974) reported on the outcome of preterm birth (Table 2; eFigure 7 in the Supplement). Preterm birth was defined as delivery at less than 37 weeks in 24 trials20,22,24,25,27-30,34,36-40,52,56,57,67,69,73,77-79,102 and less than 36 weeks in 4 trials62-64,71; 5 trials did not report a definition (eTable 4 in the Supplement).33,44,60,65,75 Gestational weight gain interventions were not associated with a lower risk of preterm birth (33 trials; RR, 0.93 [95% CI, 0.81 to 1.07]; I2 = 2.2%; ARD, −0.2% [95% CI, −1.1% to 0.7%]) (Table 2; eFigure 7 in the Supplement). In stratified analyses, effect estimates of GWG interventions on likelihood of preterm birth did not differ by BMI category, intervention type, or intensity.

There were no associations of GWG interventions with the remaining infant outcomes (respiratory distress syndrome, shoulder dystocia, neonatal intensive care unit admission, neonatal death, or infant growth during the first year); events were uncommon and estimates were imprecise. See the full report for details.17

Benefits for Weight Outcomes

Key Question 2a. Do interventions to limit excess gestational weight gain reduce gestational weight gain, postpartum weight retention, or obesity-related adverse perinatal conditions among pregnant women and their infants?

Key Question 2b. Do interventions to reduce prepregnancy weight in women who are overweight or obese improve weight outcomes or reduce obesity-related adverse perinatal conditions among women who become pregnant and their infants?

Key Question 2c. Does the effectiveness of these interventions differ by age, race/ethnicity, socioeconomic status, parity, smoking status, or BMI category?

Mean GWG

Fifty-five trials evaluated effects of GWG interventions on mean GWG (Table 3, Figure 3).19,20,22-31,33-41,43,45-53,55-60,62-68,71-76,78-82 Gestational weight gain interventions were associated with reduced GWG during pregnancy of approximately 1 kg vs controls (55 trials; n = 20 090; pooled mean difference [MD], −1.02 kg [95% CI, −1.30 to −0.75]; I2 = 60.3%) (Table 3, Figure 3).

High-intensity interventions were associated with greater effects on GWG (28 trials; MD, −1.47 kg [95% CI, −1.78 to −1.22]; I2 = 13.0%) than were moderate-intensity (18 trials; MD, −0.32 kg [95% CI, −0.71 to −0.04]; I2 = 17.6%) or low-intensity (9 trials; MD, −0.64 kg [94% CI, −1.44 to 0.02]; I2 = 48.4%; P < .001 for interaction) interventions. Subgroup analyses according to BMI category demonstrated slightly higher effect estimates among women with obesity (18 trials; MD, −1.63 [95% CI, −2.45 to −0.91]; I2 = 63.0%) compared with other BMI categories (overweight, 10 trials; MD, −0.89 [95% CI, −1.54 to −0.32]; I2 = 15.5%; overweight and obesity combined, 20 trials; MD, −0.90 [95% CI, −1.38 to −0.46]; I2 = 31.1%; mixed weight categories, 28 trials; MD, −0.81 [95% CI, −1.16 to −0.46]; I2 = 60.7%; or normal weight, 8 trials; MD, −0.48 [95% CI, −96 to −0.21]; I2 = 0.0%) (Table 3). There was no association between effects of GWG interventions and overall prepregnancy BMI category (Table 3, Figure 3).

In stratified analyses, the were no statistically significant interactions between effects of GWG interventions on mean GWG and intervention type, study quality, or timing of weight gain assessment.

Exceeding NAM Recommendations for GWG

Thirty-nine RCTs (n = 13 955) reported the outcome of GWG in excess of NAM recommendations (Table 3; eFigure 8 in the Supplement).21-23,25,27-30,32,34-37,41,43,48-50,52,54,55,57,59,61-66,68,71,74-76,78-81,95 Interventions were associated with decreased likelihood of gaining weight in excess of NAM recommendations (39 trials; RR, 0.83 [95% CI, 0.77 to 0.89]; I2 = 63.8%; ARD, −7.6% [95% CI, −11.0% to −4.6%]) (Table 3; eFigure 8 in the Supplement). Stratified analysis showed statistically significant interactions between effects of GWG interventions on excess weight gain and intervention type (P = .003) and intensity (P<.001 for interaction) but not for BMI category. There were statistically significant effects in the active (15 trials; RR, 0.73 [95% CI, 0.67 to 0.80]; I2 = 0%) and high-intensity (22 trials; RR, 0.74 [95% CI, 0.69 to 0.79]; I2 = 0%) intervention subgroups.

Adherence to NAM Recommendations for GWG

Nineteen RCTs (n = 5835) reported on the outcome of rates of adherence to GWG guidelines by prepregnancy BMI category according to ranges recommended by the NAM (ie, neither gaining excessive weight nor failing to gain sufficient weight (Table 3; eFigure 9 in the Supplement).23,29,32,36,38,43,55,58,60-62,64,68,71,74,75,77,79,80 There was no difference between GWG interventions and controls in likelihood of adherence to NAM recommendations for GWG (19 trials; RR, 1.10 [95% CI, 0.89 to 1.35]; I2 = 84.3%), although statistical heterogeneity was substantial (Table 3; eFigure 9 in the Supplement). In stratified analyses, there were not statistically significant interactions between effects GWG interventions and adherence to NAM recommendations by BMI category, intervention type, or intensity.

Postpartum Weight Retention

Thirteen RCTs (n = 4841) evaluated the effects of GWG interventions on postpartum weight retention (PPWR) (Table 3; eFigure 10 in the Supplement). Gestational weight gain interventions were associated with statistically significantly less PPWR at 12 months (10 trials; MD, −0.63 kg [95% CI, −1.44 to −0.01]; I2 = 65.5%)22,90,92-94,96,97,99,101,102 but not at 6 months postpartum (3 trials; MD, −0.85 kg [95% CI, −3.67 to 0.81]; I2 = 70.6%)62,92,105 or less than 6 months postpartum (9 trials; MD, −0.81 kg [95% CI, −2.40 to 0.55]; I2 = 84.4%).42,64,65,82,91,93,94 In stratified analyses, effect estimates of GWG interventions on likelihood of PPWR did not differ by BMI category at follow-up time of up to 6 months or 12 months.

Harms of Interventions

Key Question 3a. What are the harms of interventions to limit excess gestational weight gain among pregnant women and their infants?

Key Question 3b. What are the harms of interventions to reduce prepregnancy weight among women who are overweight or obese?

Key Question 3c. Do the harms of these interventions differ by age, race/ethnicity, socioeconomic status, parity, smoking status, or BMI category?

Evidence on harms associated with GWG interventions was very limited, with most studies not reporting harms (Table 4; eTable 4 in the Supplement). In general, there were no serious harms related to the interventions, including depression or anxiety, and most trials noted no differences between groups in the rates of adverse events, including SGA.

Discussion

The evidence from this report is summarized in Table 4. Evidence on effects of GWG interventions on maternal outcomes was most robust for gestational diabetes, gestational hypertension, preeclampsia, and cesarean delivery. Active or counseling-only GWG interventions were associated with decreased risk of GDM and emergency cesarean delivery. While there was no overall association between GWG interventions and risk of gestational hypertension, stratified analyses indicated that high-intensity and active interventions were associated with decreased rates of gestational hypertension, suggesting a possible dose effect. There was no association of GWG interventions with preeclampsia, a multisystem syndrome with less clear associations with BMI.108 Evidence on effects of GWG interventions on infant outcomes was most robust for macrosomia, LGA, and preterm birth. Gestational weight gain interventions were associated with decreased risk of macrosomia and LGA.

Gestational weight gain interventions were associated with slightly less overall gestational weight gain vs controls. The effects of interventions on GWG were greater in trials of high-intensity interventions compared with moderate- or low-intensity interventions. The effects of GWG interventions on gestational weight gain also were greater in women in the obese and overweight categories compared with women with normal prepregnancy BMI, although the overall interaction between BMI and GWG was not statistically significant.

Gestational weight gain interventions were associated with decreased likelihood of weight gain in excess of NAM recommendations vs controls, with some evidence of a dose-response relationship. The findings support the obesity and behavioral intervention literature that demonstrates more promising effects of interventions that offer more frequent patient contact.109,110

There was no significant association between GWG interventions and likelihood of adhering to NAM recommendations for GWG. The discrepancy between the effects of GWG interventions on exceeding guidelines vs adhering to guidelines could be attributable to an increased likelihood of some women not adhering to NAM recommendations because they did not gain enough weight. However, data were not available to verify this, as most studies did not report the proportion of women with less GWG than recommended. Gestational weight gain interventions were associated with effects on PPWR at 12 months; effects on PPWR at 6 months were not statistically significant, but data were more limited and imprecise. Evidence on harms of GWG interventions was limited, but there was no association with increased risk of small for gestational age and no indication of serious harms.

Trials should be designed to examine the effects of weight loss interventions in diverse populations stratified by BMI and report outcomes according to population categories, including adolescents and women with advanced maternal age. Additional studies examining the effect of prepregnancy weight loss interventions are also an important next step.

Limitations

This review had several limitations. First, data were often not available for important groups defined by race or ethnicity, age (eg, adolescents, advanced maternal age), or socioeconomic status; study results were not stratified by these factors. No study was conducted exclusively in pregnant adolescents or women of advanced maternal age, and only 1 study conducted a weight loss intervention prior to pregnancy. Trials did not address issues of health care disparities, access to prenatal care (or lack thereof), or feasibility of interventions in settings where access to care is limited or arrival to care is delayed. More studies of underrepresented populations who may have higher risk of adverse outcomes are needed.111,112

Second, there was statistical heterogeneity in some pooled analyses due to variability in intervention components, comparison groups, and timing and method of assessment of outcomes, but results were consistent with stratified analyses. Because of anticipated heterogeneity, random-effects models were used, which results in wider confidence intervals than fixed-effects models when statistical heterogeneity is present, reflecting the greater uncertainty in estimates. In addition, the profile-likelihood method was used for conducting meta-analyses, which may be more reliable when statistical heterogeneity is present.113

Third, there were methodological limitations in the literature. Poor-quality trials were excluded because of serious flaws; results were similar in analyses stratified by study quality. Trials primarily focused on the effects of GWG interventions on mean GWG, an intermediate outcome, with less evidence on the direct effects of GWG interventions on maternal and infant health outcomes. Some stratified analyses were underpowered to evaluate subgroup effects. Additionally, some trials enrolled mixed populations of women with different BMI categories, limiting the usefulness of stratified analyses. Other factors could define intervention intensity (eg, session duration or frequency or type of intervention) but were difficult to categorize. Fourth, evidence on harms was limited, particularly for effects on psychological well-being and quality of life.

Conclusions

Counseling and active behavioral interventions to limit GWG were associated with decreased risk of gestational diabetes, emergency cesarean delivery, macrosomia, and large for gestational age. Gestational weight gain interventions were also associated with modest reductions in mean GWG and decreased likelihood of exceeding NAM recommendations for GWG.

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Article Information

Corresponding Author: Amy G. Cantor, MD, MPH, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code BICC, Portland, OR 97239 (cantor@ohsu.edu).

Accepted for Publication: March 5, 2021.

Author Contributions: Dr Cantor had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Cantor, Jungbauer, McDonagh, Marshall, LeBlanc, Chou.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Cantor, Jungbauer, McDonagh, Blazina, Marshall, Weeks, Fu, Chou.

Critical revision of the manuscript for important intellectual content: Cantor, Jungbauer, Blazina, Marshall, LeBlanc, Chou.

Statistical analysis: Cantor, Jungbauer, Blazina, Marshall, Fu.

Obtained funding: Cantor, Chou.

Administrative, technical, or material support: Cantor, Jungbauer, McDonagh, Blazina, Marshall, Weeks.

Supervision: Cantor, Jungbauer, McDonagh, Chou.

Conflict of Interest Disclosures: None reported.

Funding/Support: This research was funded under contract HHSA 290201500009-I, Task Order 14, from the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services, under a contract to support the US Preventive Services Task Force (USPSTF).

Role of the Funder/Sponsor: Investigators worked with USPSTF members and AHRQ staff to develop the scope, analytic framework, and key questions for this review. AHRQ had no role in study selection, quality assessment, or synthesis. AHRQ staff provided project oversight, reviewed the report to ensure that the analysis met methodological standards, and distributed the draft for peer review. Otherwise, AHRQ had no role in the conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript findings. The opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ or the US Department of Health and Human Services.

Additional Contributions: We thank the following individuals for their contributions to this project: AHRQ Medical Officer Iris Mabry-Hernandez, MD, MPH; EPC staff member Tracy Dana, MLS; and the USPFTF. We also acknowledge past and current USPSTF members who contributed to topic deliberations. The USPSTF members, external reviewers, and federal partner reviewers did not receive financial compensation for their contributions.

Additional Information: A draft version of this evidence report underwent external peer review from 4 federal partners representing the Centers for Disease Control and Prevention, US Food and Drug Administration, and the National Institutes of Health and 3 content experts (Patrick Catalano, MD [Tufts University School of Medicine]; Rebecca Clifton, PhD [Milken Institute School of Public Health, George Washington University]; and Alan Peaceman, MD [Feinberg School of Medicine, Northwestern University]). Comments were presented to the USPSTF during its deliberation of the evidence and were considered in preparing the final evidence review.

Editorial Disclaimer: This evidence report is presented as a document in support of the accompanying USPSTF Recommendation Statement. It did not undergo additional peer review after submission to JAMA.

References
1.
Kim  SY, Dietz  PM, England  L, Morrow  B, Callaghan  WM.  Trends in pre-pregnancy obesity in nine states, 1993-2003.   Obesity (Silver Spring). 2007;15(4):986-993. doi:10.1038/oby.2007.621PubMedGoogle ScholarCrossref
2.
Deputy  NP, Dub  B, Sharma  AJ.  Prevalence and trends in prepregnancy normal weight—48 States, New York City, and District of Columbia, 2011-2015.   MMWR Morb Mortal Wkly Rep. 2018;66(51-52):1402-1407. doi:10.15585/mmwr.mm665152a3PubMedGoogle ScholarCrossref
3.
Kalliala  I, Markozannes  G, Gunter  MJ,  et al.  Obesity and gynaecological and obstetric conditions: umbrella review of the literature.   BMJ. 2017;359:j4511. doi:10.1136/bmj.j4511PubMedGoogle ScholarCrossref
4.
Adane  AA, Mishra  GD, Tooth  LR.  Maternal pre-pregnancy obesity and childhood physical and cognitive development of children: a systematic review.   Int J Obes (Lond). 2016;40(11):1608-1618. doi:10.1038/ijo.2016.140PubMedGoogle ScholarCrossref
5.
Álvarez-Bueno  C, Cavero-Redondo  I, Lucas-de la Cruz  L, Notario-Pacheco  B, Martínez-Vizcaíno  V.  Association between pre-pregnancy overweight and obesity and children’s neurocognitive development: a systematic review and meta-analysis of observational studies.   Int J Epidemiol. 2017;46(5):1653-1666. doi:10.1093/ije/dyx122PubMedGoogle ScholarCrossref
6.
Bartsch  E, Medcalf  KE, Park  AL, Ray  JG; High Risk of Pre-eclampsia Identification Group.  Clinical risk factors for pre-eclampsia determined in early pregnancy: systematic review and meta-analysis of large cohort studies.   BMJ. 2016;353:i1753-i1753. doi:10.1136/bmj.i1753PubMedGoogle ScholarCrossref
7.
Fuemmeler  BF, Wang  L, Iversen  ES, Maguire  R, Murphy  SK, Hoyo  C.  Association between prepregnancy body mass index and gestational weight gain with size, tempo, and velocity of infant growth: analysis of the Newborn Epigenetic Study Cohort.   Child Obes. 2016;12(3):210-218. doi:10.1089/chi.2015.0253PubMedGoogle ScholarCrossref
8.
Marchi  J, Berg  M, Dencker  A, Olander  EK, Begley  C.  Risks associated with obesity in pregnancy, for the mother and baby: a systematic review of reviews.   Obes Rev. 2015;16(8):621-638. doi:10.1111/obr.12288PubMedGoogle ScholarCrossref
9.
Mitanchez  D, Chavatte-Palmer  P.  Review shows that maternal obesity induces serious adverse neonatal effects and is associated with childhood obesity in their offspring.   Acta Paediatr. 2018;107(7):1156-1165. doi:10.1111/apa.14269PubMedGoogle ScholarCrossref
10.
Poorolajal  J, Jenabi  E.  The association between body mass index and preeclampsia: a meta-analysis.   J Matern Fetal Neonatal Med. 2016;29(22):3670-3676. doi:10.3109/14767058.2016.1140738PubMedGoogle ScholarCrossref
11.
Woo Baidal  JA, Locks  LM, Cheng  ER, Blake-Lamb  TL, Perkins  ME, Taveras  EM.  Risk factors for childhood obesity in the first 1,000 days: a systematic review.   Am J Prev Med. 2016;50(6):761-779. doi:10.1016/j.amepre.2015.11.012PubMedGoogle ScholarCrossref
12.
Institute of Medicine and National Research Council Committee to Reexamine IOM Pregnancy Weight Guidelines.  Weight Gain During Pregnancy: Reexamining the Guidelines. National Academies Press; 2009.
13.
American Society for Reproductive Medicine; American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice.  Prepregnancy counseling: Committee Opinion No. 762.   Fertil Steril. 2019;111(1):32-42. doi:10.1016/j.fertnstert.2018.12.003PubMedGoogle ScholarCrossref
14.
Peaceman  AM, Clifton  RG, Phelan  S,  et al; LIFE‐Moms Research Group.  Lifestyle interventions limit gestational weight gain in women with overweight or obesity: LIFE-Moms prospective meta-analysis.   Obesity (Silver Spring). 2018;26(9):1396-1404. doi:10.1002/oby.22250PubMedGoogle ScholarCrossref
15.
International Weight Management in Pregnancy (i-WIP) Collaborative Group.  Effect of diet and physical activity based interventions in pregnancy on gestational weight gain and pregnancy outcomes: meta-analysis of individual participant data from randomised trials.   BMJ. 2017;358:j3119. doi:10.1136/bmj.j3119PubMedGoogle Scholar
16.
Procedure Manual. US Preventive Services Task Force. Published 2018. Accessed April 17, 2021. https://uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual
17.
Cantor  A, Jungbauer  RM, McDonagh  MS,  et al.  Counseling and Behavioral Interventions for Healthy Weight and Weight Gain in Pregnancy: A Systematic Review for the US Preventive Services Task Force. Evidence Synthesis No. 203. Agency for Healthcare Research and Quality; 2021. AHRQ publication 20-05272-EF-1.
18.
Higgins  JPT, Thompson  SG, Deeks  JJ, Altman  DG.  Measuring inconsistency in meta-analyses.   BMJ. 2003;327(7414):557-560. doi:10.1136/bmj.327.7414.557PubMedGoogle ScholarCrossref
19.
Aguilar-Cordero  MJ, Sánchez-García  JC, Rodriguez-Blanque  R, Sánchez-López  AM, Mur-Villar  N.  Moderate physical activity in an aquatic environment during pregnancy (SWEP study) and its influence in preventing postpartum depression.   J Am Psychiatr Nurses Assoc. 2019;25(2):112-121. doi:10.1177/1078390317753675PubMedGoogle ScholarCrossref
20.
Al Wattar  BH, Dodds  J, Placzek  A,  et al; ESTEEM Study Group.  Mediterranean-style diet in pregnant women with metabolic risk factors (ESTEEM): a pragmatic multicentre randomised trial.   PLoS Med. 2019;16(7):e1002857. doi:10.1371/journal.pmed.1002857PubMedGoogle Scholar
21.
Altazan  AD, Redman  LM, Burton  JH,  et al.  Mood and quality of life changes in pregnancy and postpartum and the effect of a behavioral intervention targeting excess gestational weight gain in women with overweight and obesity: a parallel-arm randomized controlled pilot trial.   BMC Pregnancy Childbirth. 2019;19(1):50. doi:10.1186/s12884-019-2196-8PubMedGoogle ScholarCrossref
22.
Althuizen  E, van der Wijden  CL, van Mechelen  W, Seidell  JC, van Poppel  MN.  The effect of a counselling intervention on weight changes during and after pregnancy: a randomised trial.   BJOG. 2013;120(1):92-99. doi:10.1111/1471-0528.12014PubMedGoogle ScholarCrossref
23.
Asbee  SM, Jenkins  TR, Butler  JR, White  J, Elliot  M, Rutledge  A.  Preventing excessive weight gain during pregnancy through dietary and lifestyle counseling: a randomized controlled trial.   Obstet Gynecol. 2009;113(2, pt 1):305-312. doi:10.1097/AOG.0b013e318195baefPubMedGoogle ScholarCrossref
24.
Assaf-Balut  C, García de la Torre  N, Durán  A,  et al.  A Mediterranean diet with additional extra virgin olive oil and pistachios reduces the incidence of gestational diabetes mellitus (GDM): a randomized controlled trial: the St. Carlos GDM Prevention Study.   PLoS One. 2017;12(10):e0185873. doi:10.1371/journal.pone.0185873PubMedGoogle Scholar
25.
Bacchi  M, Mottola  MF, Perales  M, Refoyo  I, Barakat  R.  Aquatic activities during pregnancy prevent excessive maternal weight gain and preserve birth weight: a randomized clinical trial.   Am J Health Promot. 2018;32(3):729-735. doi:10.1177/0890117117697520PubMedGoogle ScholarCrossref
26.
Barakat  R, Cordero  Y, Coteron  J, Luaces  M, Montejo  R.  Exercise during pregnancy improves maternal glucose screen at 24-28 weeks: a randomised controlled trial.   Br J Sports Med. 2012;46(9):656-661. doi:10.1136/bjsports-2011-090009PubMedGoogle ScholarCrossref
27.
Barakat  R, Franco  E, Perales  M, López  C, Mottola  MF.  Exercise during pregnancy is associated with a shorter duration of labor: a randomized clinical trial.   Eur J Obstet Gynecol Reprod Biol. 2018;224:33-40. doi:10.1016/j.ejogrb.2018.03.009PubMedGoogle ScholarCrossref
28.
Barakat  R, Pelaez  M, Cordero  Y,  et al.  Exercise during pregnancy protects against hypertension and macrosomia: randomized clinical trial.   Am J Obstet Gynecol. 2016;214(5):649.e1-649.e8. doi:10.1016/j.ajog.2015.11.039PubMedGoogle ScholarCrossref
29.
Barakat  R, Perales  M, Bacchi  M, Coteron  J, Refoyo  I.  A program of exercise throughout pregnancy: is it safe to mother and newborn?   Am J Health Promot. 2014;29(1):2-8. doi:10.4278/ajhp.130131-QUAN-56PubMedGoogle ScholarCrossref
30.
Barakat  R, Refoyo  I, Coteron  J, Franco  E.  Exercise during pregnancy has a preventative effect on excessive maternal weight gain and gestational diabetes: a randomized controlled trial.   Braz J Phys Ther. 2019;23(2):148-155. doi:10.1016/j.bjpt.2018.11.005PubMedGoogle ScholarCrossref
31.
Bogaerts  AF, Devlieger  R, Nuyts  E, Witters  I, Gyselaers  W, Van den Bergh  BR.  Effects of lifestyle intervention in obese pregnant women on gestational weight gain and mental health: a randomized controlled trial.   Int J Obes (Lond). 2013;37(6):814-821. doi:10.1038/ijo.2012.162PubMedGoogle ScholarCrossref
32.
Brownfoot  FC, Davey  MA, Kornman  L.  Routine weighing to reduce excessive antenatal weight gain: a randomised controlled trial.   BJOG. 2016;123(2):254-261. doi:10.1111/1471-0528.13735PubMedGoogle ScholarCrossref
33.
Bruno  R, Petrella  E, Bertarini  V, Pedrielli  G, Neri  I, Facchinetti  F.  Adherence to a lifestyle programme in overweight/obese pregnant women and effect on gestational diabetes mellitus: a randomized controlled trial.   Matern Child Nutr. 2017;13(3):e12333. doi:10.1111/mcn.12333PubMedGoogle Scholar
34.
Cahill  AG, Haire-Joshu  D, Cade  WT,  et al.  Weight control program and gestational weight gain in disadvantaged women with overweight or obesity: a randomized clinical trial.   Obesity (Silver Spring). 2018;26(3):485-491. doi:10.1002/oby.22070PubMedGoogle ScholarCrossref
35.
Daley  AJ, Jolly  K, Jebb  SA,  et al.  Feasibility and acceptability of regular weighing, setting weight gain limits and providing feedback by community midwives to prevent excess weight gain during pregnancy: randomised controlled trial and qualitative study.   BMC Obes. 2015;2(1):35. doi:10.1186/s40608-015-0061-5PubMedGoogle ScholarCrossref
36.
Daley  A, Jolly  K, Jebb  SA,  et al.  Effectiveness of a behavioural intervention involving regular weighing and feedback by community midwives within routine antenatal care to prevent excessive gestational weight gain: POPS2 randomised controlled trial.   BMJ Open. 2019;9(9):e030174. doi:10.1136/bmjopen-2019-030174PubMedGoogle Scholar
37.
Daly  N, Farren  M, McKeating  A, OʼKelly  R, Stapleton  M, Turner  MJ.  A medically supervised pregnancy exercise intervention in obese women: a randomized controlled trial.   Obstet Gynecol. 2017;130(5):1001-1010. doi:10.1097/AOG.0000000000002267PubMedGoogle ScholarCrossref
38.
Dodd  JM, Deussen  AR, Louise  J.  A randomised trial to optimise gestational weight gain and improve maternal and infant health outcomes through antenatal dietary, lifestyle and exercise advice: the OPTIMISE randomised trial.   Nutrients. 2019;11(12):E2911. doi:10.3390/nu11122911PubMedGoogle Scholar
39.
Dodd  JM, Turnbull  D, McPhee  AJ,  et al; LIMIT Randomised Trial Group.  Antenatal lifestyle advice for women who are overweight or obese: LIMIT randomised trial.   BMJ. 2014;348:g1285. doi:10.1136/bmj.g1285PubMedGoogle ScholarCrossref
40.
Gallagher  D, Rosenn  B, Toro-Ramos  T,  et al.  Greater neonatal fat-free mass and similar fat mass following a randomized trial to control excess gestational weight gain.   Obesity (Silver Spring). 2018;26(3):578-587. doi:10.1002/oby.22079PubMedGoogle ScholarCrossref
41.
Garnæs  KK, Mørkved  S, Salvesen  Ø, Moholdt  T.  Exercise training and weight gain in obese pregnant women: a randomized controlled trial (ETIP trial).   PLoS Med. 2016;13(7):e1002079. doi:10.1371/journal.pmed.1002079PubMedGoogle Scholar
42.
Garnæs  KK, Mørkved  S, Salvesen  KA, Salvesen  Ø, Moholdt  T.  Exercise training during pregnancy reduces circulating insulin levels in overweight/obese women postpartum: secondary analysis of a randomised controlled trial (the ETIP trial).   BMC Pregnancy Childbirth. 2018;18(1):18. doi:10.1186/s12884-017-1653-5PubMedGoogle ScholarCrossref
43.
Gesell  SB, Katula  JA, Strickland  C, Vitolins  MZ.  Feasibility and initial efficacy evaluation of a community-based cognitive-behavioral lifestyle intervention to prevent excessive weight gain during pregnancy in Latina women.   Matern Child Health J. 2015;19(8):1842-1852. doi:10.1007/s10995-015-1698-xPubMedGoogle ScholarCrossref
44.
Guelfi  KJ, Ong  MJ, Crisp  NA,  et al.  Regular exercise to prevent the recurrence of gestational diabetes mellitus: a randomized controlled trial.   Obstet Gynecol. 2016;128(4):819-827. doi:10.1097/aog.0000000000001632PubMedGoogle ScholarCrossref
45.
Haakstad  LA, Bø  K.  Effect of regular exercise on prevention of excessive weight gain in pregnancy: a randomised controlled trial.   Eur J Contracept Reprod Health Care. 2011;16(2):116-125. doi:10.3109/13625187.2011.560307PubMedGoogle ScholarCrossref
46.
Harrison  CL, Lombard  CB, Strauss  BJ, Teede  HJ.  Optimizing healthy gestational weight gain in women at high risk of gestational diabetes: a randomized controlled trial.   Obesity (Silver Spring). 2013;21(5):904-909. doi:10.1002/oby.20163PubMedGoogle ScholarCrossref
47.
Hawkins  M, Hosker  M, Marcus  BH,  et al.  A pregnancy lifestyle intervention to prevent gestational diabetes risk factors in overweight Hispanic women: a feasibility randomized controlled trial.   Diabet Med. 2015;32(1):108-115. doi:10.1111/dme.12601PubMedGoogle ScholarCrossref
48.
Herring  SJ, Cruice  JF, Bennett  GG, Rose  MZ, Davey  A, Foster  GD.  Preventing excessive gestational weight gain among African American women: a randomized clinical trial.   Obesity (Silver Spring). 2016;24(1):30-36. doi:10.1002/oby.21240PubMedGoogle ScholarCrossref
49.
Hui  A, Back  L, Ludwig  S,  et al.  Lifestyle intervention on diet and exercise reduced excessive gestational weight gain in pregnant women under a randomised controlled trial.   BJOG. 2012;119(1):70-77. doi:10.1111/j.1471-0528.2011.03184.xPubMedGoogle ScholarCrossref
50.
Hui  AL, Back  L, Ludwig  S,  et al.  Effects of lifestyle intervention on dietary intake, physical activity level, and gestational weight gain in pregnant women with different pre-pregnancy body mass index in a randomized control trial.   BMC Pregnancy Childbirth. 2014;14:331. doi:10.1186/1471-2393-14-331PubMedGoogle ScholarCrossref
51.
Koivusalo  SB, Rönö  K, Klemetti  MM,  et al.  Gestational diabetes mellitus can be prevented by lifestyle intervention: the Finnish gestational diabetes prevention study (RADIEL): a randomized controlled trial.   Diabetes Care. 2016;39(1):24-30. Published correction appears in Diabetes Care. 2017 Aug;40(8):1133. doi:10.2337/dc15-0511PubMedGoogle ScholarCrossref
52.
Kunath  J, Gunther  J, Rauh  K,  et al.  Effects of a lifestyle intervention during pregnancy to prevent excessive gestational weight gain in routine care—the cluster-randomised GeliS trial.   BMC Med. 2019;17(1):5. doi:10.1186/s12916-018-1235-zPubMedGoogle ScholarCrossref
53.
Luoto  R, Kinnunen  TI, Aittasalo  M,  et al.  Primary prevention of gestational diabetes mellitus and large-for-gestational-age newborns by lifestyle counseling: a cluster-randomized controlled trial.   PLoS Med. 2011;8(5):e1001036. doi:10.1371/journal.pmed.1001036PubMedGoogle Scholar
54.
Magriples  U, Boynton  MH, Kershaw  TS,  et al.  The impact of group prenatal care on pregnancy and postpartum weight trajectories.   Am J Obstet Gynecol. 2015;213(5):688.e1-688.e9. doi:10.1016/j.ajog.2015.06.066PubMedGoogle ScholarCrossref
55.
McCarthy  EA, Walker  SP, Ugoni  A, Lappas  M, Leong  O, Shub  A.  Self-weighing and simple dietary advice for overweight and obese pregnant women to reduce obstetric complications without impact on quality of life: a randomised controlled trial.   BJOG. 2016;123(6):965-973. doi:10.1111/1471-0528.13919PubMedGoogle ScholarCrossref
56.
Okesene-Gafa  KAM, Li  M, McKinlay  CJD,  et al.  Effect of antenatal dietary interventions in maternal obesity on pregnancy weight-gain and birthweight: Healthy Mums and Babies (HUMBA) randomized trial.   Am J Obstet Gynecol. 2019;221(2):152e.1-152e.13. doi:10.1016/j.ajog.2019.03.003PubMedGoogle ScholarCrossref
57.
Olson  CM, Groth  SW, Graham  ML, Reschke  JE, Strawderman  MS, Fernandez  ID.  The effectiveness of an online intervention in preventing excessive gestational weight gain: the e-Moms Roc randomized controlled trial.   BMC Pregnancy Childbirth. 2018;18(1):148. doi:10.1186/s12884-018-1767-4PubMedGoogle ScholarCrossref
58.
Peccei  A, Blake-Lamb  T, Rahilly  D, Hatoum  I, Bryant  A.  Intensive prenatal nutrition counseling in a community health setting: a randomized controlled trial.   Obstet Gynecol. 2017;130(2):423-432. doi:10.1097/AOG.0000000000002134PubMedGoogle ScholarCrossref
59.
Pelaez  M, Gonzalez-Cerron  S, Montejo  R, Barakat  R.  Protective effect of exercise in pregnant women including those who exceed weight gain recommendations: a randomized controlled trial.   Mayo Clin Proc. 2019;94(10):1951-1959. doi:10.1016/j.mayocp.2019.01.050PubMedGoogle ScholarCrossref
60.
Petrella  E, Malavolti  M, Bertarini  V,  et al.  Gestational weight gain in overweight and obese women enrolled in a healthy lifestyle and eating habits program.   J Matern Fetal Neonatal Med. 2014;27(13):1348-1352. doi:10.3109/14767058.2013.858318PubMedGoogle ScholarCrossref
61.
Perales  M, Rodríguez  YC, Terrones  MV, Mulas  AL, Carballo  RB.  Exercise and depression in overweight and obese pregnant women: a randomised controlled trial.   Archivos de Medicina del Deporte. 2015(167):156-163. http://archivosdemedicinadeldeporte.com/articulos/upload/or04_perales.pdfGoogle Scholar
62.
Phelan  S, Phipps  MG, Abrams  B, Darroch  F, Schaffner  A, Wing  RR.  Randomized trial of a behavioral intervention to prevent excessive gestational weight gain: the Fit for Delivery Study.   Am J Clin Nutr. 2011;93(4):772-779. doi:10.3945/ajcn.110.005306PubMedGoogle ScholarCrossref
63.
Phelan  S, Wing  RR, Brannen  A,  et al.  Randomized controlled clinical trial of behavioral lifestyle intervention with partial meal replacement to reduce excessive gestational weight gain.   Am J Clin Nutr. 2018;107(2):183-194. doi:10.1093/ajcn/nqx043PubMedGoogle ScholarCrossref
64.
Polley  BA, Wing  RR, Sims  CJ.  Randomized controlled trial to prevent excessive weight gain in pregnant women.   Int J Obes Relat Metab Disord. 2002;26(11):1494-1502. doi:10.1038/sj.ijo.0802130PubMedGoogle ScholarCrossref
65.
Rauh  K, Gabriel  E, Kerschbaum  E,  et al.  Safety and efficacy of a lifestyle intervention for pregnant women to prevent excessive maternal weight gain: a cluster-randomized controlled trial.   BMC Pregnancy Childbirth. 2013;13:151. doi:10.1186/1471-2393-13-151PubMedGoogle ScholarCrossref
66.
Redman  LM, Gilmore  LA, Breaux  J,  et al.  Effectiveness of SmartMoms, a novel eHealth intervention for management of gestational weight gain: randomized controlled pilot trial.   JMIR Mhealth Uhealth. 2017;5(9):e133. doi:10.2196/mhealth.8228PubMedGoogle Scholar
67.
Renault  KM, Norgaard  K, Nilas  L,  et al.  The Treatment of Obese Pregnant women (TOP) study: a randomized controlled trial of the effect of physical activity intervention assessed by pedometer with or without dietary intervention in obese pregnant women.   Am J Obstet Gynecol. 2013;210(2):134.e1-134.e9. doi:10.1016/j.ajog.2013.09.029PubMedGoogle ScholarCrossref
68.
Ronnberg  AK, Ostlund  I, Fadl  H, Gottvall  T, Nilsson  K.  Intervention during pregnancy to reduce excessive gestational weight gain—a randomised controlled trial.   BJOG. 2015;122(4):537-544. doi:10.1111/1471-0528.13131PubMedGoogle ScholarCrossref
69.
Rönö  K, Grotenfelt  NE, Klemetti  MM,  et al.  Effect of a lifestyle intervention during pregnancy—findings from the Finnish gestational diabetes prevention trial (RADIEL).   J Perinatol. 2018b;38(9):1157-1164. doi:10.1038/s41372-018-0178-8PubMedGoogle ScholarCrossref
70.
Rönö  K, Stach-Lempinen  B, Eriksson  JG,  et al.  Prevention of gestational diabetes with a prepregnancy lifestyle intervention—findings from a randomized controlled trial.   Int J Womens Health. 2018a;10:493-501. doi:10.2147/IJWH.S162061PubMedGoogle ScholarCrossref
71.
Ruiz  JR, Perales  M, Pelaez  M, Lopez  C, Lucia  A, Barakat  R.  Supervised exercise-based intervention to prevent excessive gestational weight gain: a randomized controlled trial.   Mayo Clin Proc. 2013;88(12):1388-1397. doi:10.1016/j.mayocp.2013.07.020PubMedGoogle ScholarCrossref
72.
Sagedal  LR, Øverby  NC, Bere  E,  et al.  Lifestyle intervention to limit gestational weight gain: the Norwegian Fit for Delivery randomised controlled trial.   BJOG. 2017;124(1):97-109. doi:10.1111/1471-0528.13862PubMedGoogle ScholarCrossref
73.
Seneviratne  SN, Jiang  Y, Derraik  J,  et al.  Effects of antenatal exercise in overweight and obese pregnant women on maternal and perinatal outcomes: a randomised controlled trial.   BJOG. 2016;123(4):588-597. doi:10.1111/1471-0528.13738PubMedGoogle ScholarCrossref
74.
Simmons  D, Devlieger  R, van Assche  A,  et al.  Effect of physical activity and/or healthy eating on GDM risk: the DALI lifestyle study.   J Clin Endocrinol Metab. 2017;102(3):903-913. doi:10.1210/jc.2016-3455PubMedGoogle Scholar
75.
Skouteris  H, McPhie  S, Hill  B,  et al.  Health coaching to prevent excessive gestational weight gain: a randomized-controlled trial.   Br J Health Psychol. 2016;21(1):31-51. doi:10.1111/bjhp.12154PubMedGoogle ScholarCrossref
76.
Smith  K, Lanningham-Foster  L, Welch  A, Campbell  C.  Web-based behavioral intervention increases maternal exercise but does not prevent excessive gestational weight gain in previously sedentary women.   J Phys Act Health. 2016;13(6):587-593. doi:10.1123/jpah.2015-0219PubMedGoogle ScholarCrossref
77.
Thomson  JL, Tussing-Humphreys  LM, Goodman  MH, Olender  SE.  Gestational weight gain: results from the Delta Healthy Sprouts comparative impact trial.   J Pregnancy. 2016;2016:5703607. doi:10.1155/2016/5703607PubMedGoogle Scholar
78.
Van Horn  L, Peaceman  A, Kwasny  M,  et al.  Dietary approaches to stop hypertension diet and activity to limit gestational weight: maternal offspring metabolics family intervention trial, a technology enhanced randomized trial.   Am J Prev Med. 2018;55(5):603-614. doi:10.1016/j.amepre.2018.06.015PubMedGoogle ScholarCrossref
79.
Vesco  KK, Karanja  N, King  JC,  et al.  Efficacy of a group-based dietary intervention for limiting gestational weight gain among obese women: a randomized trial.   Obesity (Silver Spring). 2014;22(9):1989-1996. doi:10.1002/oby.20831PubMedGoogle ScholarCrossref
80.
Vinter  CA, Jensen  DM, Ovesen  P, Beck-Nielsen  H, Jørgensen  JS.  The LiP (Lifestyle in Pregnancy) study: a randomized controlled trial of lifestyle intervention in 360 obese pregnant women.   Diabetes Care. 2011;34(12):2502-2507. doi:10.2337/dc11-1150PubMedGoogle ScholarCrossref
81.
Willcox  JC, Wilkinson  SA, Lappas  M,  et al.  A mobile health intervention promoting healthy gestational weight gain for women entering pregnancy at a high body mass index: the txt4two pilot randomised controlled trial.   BJOG. 2017;124(11):1718-1728. doi:10.1111/1471-0528.14552PubMedGoogle ScholarCrossref
82.
Wolff  S, Legarth  J, Vangsgaard  K, Toubro  S, Astrup  A.  A randomized trial of the effects of dietary counseling on gestational weight gain and glucose metabolism in obese pregnant women.   Int J Obes (Lond). 2008;32(3):495-501. doi:10.1038/sj.ijo.0803710PubMedGoogle ScholarCrossref
83.
Claesson  IM, Josefsson  A, Sydsjö  G.  Prevalence of anxiety and depressive symptoms among obese pregnant and postpartum women: an intervention study.   BMC Public Health. 2010;10:766. doi:10.1186/1471-2458-10-766PubMedGoogle ScholarCrossref
84.
Gray-Donald  K, Robinson  E, Collier  A, David  K, Renaud  L, Rodrigues  S.  Intervening to reduce weight gain in pregnancy and gestational diabetes mellitus in Cree communities: an evaluation.   CMAJ. 2000;163(10):1247-1251.PubMedGoogle Scholar
85.
McGiveron  A, Foster  S, Pearce  J, Taylor  MA, McMullen  S, Langley-Evans  SC.  Limiting antenatal weight gain improves maternal health outcomes in severely obese pregnant women: findings of a pragmatic evaluation of a midwife-led intervention.   J Hum Nutr Diet. 2015;28(suppl 1):29-37. doi:10.1111/jhn.12240PubMedGoogle ScholarCrossref
86.
Epel  E, Laraia  B, Coleman-Phox  K,  et al.  Effects of a mindfulness-based intervention on distress, weight gain, and glucose control for pregnant low-income women: a quasi-experimental trial using the ORBIT model.   Int J Behav Med. 2019;26(5):461-473. doi:10.1007/s12529-019-09779-2PubMedGoogle ScholarCrossref
87.
HD Pulse: an ecosystem of health disparities and minority health resources. National Institute on Minority Health and Health Disparities. Published 2017. Accessed May 2019. https://hdpulse.nimhd.nih.gov/
88.
LeBlanc  ES, Smith  NX, Vesco  KK, Paul  IM, Stevens  VJ.  Weight loss prior to pregnancy and subsequent gestational weight gain: Prepare, a randomized clinical trial.   Am J Obstet Gynecol. 2021;224(1):99.e1-99.e14. doi:10.1016/j.ajog.2020.07.027PubMedGoogle ScholarCrossref
89.
Dodd  JM, McPhee  AJ, Deussen  AR,  et al.  Effects of an antenatal dietary intervention in overweight and obese women on 6 month infant outcomes: follow-up from the LIMIT randomised trial.   Int J Obes (Lond). 2018;42(7):1326-1335. doi:10.1038/s41366-018-0019-zPubMedGoogle ScholarCrossref
90.
Haire-Joshu  D, Cahill  AG, Stein  RI,  et al.  Randomized controlled trial of home-based lifestyle therapy on postpartum weight in underserved women with overweight or obesity.   Obesity (Silver Spring). 2019;27(4):535-541. doi:10.1002/oby.22413PubMedGoogle ScholarCrossref
91.
Harrison  CL, Lombard  CB, Teede  HJ.  Limiting postpartum weight retention through early antenatal intervention: the HeLP-her randomised controlled trial.   Int J Behav Nutr Phys Act. 2014;11:134. doi:10.1186/s12966-014-0134-8PubMedGoogle ScholarCrossref
92.
Herring  SJ, Cruice  JF, Bennett  GG,  et al.  Intervening during and after pregnancy to prevent weight retention among African American women.   Prev Med Rep. 2017;7:119-123. doi:10.1016/j.pmedr.2017.05.015PubMedGoogle ScholarCrossref
93.
Hoffmann  J, Günther  J, Stecher  L,  et al.  Effects of a lifestyle intervention in routine care on short- and long-term maternal weight retention and breastfeeding behavior—12 months follow-up of the cluster-randomized GeliS trial.   J Clin Med. 2019;8(6):19. doi:10.3390/jcm8060876PubMedGoogle ScholarCrossref
94.
Huvinen  E, Koivusalo  SB, Meinilä  J,  et al.  Effects of a lifestyle intervention during pregnancy and first postpartum year: findings from the RADIEL study.   J Clin Endocrinol Metab. 2018;103(4):1669-1677. doi:10.1210/jc.2017-02477PubMedGoogle ScholarCrossref
95.
Kinnunen  TI, Raitanen  J, Aittasalo  M, Luoto  R.  Preventing excessive gestational weight gain—a secondary analysis of a cluster-randomised controlled trial.   Eur J Clin Nutr. 2012;66(12):1344-1350. doi:10.1038/ejcn.2012.146PubMedGoogle ScholarCrossref
96.
Phelan  S, Phipps  MG, Abrams  B,  et al.  Does behavioral intervention in pregnancy reduce postpartum weight retention? twelve-month outcomes of the Fit for Delivery randomized trial.   Am J Clin Nutr. 2014;99(2):302-311. doi:10.3945/ajcn.113.070151PubMedGoogle ScholarCrossref
97.
Rauh  K, Gunther  J, Kunath  J, Stecher  L, Hauner  H.  Lifestyle intervention to prevent excessive maternal weight gain: mother and infant follow-up at 12 months postpartum.   BMC Pregnancy Childbirth. 2015;15:265. doi:10.1186/s12884-015-0701-2PubMedGoogle ScholarCrossref
98.
Thomson  JL, Goodman  MH, Tussing-Humphreys  LM, Landry  AS.  Infant growth outcomes from birth to 12 months of age: findings from the Delta Healthy Sprouts randomized comparative impact trial.   Obes Sci Pract. 2018;4(4):299-307. doi:10.1002/osp4.272PubMedGoogle ScholarCrossref
99.
Vesco  KK, Leo  MC, Karanja  N,  et al.  One-year postpartum outcomes following a weight management intervention in pregnant women with obesity.   Obesity (Silver Spring). 2016;24(10):2042-2049. doi:10.1002/oby.21597PubMedGoogle ScholarCrossref
100.
Garnæs  KK, Nyrnes  SA, Salvesen  KA, Salvesen  Ø, Mørkved  S, Moholdt  T.  Effect of supervised exercise training during pregnancy on neonatal and maternal outcomes among overweight and obese women: secondary analyses of the ETIP trial: a randomised controlled trial.   PLoS One. 2017;12(3):e0173937. doi:10.1371/journal.pone.0173937PubMedGoogle Scholar
101.
Phelan  S, Wing  RR, Brannen  A,  et al.  Does partial meal replacement during pregnancy reduce 12-month postpartum weight retention?   Obesity (Silver Spring). 2019;27(2):226-236. doi:10.1002/oby.22361PubMedGoogle ScholarCrossref
102.
Sagedal  LR, Sanda  B, Øverby  NC,  et al.  The effect of prenatal lifestyle intervention on weight retention 12 months postpartum: results of the Norwegian Fit for Delivery randomised controlled trial.   BJOG. 2017b;124(1):111-121. doi:10.1111/1471-0528.13863PubMedGoogle ScholarCrossref
103.
Tanvig  M, Vinter  CA, Jørgensen  JS,  et al.  Effects of lifestyle intervention in pregnancy and anthropometrics at birth on offspring metabolic profile at 2.8 years: results from the Lifestyle in Pregnancy and Offspring (LiPO) study.   J Clin Endocrinol Metab. 2015;100(1):175-183. doi:10.1210/jc.2014-2675PubMedGoogle ScholarCrossref
104.
Tanvig  M, Vinter  CA, Jørgensen  JS,  et al.  Anthropometrics and body composition by dual energy x-ray in children of obese women: a follow-up of a randomized controlled trial (the Lifestyle in Pregnancy and Offspring [LiPO] study).   PLoS One. 2014;9(2):e89590. doi:10.1371/journal.pone.0089590PubMedGoogle Scholar
105.
Vinter  CA, Jensen  DM, Ovesen  P,  et al.  Postpartum weight retention and breastfeeding among obese women from the randomized controlled Lifestyle in Pregnancy (LiP) trial.   Acta Obstet Gynecol Scand. 2014;93(8):794-801. doi:10.1111/aogs.12429PubMedGoogle ScholarCrossref
106.
American College of Obstetricians and Gynecologists.  ACOG practice bulletin No. 202: gestational hypertension and preeclampsia.   Obstet Gynecol. 2019;133(1):e1-e25. doi:10.1097/aog.0000000000003018PubMedGoogle Scholar
107.
Dodd  JM, Grivell  RM, Owens  JA.  Antenatal dietary and lifestyle interventions for women who are overweight or obese: outcomes from the LIMIT randomized trial.   Curr Nutr Rep. 2014;3(4):392-399. doi:10.1007/s13668-014-0101-7Google ScholarCrossref
108.
Patnode  CD, Evans  CV, Senger  CA, Redmond  N, Lin  JS.  Behavioral Counseling to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Known Cardiovascular Disease Risk Factors: Updated Systematic Review for the U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality; 2017.
109.
LeBlanc  ES, Patnode  CD, Webber  EM, Redmond  N, Rushkin  M, O’Connor  EA.  Behavioral and pharmacotherapy weight loss interventions to prevent obesity-related morbidity and mortality in adults: updated evidence report and systematic review for the US Preventive Services Task Force.   JAMA. 2018;320(11):1172-1191. doi:10.1001/jama.2018.7777PubMedGoogle ScholarCrossref
110.
Patnode  CD, Evans  CV, Senger  CA, Redmond  N, Lin  JS.  Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults without known cardiovascular disease risk factors: updated evidence report and systematic review for the US Preventive Services Task Force.   JAMA. 2017;318(2):175-193. doi:10.1001/jama.2017.3303PubMedGoogle ScholarCrossref
111.
MacDorman  MF, Declercq  E, Thoma  ME.  Trends in maternal mortality by sociodemographic characteristics and cause of death in 27 states and the District of Columbia.   Obstet Gynecol. 2017;129(5):811-818. doi:10.1097/AOG.0000000000001968PubMedGoogle ScholarCrossref
112.
Tucker  MJ, Berg  CJ, Callaghan  WM, Hsia  J.  The Black-White disparity in pregnancy-related mortality from 5 conditions: differences in prevalence and case-fatality rates.   Am J Public Health. 2007;97(2):247-251. doi:10.2105/AJPH.2005.072975PubMedGoogle ScholarCrossref
113.
Cornell  JE, Mulrow  CD, Localio  R,  et al.  Random-effects meta-analysis of inconsistent effects: a time for change.   Ann Intern Med. 2014;160(4):267-270. doi:10.7326/M13-2886PubMedGoogle ScholarCrossref
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