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Original Investigation
November 20, 2019

Association of Maternal Eating Disorders With Pregnancy and Neonatal Outcomes

Author Affiliations
  • 1Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
  • 2Theme Children’s and Women’s Health, Pregnancy Care and Delivery, Karolinska University Hospital, Stockholm, Sweden
  • 3Division of Obstetrics and Gynecology, Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
  • 4Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
JAMA Psychiatry. Published online November 20, 2019. doi:https://doi.org/10.1001/jamapsychiatry.2019.3664
Key Points

Question  Are maternal eating disorders associated with an increased risk of adverse pregnancy and neonatal outcomes?

Findings  In this cohort study comprising all singleton births in Sweden between 2003 and 2014, maternal eating disorders were associated with adverse pregnancy outcomes, such as antepartum hemorrhage, and with adverse neonatal outcomes, such as preterm birth, small size for gestational age, and microcephaly. The risk of most of these outcomes was most pronounced in women with an active eating disorder but was also significantly increased in women with a previous eating disorder.

Meaning  Eating disorders appear to be associated with an increased risk of adverse pregnancy and neonatal outcomes; these results highlight the importance of acknowledging eating disorders among pregnant women and considering the potential association with maternal and neonatal health.


Importance  The prevalence of eating disorders is high among women of reproductive age, yet the association of eating disorders with pregnancy complications and neonatal health has not been investigated in detail, to our knowledge.

Objective  To investigate the relative risk of adverse pregnancy and neonatal outcomes for women with eating disorders.

Design, Setting, and Participants  This population-based cohort study included all singleton births included in the Swedish Medical Birth Register from January 1, 2003, to December 31, 2014. A total of 7542 women with eating disorders were compared with 1 225 321 women without eating disorders. Statistical analysis was performed from January 1, 2018, to April 30, 2019. Via linkage with the national patient register, women with eating disorders were identified and compared with women free of any eating disorder. Eating disorders were further stratified into active or previous disease based on last time of diagnosis.

Main Outcomes and Measures  The risk of adverse pregnancy outcomes (hyperemesis, anemia, preeclampsia, and antepartum hemorrhage), the mode of delivery (cesarean delivery, vaginal delivery, or instrumental vaginal delivery), and the neonatal outcomes (preterm birth, small and large sizes for gestational age, Apgar score <7 at 5 minutes, and microcephaly) were calculated using Poisson regression analysis to estimate risk ratios (RRs). Models were adjusted for age, parity, smoking status, and birth year.

Results  There were 2769 women with anorexia nervosa (mean [SD] age, 29.4 [5.3] years), 1378 women with bulimia nervosa (mean [SD] age, 30.2 [4.9] years), and 3395 women with an eating disorder not otherwise specified (EDNOS; mean [SD] age, 28.9 [5.3] years), and they were analyzed and compared with 1 225 321 women without eating disorders (mean [SD] age, 30.3 [5.2] years). All subtypes of maternal eating disorders were associated with an approximately 2-fold increased risk of hyperemesis during pregnancy (anorexia nervosa: RR, 2.1 [95% CI, 1.8-2.5]; bulimia nervosa: RR, 2.1 [95% CI, 1.6-2.7]; EDNOS: RR, 2.6 [95% CI, 2.3-3.0]). The risk of anemia during pregnancy was doubled for women with active anorexia nervosa (RR, 2.1 [95% CI, 1.3-3.2]) or EDNOS (RR, 2.1 [95% CI, 1.5-2.8]). Maternal anorexia nervosa was associated with an increased risk of antepartum hemorrhage (RR, 1.6 [95% CI, 1.2-2.1]), which was more pronounced in active vs previous disease. Women with anorexia nervosa (RR, 0.7 [95% CI, 0.6-0.9]) and women with EDNOS (RR, 0.8 [95% CI, 0.7-1.0]) were at decreased risk of instrumental-assisted vaginal births; otherwise, there were no major differences in mode of delivery. Women with eating disorders, all subtypes, were at increased risk of a preterm birth (anorexia nervosa: RR, 1.6 [95% CI, 1.4-1.8]; bulimia nervosa: RR, 1.3 [95% CI, 1.0-1.6]; and EDNOS: RR, 1.4 [95% CI, 1.2-1.6]) and of delivering neonates with microcephaly (anorexia nervosa: RR, 1.9 [95% CI, 1.5-2.4]; bulimia nervosa: RR, 1.6 [95% CI, 1.1-2.4]; EDNOS: RR, 1.4 [95% CI, 1.2-1.9]).

Conclusions and Relevance  The findings of this study suggest that women with active or previous eating disorders, regardless of subtype, are at increased risk of adverse pregnancy and neonatal outcomes and may need increased surveillance in antenatal and delivery care.

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