The association between pre pregnancy body mass index and risk of preeclampsia: a registry based study from Tanzania

Preeclampsia is a serious complication affecting 2-8% of all pregnancies. Globally, more than 287,000 women die each year due to pregnancy related causes [1], of which 10-15% are estimated to be due to preeclampsia. Most maternal deaths occur in developing countries. Millennium Development Goal number five is to reduce maternal mortality by three quarters by 2015. Given the high number of maternal deaths in low income countries due to preeclampsia, both prevention of preeclampsia and optimal management of preeclamptic pregnancies are important to further reduce maternal mortality [2].

The etiology of preeclampsia remains unclear, but mechanisms related to the placenta, genes, immune response, insulin resistance, and maternal vascular disease are suggested to contribute [3–6]. Established risk factors for preeclampsia include nulliparity, advanced maternal age, overweight/obesity, chronic hypertension, diabetes, previous preeclampsia, family history of preeclampsia, long time since previous pregnancy, and multiple pregnancy [7]. Obesity has been associated with a 2-4 fold increased risk of preeclampsia in different populations [8–12], and is a leading identified attributable risk for this disorder. A population based study from Dar Es Salaam, Tanzania, reported that the prevalence of obesity among women of reproductive age increased progressively from 3.6% in 1995 to 9.1% in 2004 [13]. The Tanzanian Demographic Health Survey for the years 2004 and 2005 reported a prevalence of 13% and 4%, respectively of overweight and obesity among women of reproductive age [14].

Since clinical records of births are lacking or not suitable for research in many African countries, studies on preeclampsia in women of African descent have been mostly based on immigrants to high income countries or descendants of immigrants [15]. Some studies have reported that women of African origin are at increased risk of preeclampsia, but it is not clear to which extent this is explained by the presence of specific risk factors for preeclampsia. Also studies on the association between preeclampsia and obesity are mainly based on women in resource rich countries [16].

Etiology, epidemiology and cultural significance of overweight and obesity likely vary from population to population. There are also indications that the course and outcome of preeclamptic pregnancies differs by race and ethnicity [17]. These aspects call for collection of high quality data to study overweight and obesity as risk factors of preeclampsia in indigenous African women. We aimed to examine the association between pre pregnancy BMI and development of preeclampsia in a low income setting in Tanzania. A secondary aim was to explore to which extent this association can be explained by maternal disease before pregnancy (hypertension, heart disease, diabetes).

After adjustment, overweight and obese women were 1.4 and 1.8 times more likely to have preeclampsia than women with normal BMI (95% CI 1.2-1.8 and 1.3-2.4, respectively), while underweight women were less likely to have preeclampsia (adjusted OR 0.7, 95% CI 0.4-1.1). Mother’s age, marital status and tribe remained associated with preeclampsia after adjustment, and p-values for trend were significant for pre pregnancy BMI, mother’s age, and mother’s height.

We further adjusted for selected medical conditions known to be associated with both BMI and preeclampsia, i.e. chronic hypertension, heart disease and diabetes before pregnancy. The effect of BMI then changed slightly from 1.8 in the highest BMI class to 1.7 (data not presented in table).

The association between BMI and preeclampsia was slightly stronger among mothers delivering at term than among mothers delivering preterm; adjusted OR (CI) per unit increase in BMI 1.08 (1.05-1.11) vs 1.05 (1.01-1.08), p-value for interaction 0.15.

The association between BMI and preeclampsia was slightly stronger among mothers with a height below 160 cm (45% of the women) compared to mothers with a height 160 cm or above; adjusted OR (CI) per unit increase in BMI 1.08 (1.04-1.11) vs. 1.05 (1.03-1.09), p-value for interaction 0.40.

A total of 1499 women were recorded with two pregnancies in the study population. Results from a clustered analysis accounting for correlation between births from the same mother were almost identical to the presented results (data not shown).

We found a positive association between increasing pre pregnancy body mass index and the risk of developing preeclampsia, amounting to an adjusted odds ratio of 1.8 for obese women with BMI above 30 as compared to normal weight women with BMI between 20 and 24.9. Among the maternal characteristics included in our analysis, only maternal age above 35 years of age showed a higher odds ratio. Our findings are in line with previous studies based on populations of pregnant women in high income countries [8–12].

Using the WHO definition of overweight and obesity, the prevalence of pre pregnancy overweight and obesity in our study population of ethnic African women was 24.0% and 7.3%, respectively. This compares with a study from Dar Es Salaam, where prevalence of obesity among females of reproductive age increased from 3.6% in 1995 to 9.1% in 2004 [13]. Our results, with nearly one third of the women were overweight or obese, correspond with global numbers of obesity, showing that obesity has now become a significant health challenge also in many low income countries [19].

We had no information on severity of preeclampsia or time of onset, but used preterm birth as a proxy for severity. The association between increasing BMI and preeclampsia was strongest for preeclampsia in connection with a term delivery, although the interaction between gestational age at delivery and preeclampsia was not statistically significant. These results are consistent with a study from the Swedish birth registry where the association between increasing BMI was stronger for term preeclampsia than for preeclampsia before term [20]. A possible explanation for these findings is that early and severe preeclampsia more often originates in placenta, whereas late and mild preeclampsia is more related to metabolic disease and hence more often associated with high BMI [21].

In our data, being overweight and obese was associated with higher maternal age, being married, high education, and being from the Chagga tribe, the majority tribe in the area. This indicates that overweight and obesity in this population are associated with higher socioeconomic status rather than low socioeconomic status which is the case in resource rich countries. In our study, adjustment for socioeconomic factors had, however, little influence on the effect of BMI. Socioeconomic factors are not among major risk factors of preeclampsia [7], and, although associated with BMI, are therefore not likely important confounders.

Our study was based on women of African origin in a low income setting, but we found an association between BMI and preeclampsia that was similar both in direction and magnitude to those from resource rich countries. However, the course and outcome of a preeclamptic pregnancy may vary not only by race or ethnicity but also by available resources. It is therefore important that African women, who bear a disproportionate burden of global maternal morbidity and mortality due to preeclampsia and other pregnancy complications, are included in studies on preeclampsia.

‘There appears to be an association between increased pre pregnancy body mass index category and increased preeclampsia risk, in this resource limited population. The increasing prevalence of obesity in pre pregnant women in low income countries hinders efforts to improve perinatal health and reduce maternal mortality. Close clinical antenatal monitoring of all pregnant women in Tanzania, especially blood pressure monitoring, is critically important, but especially so for overweight and obese women.