The association between pre-pregnancy body mass index and perinatal death and the role of gestational age at delivery.

Abstract

The pathophysiology behind the association between obesity and perinatal death is not fully understood but may be in part due to higher rates of pregnancy complications at earlier gestation amongst obese women. We aimed to quantify the proportion of perinatal deaths amongst obese and overweight women mediated by gestational age at stillbirth or live birth. The study included all singleton births at ≥20 weeks' gestation in British Columbia, 2004-2017, and excluded pregnancy terminations. The proportion of the association between BMI and perinatal death mediated by gestational age at delivery (in weeks) was estimated using natural effect models, with adjustment for potential confounders. Sensitivity analyses for unmeasured confounding and women missing BMI were conducted. Of 392,820 included women, 20.6% were overweight and 12.8% obese. Women with higher BMI had a lower gestational age at delivery. Perinatal mortality was 0.5% (1834 pregnancies); and was elevated in overweight (adjusted odds ratio [AOR] = 1.22, 95% confidence interval [CI] 1.08-1.37) and obese women (AOR = 1.55, 95% CI 1.36-1.77). Mediation analysis showed that 63.1% of the association between obesity and perinatal death was mediated by gestational age at delivery (natural indirect effect AOR = 1.32, 95% CI 1.23-1.42, natural direct effect AOR = 1.18, 95% CI 1.05-1.32). Similar, but smaller effects were seen when comparing overweight women vs. women with a normal BMI. Estimated effects were not affected by adjustment for additional risk factors for perinatal death or sensitivity analyses for missing data. Obese pregnancies have a higher risk of perinatal death in part mediated by a lower gestational age at delivery.