Download Retention of Pregnancy-Related Weight in the Early Postpartum

IN REVIEW
Retention of Pregnancy-Related Weight
in the Early Postpartum Period:
Implications for Women’s Health Services
Lorraine O. Walker, Bobbie Sue Sterling, and Gayle M. Timmerman
Objective: To examine the proportion of women
who reached their prepregnant weight at 6 weeks
postpartum and the average amount of weight
retained or lost by this time; to determine predictors of
early (6 week) postpartum weight retention; and to
propose related implications for women’s health care
and services.
Data Sources: The literature review was based
on a search of Medline for the years 1986 to 2004
using the keywords postpartum weight with inclusion
of additional articles known to the authors that did not
appear in the electronic search.
Study Selection: The resulting 83 articles were
scrutinized to identify those that reported data on
weight retention at 6 weeks postpartum (range, delivery to 3 months) and associated anthropometric,
social, obstetric, or behavioral predictors. A total of
12 articles met inclusion criteria for the review.
Data Extraction: Data were extracted related to
the proportion of women achieving their postpartum
weight at 6 weeks postpartum, the amount of weight
retained or lost up to 6 weeks postpartum, and predictors of amount of weight retained or lost.
Data Synthesis: On average, at 6 weeks postpartum, women retain 3 to 7 kg of the weight gained
during pregnancy, with at least two thirds exceeding
their prepregnant weights. Gestational weight gain is
the most significant predictor of weight retention.
Conclusions: Women vulnerable to obesity and
weight gain need weight-related health care and
improved access to such care to promote weight loss
after 6 weeks postpartum. JOGNN, 34, 418-427;
2005. DOI: 10.1177/0884217505278294
Keywords: African American—body mass
index—Hispanic—postpartum weight—pregnancy
418 JOGNN
Accepted: October 2004
Promotion of women’s health across the lifespan
requires that health care professionals address health
risks at each life stage. Because pregnancy is considered a “normal” event, risks in later life stemming
from large weight gains and obesity as a consequence of pregnancy have received only limited
attention. Only a few studies have tracked long-term
aftereffects (8 to 15 years) of weight gain associated
with pregnancy (Linne, Barkeling, & Rossner, 2002;
Linne, Dye, Barkeling, & Rossner, 2003; Rooney &
Schauberger, 2002). The epidemic of obesity in the
United States provides an important reason for critically examining weight gain and obesity after childbirth.
This review focuses on articles about weight at
the end of the 6th postpartum week, because for
most women, the 6th postpartum week is the endpoint of maternity-related care. Articles addressing
the proportion of women who reach their prepregnant weight at 6 weeks postpartum, the average
amount of weight retained or lost by this time, and
predictors of early (6 week) postpartum weight
retention are considered.
Reproductive Weight Gain
and Health Disparities
During pregnancy, probably through hormonal
mechanisms (Hytten, 1991), 2 to 10 kg of fat is
stored in women’s bodies (Harris & Ellison, 1997).
In their review, Gunderson and Abrams (1999) concluded that 14% to 20% of women do not lose all
Volume 34, Number 4
this weight and have an enduring weight gain of 5 kg or
more as an aftereffect of pregnancy. Excessive weight gain
or obesity pose health risks in relation to perinatal complications, such as birth defects, hypertension of pregnancy, gestational diabetes, macrosomia, and cesarean delivery (Cedergren & Kallen, 2003; Crane, Wojtowycz, Dye,
Aubry, & Artal, 1997; Shaw, Velie, & Schaffer, 1996;
Weiss et al., 2004), as well as a number of chronic illnesses, such as coronary heart disease, type 2 diabetes,
and cancer (Calle, Thun, Petrelli, Rodriguez, & Heath,
1999; Field et al., 2001; Kumar, Lyman, Allen, Cox, &
Schapira, 1995; Must et al., 1999; Willett et al., 1995).
Consequently, postpartum weight gain as a result of pregnancy should not be considered benign.
Furthermore, because overweight and obesity generally have a higher prevalence among African American and
Hispanic women (Flegal, Carroll, Kuczmarski, & Johnson, 1998; Must et al., 1999), it is also important to
assess whether these groups have higher retained weight
during the early postpartum period. There is some evidence that during the latter half of the 1st postpartum
year African American women retain more weight from
pregnancy than do White women (Boardley, Sargent,
Coker, Hussey, & Sharpe, 1995; Keppel & Taffel, 1993;
Parker & Abrams; 1993; Smith et al., 1994). For example, in a low-income sample assessed at 7 to 12 months
postpartum, Boardley and colleagues found that African
American women overall retained about 3 kg more
pregnancy-related weight than did White women. In the
National Maternal and Infant Health Survey, African
American women (45%) were more likely than White
women (25%) to retain at least 9 lb (4.1 kg) between 10
and 18 months postpartum (Keppel & Taffel, 1993).
Despite this finding, African American women and Hispanic women are less likely than White women to have
excessive weight gains during pregnancy (Centers for Disease Control and Prevention, 1998). Thus, analysis of
early weight retention, such as at 6 weeks postpartum,
may contribute insights into when ethnic minority women
experience turning points for weight retention and what
factors may be important to prevent permanent weight
gain.
Methodology
This literature review is based on a search of Medline
for the years 1986 to 2004 using the keywords postpartum weight. That search identified 78 articles, and to
these we added 5 additional articles on postpartum
weight that did not appear in the Medline search. We
scrutinized the resulting 83 articles to identify those that
reported data on weight retention at 6 weeks postpartum
(range, postdelivery to 3 months) and associated anthropometric, social, obstetric, or behavioral predictors. We
July/August 2005
omitted studies that did not report 6 weeks weight retention data, had fewer than 100 participants, analyzed
weight data as trends that did not allow specific identification of 6-week predictors, reported data from clinical
trials attempting to modify postpartum weight, or failed
to report how weight-retention data were collected and
computed. We also omitted articles that were editorials or
commentaries, literature reviews, repeats of a preceding
article, non-English articles, studies of malnourished populations, investigations of specific hormones and weight,
and one study of only obese women, because of their
unique characteristics. A total of 12 articles reported
research on weight retention at 6 weeks postpartum and
associated anthropometric, social, obstetric, or behavioral
predictors (Tables 1 and 2).
Reaching Prepregnant Weight
at 6 Weeks Postpartum
Early studies estimating how many women reached
their prepregnancy weight at 6 weeks postpartum focused
primarily on middle-class White women (Olsen, 1979;
Olsen & Mundt, 1986; Schauberger, Rooney, & Brimer,
1992). Olsen and Mundt found that 28% of women in
the sample reached their prepregnancy weight by the 6th
postpartum week. Schauberger et al. reported that 22%
of women in their study at 6 weeks postpartum reached
their baseline weight measured in early pregnancy. A
recent study of low-income, ethnically diverse women
found that 15% of women overall reached their prepregnant weights at 6 weeks postpartum, and the proportions
for specific ethnic groups did not differ significantly
(12.6% to 17.8%) (Walker, Timmerman, Sterling, Kim,
& Dickson, 2004). From these studies, it is clear that only
a small proportion of women reach their prepregnant
weight by 6 weeks postpartum. Even if studies underestimate those proportions because of use of self-reported
prepregnancy weights (Walker et al., 2004), it is likely
that more than two thirds of women face some degree of
weight retention at 6 weeks postpartum.
Weight Retention at 6 Weeks
Postpartum and Its Predictors
Because most women do not attain their prepregnant
weight by 6 weeks postpartum, it is important to determine how much weight they retain. Table 1 presents a
summary of studies on postpartum weight retention in the
early postpartum months. Studies in Table 1 computed
postpartum weight retention in reference to prepregnant
weight (Luke, Hediger, & Scholl, 1996; Muscati, GrayDonald, & Koski, 1996; Olsen & Mundt, 1986; Parham,
Astrom, & King, 1990; Scholl, Hediger, Schall, Ances, &
Smith, 1995; Sampselle, Seng, Yeo, Killion, & Oakley,
JOGNN 419
TABLE 1
Studies of Early Postpartum Weight Retention (Based on Prepregnant or 1st Trimester Weight)
Study
Sample
Time
PP
Olsen &
Mundt, 1986
Parham et al.,
1990
182 White, African American, and
Hispanic women
114 White, African American,
Hispanic, and Asian women
6 wk
Lawrence
et al., 1991
115 women in the United Kingdom.
2-3 wk
Schauberger
et al., 1992
795 White women
6 wk
Scholl et al.,
1995
274 African American, Puerto
Rican Hispanic, and White
adolescents and adult women
4-6 wk
Luke et al.,
1996
487 African American and (?) White
women
2d
2.7 kg
Ethnicity Effects
on Weight
Retained
Predictors of Weight Retention
Not reported Not reported
1 to 3 mo 4.2 kg
Muscati et al., 371 White Canadian women
1996
6 wk
To & Cheung, 292 Chinese women
1998
6 wk,
3 mo
Sampselle
et al., 1999
Walker et al.,
2004
6 wk
1,003 White, Asian, and African
American women
419 African American, Hispanic, and
White women
Weight
Retaineda
6 wk
Not reported + MWG; + prepregnant BMI; 0 age;
0 parity; 0 gravidity; 0 birth weight;
0 gestational length; 0 week entered
prenatal care
-0.6-8.6
One ethnic
+ GWG; U initial prenatal weight;
kg for
group (?);
0 adjusted birth weight; 0 height;
GWG
no
0 gestational length; 0 maternal age;
subgroups comparisons 0 infant sex; 0 parity; 0 initial body
fat content; U skinfold thickness
during pregnancy
3 kg
One ethnic
Not reported
group; no
comparisons
3.1-9.4
Ethnicity
+ GWG; 0 breastfeeding
kg for
controlled;
GWG
effects not
subgroups explicitly
reported
4.2-6.6 kg Ethnicity
+ GWG; – prepregnancy BMI
for BMI
controlled;
subgroups effects not
explicitly
reported
5.3 kg
One ethnic
+ GWG; 0 birth weight; 0 prepregnant
group (?); no weight; 0 parity; 0 gestational length;
comparisons 0 infant sex
6.77 kg,
One ethnic
+ GWG; 0 prepregnant weight; 0 parity;
3.64 kg
group; no
0 gestational length; + height; 0 infant
comparisons sex; 0 birth weight
4.8 kg
Not reported - Physical activity level (i.e., exercise)
6.2 kg for Ethnic groups + MWG; – prepregnant BMI; 0 parity;
Hispanic,
did not differ 0 gestational length; 0 age; 0 partner
6.7 kg for on amount of status; 0 employment; 0 cesarean
African
retained
delivery; 0 breastfeeding; 0 smoking;
American, weight
0 weight management strategies
and 6.9 kg
for White
women
Note. + = positive association; – = negative association; 0 = no association; U = curvilinear or nonlinear association; (?) = unclear or not stated; GWG
= gestational weight gain, MWG = GWG minus infant birth weight; BMI = body mass index; Time PP = postpartum time point when weight change
was measured.
aTo
convert kg to lb, multiply kg × 2.205.
1999; To & Cheung 1998; Walker et al., 2004) or a surrogate weight, such as weight at the 1st prenatal visit
(Lawrence, McKillop, & Durnin, 1991; Schauberger et
al., 1992). In some studies, the retained weights listed
were reported by subgroups, such as prepregnant body
420 JOGNN
mass index, or were measured at varying times during the
early postpartum months (2 days through 1-3 months). In
studies reporting retained weight specifically at 6 weeks
postpartum, the range was approximately 3 to 7 kg, with
higher retained weights reported in studies that were
Volume 34, Number 4
TABLE 2
Studies of Early Postpartum Weight Loss (Referenced to Weight at End of Pregnancy)
Study
Olsen &
Mundt,
1986
Potter
et al., 1991
Sample
Time PP
182 White, African American, 6 wk
and Hispanic women
101 low-income and 269
non-low-income women
(ethnicity not given)
Schauberger 795 White women
et al., 1992
Gunderson 985 Hispanic, White,
et al., 2001 African American, and
Asian women
Weight Lossa
9.9 kg (21.9 lb)
Ethnicity Effects
on Weight Loss
Not reported
Predictors of Weight Loss
+ GWG; U gravidity; 0 breastfeeding; 0 contraceptive method
Low income group: + cesarean
delivery; – breastfeeding;
0 gestational length; 0 gravidity
Non-low-income group:
– gestational length; – gravidity;
0 cesarean delivery; 0 breastfeeding
Both groups: + GWG; 0 infant
sex; 0 age; 0 birth weight;
0 prepregnant weight
6 wk
8.9-12.1 kg for
One ethnic group; + GWG; 0 age; 0 marital status;
GWG
no comparisons
0 employment; – parity; + birth
subgroups
weight; + cesarean delivery;
0 breastfeeding; 0 exercise;
0 smoking; 0 contraceptive
method; 0 alcohol use
Adjusted Adjusted means Ethnicity controlled 0 prepregnant BMI
to 6 wk of 6.3-6.6 kg
in most analyses
for BMI suband did not
groups (birth
moderate BMI
weight excluded) group effects on
weight change;
“similar patterns”
for African
American and
White women
noted but main
effects for
ethnicity not
reported explicitly
6 wk
6.3 kg, lowNot reported
income; 6.6 kg,
non-low-income
(birth weight
excluded)
Note. + = positive association; – = negative association; 0 = no association; U = curvilinear or nonlinear association; GWG = gestational weight gain,
MWG = GWG minus infant birth weight; BMI = body mass index; Time PP = postpartum time point when weight change was measured.
more recent. Regarding weight retention and ethnicity, 6
of 10 studies contained multiethnic samples. Only one
compared retained weight among ethnic groups, and
these did not differ significantly (Walker et al., 2004).
G
estational weight gain has a consistent
positive relationship to weight retained during
the postpartum period.
Table 1 also identifies predictors of early postpartum
weight retention. Gestational weight gain (or maternal
July/August 2005
prenatal weight gain, which excludes birth weight) had a
consistent positive relationship to postpartum retained
weight, whereas maternal height and prepregnant weight
or prepregnant body mass index each demonstrated varying relationships to retained weight. Maternal age, gravidity or parity, gestational length, infant sex, breastfeeding, and infant birth weight were consistently unrelated to
retained weight. Other variables occurred in too few studies to discern a pattern. Regarding health practices associated with postpartum weight change at 6 weeks postpartum, Walker et al. (2004) examined multiple health
practices, such as smoking and weight management
strategies, and none was significantly associated with
weight retention at 6 weeks postpartum. In two of the
three studies that tested multivariate regression models
JOGNN 421
predicting postpartum retained weight, maternal prenatal
weight gain (Parham et al., 1990) or gestational weight
gain (Muscati et al., 1996) was the only significant predictor. In the 3rd study, maternal weight gain accounted
for the most variance in amount of postpartum retained
weight with additional small amounts accounted for by
Hispanic ethnicity and interactions between maternal
weight gain and gestational length (Walker et al., 2004).
Failure of most women to reach their prepregnant
weights at 6 weeks may be explained in part by patterns
of weight loss in the early postpartum days. For example,
even normal weight women whose prenatal gain is at the
midpoint of Institute of Medicine (IOM, 1990) recommendations for their weight class (13.75 kg) would be
expected to retain about 4.75 kg after delivery of the
products of conception (5 kg) and early fluid loss and tissue reductions (4 kg) during the 1st 2 postpartum weeks
(Hytten, 1991; Lawrence et al., 1991; Schauberger et al.,
1992). Weight remaining thereafter is largely attributable
to fat stores (Sohlstrom & Forsum, 1995). To lose weight,
the National Heart, Lung, and Blood Institute (1998) recommends that overweight (nonlactating) women seek a
weight loss of 0.22 to 0.45 kg per week by reducing
caloric intake 300 to 500 kcal per day. Accordingly, it
should take from 11 to 22 weeks to lose 4.75 kg. However, Lawrence et al. (1991) reported that fat stores in the
early postpartum period are lost at the rate of 0.25 kg per
week. Thus, the longer estimated time for weight loss may
be more typical in the postpartum period. Because many
women exceed the upper limits of IOM recommended
gestational weight gain (Schieve, Cogswell, & Scanlon,
1998; Walker & Kim, 2002), this factor is a key influence
on the amount of retained weight at 6 weeks postpartum
(Muscati et al., 1996; Parham et al., 1990; Walker et al.,
2004). Thus, evidence that the majority of women fail to
reach prepregnant weight by 6 weeks postpartum is congruent with current recommendations for weight gain in
pregnancy and sources of very early postpartum weight
loss.
Weight Loss at 6 Weeks Postpartum
and Its Predictors
It is important to address one criticism of using
retained weight to study postpartum weight changes. The
computation of retained weight raises the possibility of
inflated relationships between gestational weight gain and
postpartum weight retention (Gunderson & Abrams,
1999). This problem occurs because both of these reproductive weights use a common prepregnant or prenatal
weight as their baseline. Thus, some researchers have used
late pregnancy weight (such as weight at the last prenatal
visit) as a baseline for computing postpartum weight
change.
422 JOGNN
Table 2 presents a summary of studies of postpartum
weight loss in the early postpartum months. For some
studies in Table 2, postpartum weight loss was computed
using weight at the end of pregnancy as the reference
weight (Olsen & Mundt, 1986; Schauberger et al., 1992).
In other studies, the reference weight at the end of pregnancy excludes infant birth weight but not other products
of conception (Gunderson, Abrams, & Selvin, 2001; Potter et al., 1991). Postpartum weight loss at 6 weeks
ranged from about 6.5 kg to about 9.5 kg; differences of
about 3 kg are evident between studies, dependening on
whether birth weight was included or excluded from
weight at the end of pregnancy. Only one of two studies
including ethnic minority women reported weight loss
findings by ethnic group. Gunderson et al. (2001) provided means for early postpartum weight loss (excluding
birth weight) at 6 weeks postpartum according to
women’s body mass index classifications: for Hispanic
women, mean weight loss ranged from 5.0 to 6.3 kg,
depending on body mass index; for White women, from
6.6 to 7.4 kg; for African American women, from 5.7 to
7.1 kg; and for Asian women, from 5.7 to 7.1 kg.
The articles in Table 2 demonstrate that gestational
weight gain had a consistent relationship to postpartum
weight loss. In contrast, prepregnant body mass index
was not associated with postpartum weight loss at 6
weeks postpartum. Moreover, a number of predictors had
inconsistent (e.g., birth weight, gravidity or parity, and
cesarean delivery) or nonsignificant (e.g., age and contraception) relationships to weight loss. Still other predictors
occurred in too few studies to discern a pattern. Regarding health practices associated with postpartum weight
loss at 6 weeks postpartum, Table 2 demonstrates that
infant feeding method is one of the few health practices to
receive attention across studies. Breastfeeding was either
associated with no differences in weight loss or with less
weight loss at 6 weeks postpartum. Only Schauberger and
colleagues (1992) examined multiple health practices,
such as exercise or alcohol use, and none was significantly associated with weight loss at 6 weeks postpartum.
M
ore than two thirds of women face some
degree of weight retention at 6 weeks
postpartum.
In examining multivariate predictors of postpartum
weight loss, Schauberger et al. (1992) found five significant predictors: gestational weight gain, prepregnant
weight, infant birth weight, parity, and delivery method.
Volume 34, Number 4
TABLE 3
Internet Resources for Healthy Women of Childbearing Age
http://nhlbi.nih.gov/index.htm
http://www.niddk.nih.gov/health/nutrit/nutrit.htm
http://healthypeople.gov/
http://www.cdc.gov/nccdphp/dnpa/obesity/index.htm
http://www.health.gov/dietaryguidelines/
National Heart, Lung, and Blood Institute of the NIH. Includes links for
publications and educational tutorials on weight, physical activity, and
healthy eating.
Weight Control Information Network of the NIH. Links to general and
specific weight-loss approaches.
Home site for Healthy People 2010, including goals, objectives,
determinants of health and health status. Includes links to individual
state and community projects for achieving Healthy People 2010 goals.
Centers for Disease Control and Prevention. Includes links to definitions of
obesity, trends in obesity development, contributing factors and consequences
of overweight and obesity.
Information about nutrition and weight, including dietary guidelines and
other selected governmental documents
Potter et al. (1991) also examined multivariate predictors
of weight loss with gestational weight gain acting as a significant predictor for both low-income and non-lowincome women. Cesarean delivery and breastfeeding were
additional predictors for low-income women, as were gestational length and gravidity for non-low-income women.
In multivariate analyses of both postpartum retained
weight and postpartum weight loss outcomes, gestational
or maternal prenatal weight gain was consistently the
major predictor. For other variables in multivariate analyses, it is difficult to determine whether the differing patterns of predictors of weight loss at 6 weeks postpartum
compared to those mentioned earlier for retained weight
derive from inherent differences between these two postpartum weight phenomena or from other facets of the
studies.
Although studies of postpartum weight loss circumvent
the computational problems inherent in studies of weight
retention mentioned earlier, it is not clear that postpartum
weight loss has the same clinical implications for longterm health as does weight gain (Willett et al., 1995),
which is reflected in retained weight. In addition, knowing how much weight women have lost is not necessarily
informative because the significance of the loss depends
on how much weight they gained during pregnancy. To
solve this interpretive problem, Gunderson and colleagues
(2001) computed weight loss as a percentage of gestational weight gain. However, in doing so, they may have
indirectly introduced the computational problems associated with postpartum weight retention. One other limitation of measuring postpartum weight loss as an outcome
is that it does not distinguish between solely maternal
weight loss and weight loss attributable to fetal-related
tissues (e.g., placenta and amniotic fluid).
July/August 2005
Implications of Retained Weight for
Women’s Health Services
Regardless of the method used to calculate postpartum
weight change, excess weight retained after a pregnancy
may predispose a woman to chronic health problems.
Lederman (2001) identified three spheres of action to
reduce overweight and obesity among childbearing
women: preconception weight management, attainment
of recommended weight gain during pregnancy, and postpartum weight management. Each sphere contributes to
reducing morbidities associated with obesity and weight
gain.
With obesity now at epidemic proportions (National
Task Force on the Prevention and Treatment of Obesity,
2000), it is imperative that nurses be actively involved in
identifying those at risk for obesity and providing educational resources and support to overweight women,
whatever their current reproductive status. Preconception
interventions to reduce weight are ideal yet challenging,
because 50% to 60% of all pregnancies are unplanned
(Henshaw, 1998). Clinical guidelines for managing overweight and obesity (National Heart, Lung, and Blood
Institute Obesity Education Initiative Expert Panel, 1998)
are useful in planning care for nonpregnant and nonlactating women. Table 3 includes a list of Internet Web sites
that offer information in Spanish and English on weight,
nutrition, and physical activity that can be downloaded
and printed for dissemination to patients and providers.
Current IOM implementation guidelines (1992) provide recommendations for patient guidance regarding
nutrition and weight gain during pregnancy. Unfortunately, research on effective approaches to prevent high
weight gain during pregnancy is sparse because the major-
JOGNN 423
ity of weight-related research in the perinatal period has
focused on reducing low gestational weight gain to avoid
low birth weight. Various approaches that women can use
between scheduled prenatal visits, such as self-monitoring
of weight using a commercially provided grid that shows
recommended weekly weight gain for body mass index
(Ann Cooney, RNC, MSN, personal communication,
February 9, 2004) or keeping a journal of food intake to
compare with recommended dietary intake, may encourage greater efficacy in gaining weight within recommended amounts. Recent guidelines for exercise during pregnancy from the American College of Obstetricians and
Gynecologists (ACOG, 2002) provide a framework for
helping pregnant women increase physical activity to
maximize health benefits without compromising fetal
well-being.
Prenatal weight gain recommendations, however, will
have limited benefit for women who enter prenatal care
late in pregnancy. Because gestational weight gain is one
of the most significant predictors for postpartum retained
weight, it is critical that pregnant women be encouraged
to begin prenatal care early and continue regular visits.
During the postpartum period, it has traditionally been
assumed that women return to a prepregnant status by
the 6th postpartum week (Cunningham et al., 2001).
Although this assumption may be true for some body systems, for at least two thirds of women, it is unlikely to be
true of prenatally stored fat reflected in postpartum
retained weight. In studies reporting mean retained
weight at 6 weeks postpartum, women were about 3 to 7
kg heavier at 6 weeks than before pregnancy (Table 1).
Thus, early detection of high postpartum retained weight
is an important step in preventing that weight from contributing to enduring health problems.
Research findings of the effect of lactation on weight
changes during the early postpartum period are inconsistent (Walker, 1995), probably resulting from variations in
maternal dietary intakes and intensity of breastfeeding as
well as the timing of solid food introduction. Still, lactation continued for at least 6 months may enhance later
postpartum weight loss (Dewey, Heinig, & Nommsen,
1993). Nurses can be valuable resources for breastfeeding
women by referring them to available resources (e.g., hospital lactation resources or the La Leche League) for support in balancing physical and nutritional needs for effective breastfeeding, especially if the women resume
employment. Although reduced-calorie diets to promote
postpartum weight loss have been tested with breastfeeding mothers in a few studies (Lovelady, Garner, Moreno,
& Williams, 2000), it is controversial as to when such
diets should begin. For example, Butte (2000) recommended that reduced-calorie diets not begin before 4 to 6
months postpartum to ensure adequate growth of breastfed infants. For this reason, nurses should work in col-
424 JOGNN
laboration with clinical dietitians in monitoring or counseling women about dietary changes when breastfeeding.
Women who are able to increase or maintain physical
activity after childbirth receive positive health benefits
(Sampselle et al., 1999; Mottola, 2002). Thus, helping
women identify suitable types of exercise and areas in
which to exercise safely and inexpensively should also be
a part of counseling with women during the postpartum
period.
The postpartum period is heavily vested in the psychosocial, making it critical that weight management
services be responsive in that context (Walker, 1995), and
managing depression is a part of the postpartum experience for many new mothers (O’Hara, 1995; Sobey, 2002).
It has been reported that 50% to 80% of new mothers
experience postpartum “baby blues,” which is common
after pregnancy and not considered a mental health condition. However, up to 20% of women experience severe
symptoms and may develop postpartum depression
(Sobey, 2002). Elevated depressive symptoms affect
women differently, resulting in either increased or
decreased caloric intakes that affect weight. Because
symptoms may not develop until several months after
birth, pediatric nurses and pediatricians may be in a
unique position to assess women for signs of postpartum
depression while providing routine and episodic infant
care (Olson et al., 2002).
In counseling women about weight management during the postpartum period, it is important that nurses be
responsive to women’s readiness for change. Research has
shown that for postpartum women, ignoring weight during the early postpartum period may be common when
faced with the daunting task of caring for a newborn
(Walker et al., 2004). Understanding of the transtheoretical behavioral model—a model of the stages of behavioral
change—allows the nurse to interpret such disinterest as
the 1st stage of the change process. Thus, in the precontemplation stage of behavior change (Prochaska, Redding, & Evers, 1997), a period during which one is not
interested in addressing behavior change, specific strategies that may facilitate change involve increasing the pros
of changing the behavior (i.e., advantages of losing
weight). In addition, some obese women may have
attempted weight loss previously, or retained weight after
an earlier pregnancy, and feel conflicted or powerless to
attempt this change at the present time. Providing options
for women to complete periodic self-assessments of readiness to change and offering resources when there is a
readiness to begin active weight-loss activities enable
women to begin a healthier lifestyle when there is the
greatest commitment to achieving that goal. Commercial
weight-loss programs can also be effective (Lowe, MillerKovach, Frye, & Phelan, 1999), however, such programs
may be cost prohibitive for low-income populations.
Volume 34, Number 4
A shortcoming of the existing literature is a lack of
consideration of how best to customize postpartum
weight care of African American women and other
groups vulnerable to obesity. In general, nurses should
make every effort to provide weight management counseling in a context that is culturally competent (Callister,
2001), and research in this area should be a high priority.
Implications for Health Care Policy
Recent federal legislation, including Temporary Assistance for Needy Families, has substantially changed eligibility and access to reproductive health care for lowincome women in the United States (Boonstra & Gold,
2002). Time limits for maternity-related care are of special concern. Under provisions of Medicaid, pregnancyrelated coverage ends at 60 days postpartum, except in
states with federally approved waivers to cover family
planning services (Kaiser Family Foundation, 2005).
After this period, many low-income women no longer
qualify for Medicaid because of the time-limited higher
ceiling that is in place for pregnancy-related care. Consequently, low-income women during the postpartum period may face strictly limited access to ongoing health care.
Even women with private health insurance may have
trouble establishing a new source of health care after
pregnancy (Kahn et al., 1999).
Extended postpartum care (where available) that
includes weight-related assessment and management is
one option for reducing the risk of childbearing becoming
a transitional event for obesity and weight gain. Strobino,
Grason, and Minkovitz (2002) and Moos (2003) recommended that health interventions focus on women’s
health beyond the episode of pregnancy and that
providers receive improved training about women’s needs
and their perceptions of their health needs. Other
researchers (Lederman, Alfasi, & Deckelbaum, 2002;
Walker et al., 2004) have argued for extended postpartum
care that includes periodic visits to providers to focus on
support and education for weight changes, increased
physical activity, and healthy nutrition.
N
urses should be actively involved in
identifying those at risk for obesity and in
providing educational resources and support.
Conclusions
The pregnancy and postpartum period constitutes a
significant transition in a woman’s life. This transition
July/August 2005
may predispose a woman to retain excess weight that may
become the stimulus for serious, chronic health problems.
Current research clearly documents the effect that gestational weight gain has on retained weight after delivery.
Less than one third of women reach their prepregnancy
weight by the traditional end of postpartum care at 6
weeks, and some ethnic minority groups are at higher vulnerability to long-term weight retention after pregnancy.
However, this literature review indicates that higher
weight retention experienced by some ethnic minority
women is not evident at 6 weeks postpartum and is likely to only emerge thereafter (Boardley et al., 1995). Nurses, who interact with women in a variety of clinical settings should take advantage of every opportunity to
educate women and provide them with resources to minimize retained pregnancy-associated weight and maximize
health during the childbearing years.
Acknowledgment
Supported in part by grant RO1 NR04679 from the
National Institute of Nursing Research.
REFERENCES
ACOG Committee. (2002). Opinion # 267: Exercise during
pregnancy and the postpartum period. Obstetrics and
Gynecology, 9, 171-173.
Boardley, D. J., Sargent, R. G., Coker, A. L., Hussey, J. R., &
Sharpe, P.A. (1995). The relationship between diet, activity, and other factors, and postpartum weight change by
race. Obstetrics & Gynecology, 86, 834-838.
Boonstra, H., & Gold, R.B. (2002). Overhauling welfare: Implications for reproductive health policy in the United States.
Journal of the American Medical Women’s Association,
57, 41-46.
Butte, N. F. (2000). Dieting and exercise in overweight, lactating women. New England Journal of Medicine, 342, 502503.
Calle, E. E., Thun, M. J., Petrelli, J. M., Rodriguez, C., &
Heath, C. W. (1999). Body-mass index and mortality in a
prospective cohort of U.S. adults. New England Journal
of Medicine, 341, 1097-1105.
Callister, L. C. (2001). Culturally competent care of women and
newborns: Knowledge, attitude, and skills. Journal of
Obstetric, Gynecological, and Neonatal Nursing, 30,
209-215.
Cedergren, M. I., & Kallen, B. A. J. (2003). Maternal obesity
and infant heart defects. Obesity Research, 11, 10651071.
Centers for Disease Control and Prevention. (1998). Pregnancy
nutrition surveillance 1996 full report. Atlanta, GA:
Author.
Crane, S. S., Wojtowycz, M. A., Dye, T. D., Aubry, R. H., &
Artal, R. (1997). Association between pre-pregnancy obesity and the risk of cesarean delivery. Obstetrics & Gynecology, 89, 213-216.
JOGNN 425
Cunningham, F. G., Gant, N. F., Leveno, K. J., Gilstrap, L. C.,
Hauth, J. C., & Wenstrom, C. D. (2001). Williams obstetrics. (21st ed.) New York: McGraw-Hill.
Dewey, K. G., Heinig, M. J., & Nommsen, L.A. (1993). Maternal weight-loss patterns during prolonged lactation.
American Journal of Clinical Nutrition, 58(2), 162-166.
Field, A. E., Coakley, E. H., Must, A., Spadano, J. L., Laird, N.,
Dietz, W. H., et al. (2001). Impact of overweight on the
risk of developing common chronic diseases during a 10year period. Archives of Internal Medicine, 161, 15811586.
Flegal, K. M., Carroll, M. D., Kuczmarski, R. J., & Johnson, C.
L. (1998). Overweight and obesity in the United States:
Prevalence and trends, 1960-1994. International Journal
of Obesity, 22, 39-47.
Gunderson, E. P., & Abrams, B. (1999). Epidemiology of gestational weight gain and body weight changes after pregnancy. Epidemiologic Reviews, 21, 261-275.
Gunderson, E. P., Abrams, B., & Selvin, S. (2001). Does the pattern of postpartum weight change differ according to pregravid body size? International Journal of Obesity, 25,
853-862.
Harris, H. E., & Ellison, G. T. H. (1997). Do the changes in
energy balance that occur during pregnancy predispose
parous women to obesity? Nutrition Research Reviews,
10, 57-81.
Henshaw, S. K. (1998). Unintended pregnancy in the United
States. Family Planning Perspectives, 30, 24-29, 46.
Hytten, F. E. (1991). Weight gain in pregnancy. In F. Hytten &
G. Chamberlain (Eds.), Clinical Physiology in Obstetrics
(2nd ed.) (pp. 173-203). Oxford, England: Blackwell Scientific.
Institute of Medicine. (1990). Nutrition during pregnancy.
Washington, DC: National Academy Press.
Institute of Medicine. (1992). Nutrition during pregnancy and
lactation: An implementation guide. Washington, DC:
National Academy Press.
Kahn, R. S., Wise, P. H., Finkelstein, J. A., Bernstein, H. H.,
Lowe, J. A., & Homer, C. J. (1999). The scope of unmet
maternal health needs in pediatric settings. Pediatrics,
103, 576-581.
Kaiser Family Foundation (2005). KFF state health facts online:
50 state comparisons of Medicaid waivers to cover family planning. Retrieved March 21, 2005, from http://
www.statehealthfacts.kff.org/cgi-bin/healthfacts.cgi?action
=compare&category=Women’s+Health&subcategory=
Medicaid+Policy&topic=Family+Planning+Waiver.
Keppel, K. G., & Taffel, S. M. (1993). Pregnancy-related weight
gain and retention: Implications of the 1990 Institute of
Medicine guidelines. American Journal of Public Health,
83, 1100-1103.
Kumar, N. B., Lyman, G. H., Allen, K., Cox, C. E., & Schapira,
D. V. (1995). Timing of weight gain and breast cancer
risk. Cancer, 76, 243-249.
Lawrence, M., McKillop, F. M., & Durnin, J. V. G. A. (1991).
Women who gain more fat during pregnancy may not
have bigger babies: Implications for recommended weight
gain during pregnancy. British Journal of Obstetrics and
Gynaecology, 98, 254-259.
426 JOGNN
Lederman, S. A. (2001). Pregnancy weight gain and postpartum
weight loss: Avoiding obesity while optimizing the growth
and development of the fetus. Journal of the American
Medical Women’s Association, 56, 53-58.
Lederman, S. A., Alfasi, G., & Deckelbaum, R. J. (2002). Pregnancy-associated obesity in Black women in New York
City. Maternal and Child Health Journal, 6(1), 37-42.
Linne, Y., Barkeling, B., & Rossner, S. (2002). Long-term weight
development after pregnancy. Obesity Reviews, 3, 75-83.
Linne, Y., Dye, L., Barkeling, B., & Rossner, S. (2003). Weight
development over time in parous women – The SPAWN
study – 15 years follow-up. International Journal of Obesity, 27, 1516-1522.
Lovelady, C. A., Garner, K. E., Moreno, K. L., & Williams, J. P.
(2000). The effect of weight loss in overweight, lactating
women on the growth of their infants. New England Journal of Medicine, 342, 449-453.
Lowe, M. R., Miller-Kovach, K., Frye, N., & Phelan, S. (1999).
An initial evaluation of a commercial weight loss program: Short-term effects on weight, eating behavior, and
mood. Obesity Research, 7, 51-59.
Luke, B., Hediger, M. L, & Scholl, T. O. (1996). Point of diminishing returns: When does gestational weight gain cease
benefiting birth weight and begin adding to maternal obesity? Journal of Maternal-Fetal Medicine, 5, 168-173.
Moos, M. (2003). Preconceptional wellness as a routine objective for women’s health care: An integrative strategy. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 32,
550-556.
Mottola, M. F. (2002). Exercise in the postpartum period: Practical applications. Current Sports Medicine Reports, 1,
362-368.
Muscati, S. K., Gray-Donald, K., & Koski, K. G. (1996). Timing of weight gain during pregnancy: Promoting fetal
growth and minimizing maternal weight retention. International Journal of Obesity, 20, 526-532.
Must, A., Spadano, J., Coakley, E. H., Field, A. E., Colditz, G.,
& Dietz, W. H. (1999). The disease burden associated
with overweight and obesity. Journal of the American
Medical Association, 282, 1523-1529.
National Heart, Lung, and Blood Institute Obesity Education
Initiative Expert Panel. (1998). Clinical guidelines on the
identification, evaluation, and treatment of overweight
and obesity in adults—The evidence report. Obesity
Research, 6(Suppl 2), 51S-209S.
National Task Force on the Prevention and Treatment of Obesity. (2000). Overweight, obesity, and health risk. Archives
in Internal Medicine, 160, 898-904.
O’Hara, M. W. (1995). Postpartum depression: Causes and consequences. New York: Springer-Verlag.
Olsen, L. C. (1979). Portrait of nurse-midwifery patients in a
private practice. Journal of Nurse-Midwifery, 24(2), 1017.
Olsen, L. C., & Mundt, M. H. (1986). Postpartum weight loss
in a nurse-midwifery practice. Journal of Nurse-Midwifery, 31(4), 177-181.
Olson, A. L., Kemper, K. J., Kelleher, K. J., Hammond, C. S.,
Zuckerman, B. S., & Dietrich, A. J. (2002). Primary care
pediatricians’ roles and perceived responsibilities in the
Volume 34, Number 4
identification and management of maternal depression.
Pediatrics, 110, 1169-1176.
Parham, E. S., Astrom, M. F., & King, S. H. (1990). The association of pregnancy weight gain with the mother’s postpartum weight. Journal of the American Dietetic Association, 90, 550-554.
Parker, J. D., & Abrams, B. (1993). Differences in postpartum
weight retention between black and white mothers.
Obstetrics & Gynecology, 81, 768-774.
Potter, S., Hannum, S., McFarlin, B., Essex-Sorlie, D., Campbell,
E., & Turpin, S. (1991). Does infant feeding method influence maternal postpartum weight loss? Journal of the
American Dietetic Association, 91, 441-446.
Prochaska, J. O., Redding, C. A., & Evers, K. E. (1997). The
transtheoretical model and stages of change. In K. Glanz,
F. M. Lewis, & B. K. Rimer (Eds.), Health behavior and
health education (pp. 60-84). San Francisco: Jossey-Bass.
Rooney, B. L., & Schauberger, C. W. (2002). Excess pregnancy
weight gain and long-term obesity: One decade later.
Obstetrics & Gynecology, 100, 245-252.
Sampselle, C. M., Seng, J., Yeo, S., Killion, C., & Oakley, D.
(1999). Physical activity and postpartum well being. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 28,
41-49.
Schauberger, C. W., Rooney, B. L., & Brimer, L. M. (1992). Factors that influence weight loss in the puerperium. Obstetrics & Gynecology, 79, 424-429.
Schieve, L. A., Cogswell, M. E., & Scanlon, K. S. (1998). Trends
in pregnancy weight gain within and outside ranges recommended by the Institute of Medicine in a WIC population. Maternal and Child Health Journal, 2(2), 111-116.
Scholl, T. O., Hediger, M. L., Schall, J. I., Ances, I. G., & Smith,
W. K. (1995). Gestational weight gain, pregnancy outcome, and postpartum weight retention. Obstetrics &
Gynecology, 86, 423-427.
Shaw, G. M., Velie, E. M, & Schaffer, D. (1996). Risk of neural
tube defect–affected pregnancies among obese women.
Journal of the American Medical Association, 275, 10931096.
Sobey, W. S. (2002). Barriers to postpartum depression prevention and treatment: A policy analysis. Journal of Midwifery & Women’s Health, 47, 331-336.
Sohlstrom, A., & Forsum, E. (1995). Changes in adipose tissue
volume and distribution during reproduction in Swedish
women as assessed by magnetic resonance imaging. American Journal of Clinical Nutrition, 61, 287-295.
Smith, D. E., Lewis, C. E., Caveny, J. L., Perkins, L. L., Burke,
G. L., & Bild, D. E. (1994). Longitudinal changes in adiposity associated with pregnancy: The CARDIA study.
July/August 2005
Journal of the American Medical Association, 271, 17471751.
Strobino, D. M., Grason, H., & Minkovitz, C. (2002). Charting
a course for the future of women’s health in the United
States: Concepts, findings, and recommendations. Social
Science & Medicine, 54, 839-848.
To, W. W. K., & Cheung, W. (1998). The relationship between
weight gain in pregnancy, birth-weight and postpartum
weight retention. Australian and New Zealand Journal of
Obstetrics and Gynaecology, 38, 176-179.
Walker, L. O. (1995). Weight gain after childbirth: A women’s
health concern? Annals of Behavioral Medicine, 17, 132141.
Walker, L. O., & Kim, M. (2002). Psychosocial thriving in late
pregnancy: Relations to ethnicity, gestational weight gain
and birth weight. Journal of Obstetric, Gynecologic, and
Neonatal Nursing, 31, 263-274.
Walker, L. O., Timmerman, G. M., Sterling, B. S., Kim, M., &
Dickson, P. (2004). Do low income women attain their
prepregnant weight by the 6th week of postpartum? Ethnicity and Disease, 14, 119-126.
Weiss, J. L., Malone, F. D., Emig, D., Ball, R. H., Nyberg, D. A.
Comstock, C. H., et al. (2004). Obesity, obstetric complications and cesarean delivery rate—A population-based
screening study. American Journal of Obstetrics and
Gynecology. 190, 1091-1097.
Willett, W. C., Manson, J. E., Stampfer, M. J., Colditz, G. A.,
Rosner, B., Speizer, F. E., et al. (1995). Weight, weight
change, and coronary heart disease in women: Risk within the “normal” weight range. Journal of the American
Medical Association, 273, 461-465.
Lorraine O. Walker, RN, EdD, is the Luci B. Johnson Centennial Professor in the School of Nursing at the University of
Texas at Austin.
Bobbie Sue Sterling, RN, PhD, is an assistant professor of clinical nursing at the School of Nursing at the University of Texas
at Austin.
Gayle M. Timmerman, RN, PhD, is an associate professor in
the School of Nursing at the University of Texas at Austin.
Address for correspondence: Lorraine O. Walker, RN, EdD, The
University of Texas at Austin School of Nursing, 1700 Red
River Street, Austin, TX 78701-1499. E-mail: lwalker@mail
.nur.utexas.edu.
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