A cross sectional survey with both prospective and retrospective data collection was carried out over a period of 12 consecutive months (including recruitment and follow up) from February 2018 to January 2019.

The target population was pregnant women who attended the antenatal care clinics at the Cape Coast Metropolitan Hospital and had subsequent visits till the final outcome of their pregnancies.

The data was obtained from the client’s antenatal book and the records of the Antenatal clinic, obstetrics emergency and delivery suite records of the Cape Coast Metropolitan Hospital, located in the Central Regional capital of Ghana.

Inclusion criteria:

• All pregnant women, who attended for antenatal services at the Cape Coast Metropolitan Hospital during the study period and with a recorded body mass index during the first trimester of pregnancy.

Exclusion criteria:

• The pregnant women who could not have their subsequent antenatal visits and those who could not have their delivery at the Cape Coast Metropolitan Hospital.

Maternal overweight and obesity was defined using a cut point of a Body Mass Index (BMI) more or equal to 25 (in kg/m²) estimated in the first trimester of pregnancy.

Purposive total sampling was performed in recruiting our study sample. All pregnant women who met the inclusion criteria were surveyed.

A structured predesigned questionnaire was used in data collection. The questionnaire comprised items to collect socio-demographic, medical and obstetric history, BMI, events during pregnancy and outcomes.

Data was coded and entered with Statistical Package for Social Sciences (SPSS) version 21 and later imported with STATA/IC version 15 (StataCorp LLC, Texas 77845, USA) for management and analysis. Descriptive indices such as proportions (frequencies and prevalence) and mean (standard deviation) were used to summarize mothers’ socio-demographic characteristics and maternal factors. One-way ANOVA test and t-test were used to determine whether mean body mass index (BMI) differ between the levels of socio-demographic characteristics and maternal factors, and complications. Further, a simple linear regression was performed to assess whether maternal obesity was associated with socio-demographic characteristics, maternal factors, and complications. All associations were considered at 95% confidence interval (CI) and 5% level of significance. The results were presented in tables and charts.

The independent variable was Body Mass Index (BMI) more or equal to 25 (in kg·m⁻²) estimated in the first trimester of pregnancy.

The dependent variable was the occurrence of obstetric complication both in antepartum and post partum period.

Ethical clearance was obtained from the University of Cape Coast’s Institutional Review Board prior to the survey. Anonymity and confidentiality of the collected data were maintained.

Records were reviewed on 510 pregnant women over aone year period. The mean age was 27.8 years with a stardard deviation of 5.1 years, most of the women were between the ages of 20 and 35 years (73.2%). Majority of these women stopped their education at first (42%) and second (22%) cycle schools. Trade was the most common occupation (41%) and 15.1% of the mothers were unemployed (Table 1).

More than half (57.9%) of women had conceived 3 or more times, 23.3% and 18.8% are Para 1 and Para 2 respectively. Majority (72.9%) of the women had spontaneous vaginal delivery while 18.4% delivered through Caesarean section (Table 2).

The prevalence of maternal obesity (overweight/obese, BMI ≥ 25 kg/m²) among women in this survey was estimated at 37.3% (190/510), with a mean BMI of 43.5 kg/m².

The statistical analysis among those with maternal obesity (n = 190) has revealed one year’s increase in maternal age accounts for 0.19 increase in mean BMI and this was found to be highly significant (95% CI = 0.08 - 0.29, p < 0.001) and client’s parity was also significantly associated with maternal obesity (95% CI = 1.63 - 5.37, p < 0.001) meaning women who had three or more (≥3) live births had a 3.5 increase in mean BMI compared to nulliparous.

How ever there was no significant association between maternal obesity and educational level as well the occupation (Table 3).

Among the 190 maternal obesity cases, 72 of them had complications during the course of the pregnancy and delivery, making a prevalence of 37.9% (72/190), with postpartum hemorrhage (40.3%), fetal distress (15.3%) Cephalo-pelvic disproportion (15.2%) being the top three complications. The caesarian section rate among them was 20.5% (39/190).

Table 4 summarizes the complications found during the study.

We found that among the 320 non obese women in our study, only 64 of them had obstetrical complications, making a prevalence of 20% (64/320).

Β: coefficient, CI: confidence interval, Ref.: reference or baseline.

In comparison with the maternal obesity group, postpartum hemorrhage (32.8%), fetal distress (12.5%) Cephalo-pelvic disproportion (10.9%) was among the common complications. The caesarian section rate among them was 16.2% (52/320).

Table 5 shows the different complication encountered by the non obese women.

In term of prevalence, the statistical analysis showed a significant association between maternal obesity and the occurrence of obstetric complications (Chi-square = 18.6 p = 0.000001). Obese pregnant women were more likely to suffer from pregnancy related complications than non-obese pregnant women.

In our study we could not record the subject’s weight changes (gains or losses) during the course of pregnancy, which could have given us more information to do a detailed analysis of the obstetric complications.

The prevalence of maternal obesity (overweight/obese, BMI ≥ 25 kg/m²) among women in this study was estimated at 37.3% (190/510). This finding is in line

with that found in population study by Cheng et al who reported a prevalence of maternal obesity in Africa ranging from 6.5% to 50.7% [7]. Several studies also have reported similar high trends of maternal obesity; 48.2% (31.3% being overweight and 16.9% obese) in a cohort study in 1000 women in Accra [8], 46% among 484 cohort of women in Wales [9], and 17% - 32% across 48 states of America in retrospective study [10].

The high prevalence of maternal obesity observed in our study could be linked to unhealthy dietary habits (highly processed food and carbohydrate dominated diet) and the lack of physical activity among our subjects which is termed as obesogenic environment.

In this study, it was observed that 34.4% of the obese women developed maternal complications, postpartum hemorrhage (42.1%), obstructed labor (16.7%), fetal distress (14.4%), antepartum haemorrhage (9.6%) and eclampsia (5.7%) been the top five complications. Similar findings were observed by Van Der Linden et al., (2016) [8] who reported a higher increase in the occurrence of PPH and hypertensive disorders in pregnancy as the BMI increases.

The Caesarian section rate was 20.5% which is high above the recommend World Health Organization. Higher prevalence of CS among obese women was also recorded in other studies [8] [11].

Maternal obesity has been associated with risk of maternal complications [8] [11] [12], our study is in line with the literature, it was revealed in our survey that maternal obesity is significantly associated with pregnancy related complications (p = 0.00001). Similarly a pregnancy risk assessment and monitoribg system in Maryland (2010) [13], found association between delivery methods, hypertension, diabetes and other complications with maternal obesity in USA. Also, Van Der Linden et al., (2016) [8] in Ghana made similar observation.

In our survey, there was a significant association between age and higher parity with the presence of maternal obesity with P-values < 0.001. However the level of education and the occupation were not significantly associated with maternal obesity.

These findings confirmed similar studies in Cape Coast, who report that mean BMI increased with age among women in Central region [14] [15]. Another study in USA also linked pre-pregnancy obesity with age [16]. The mean BMI was higher for women within the ages of 40 - 44 years (46.3 kg/m²) and 25 - 29 years (44.9 kg/m²). Older women are susceptible to weight gain mostly due the change of body metabolism which become slower and reduction of the body muscles being replaced by fat associated with physical inactivity.

It was established that mothers who have had three or more live births were more likely to have 3.5 folds increase in mean BMI compared to mothers who have not given birth before (p < 0.001). These confirmed the findings of Amegah (2014), and Tuoyire, Kumi-kyereme, and Doku (2016), who reported a higher BMI among multiparous women compared with nulliparous women. These findings assert to fact that women generally gain weight during pregnancy and those excess kilograms tend to accumulate if the women failed to lose weight after delivery.

Despite the fact that several studies have associated maternal obesity with both education and occupation (Tuoyire et al., 2016; Shen et al., 2018; Stubert, Reister, Hartmann, & Janni, 2018 [17]; Siega-riz, 2012 [18] ), this study observed no association for both education and occupation. This could explained by the fact that most of our subjects didn’t have higher education and were mostly traders, making our study population more homogenous in terms of education and occupation.