{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,24]],"date-time":"2026-09-24T15:55:24Z","timestamp":1790265324147,"version":"4.1.0"},"reference-count":37,"publisher":"Wiley","issue":"4","license":[{"start":{"date-parts":[[2019,5,20]],"date-time":"2019-05-20T00:00:00Z","timestamp":1558310400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"funder":[{"DOI":"10.13039\/100000056","name":"National Institute of Nursing Research","doi-asserted-by":"publisher","award":["R01 NR017020"],"award-info":[{"award-number":["R01 NR017020"]}],"id":[{"id":"10.13039\/100000056","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100009633","name":"Eunice Kennedy Shriver National Institute of Child Health and Human Development","doi-asserted-by":"publisher","award":["F32 HD091945"],"award-info":[{"award-number":["F32 HD091945"]}],"id":[{"id":"10.13039\/100009633","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Paediatric Perinatal Epid"],"published-print":{"date-parts":[[2020,7]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Background<\/jats:title><jats:p>An association between prepregnancy body mass index (BMI) and severe maternal morbidity (SMM) has been reported, but evidence has been mixed and potential explanations have not been examined.<\/jats:p><\/jats:sec><jats:sec><jats:title>Objective<\/jats:title><jats:p>To evaluate the association between prepregnancy BMI and SMM in a large, diverse birth cohort and assess potential mediation by obesity\u2010related co\u2010morbidities and caesarean birth.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>This cohort study used linked birth certificate and hospitalisation discharge records from Californian births during 2007\u20102012. We assessed associations between prepregnancy BMI and SMM, and used inverse probability weighting for multiple mediators to estimate relative and absolute natural direct and indirect effects accounting for mediation by co\u2010morbidities (hypertensive conditions, diabetes, asthma) and caesarean birth.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Among 2\u00a0650\u00a0182 births, the prevalence of SMM was 1.42%. Adjusted risk ratios for the total association between prepregnancy BMI category and SMM were 1.12 (95% confidence interval [CI] 1.07, 1.18) for underweight, 1.02 (95% CI 0.99, 1.04) for overweight, 1.04 (95% CI 1.00, 1.07) for obesity class 1, 1.14 (95% CI 1.09, 1.20) for obesity class 2, and 1.28 (95% CI 1.22, 1.36) for obesity class 3 compared to women with normal weight. After accounting for mediation by co\u2010morbidity and caesarean birth, the risk ratios were 1.19 (95% CI 1.14, 1.26) for underweight, 0.91 (95% CI 0.89, 0.94) for overweight, 0.86 (95% CI 0.84, 0.89) for obesity class 1, 0.88 (95% CI 0.84, 0.92) for obesity class 2, and 0.89 (95% CI 0.83, 0.95) for obesity class 3.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Co\u2010morbidities and caesarean birth explained an association between high prepregnancy BMI and SMM. These findings suggest that promotion of healthy prepregnancy weight, along with management of co\u2010morbidities and support of vaginal birth in pregnant women with high BMI, could reduce the risk of SMM. However, these mediators did not reduce the elevated risk of SMM observed in women with low BMI.<\/jats:p><\/jats:sec>","DOI":"10.1111\/ppe.12555","type":"journal-article","created":{"date-parts":[[2019,5,20]],"date-time":"2019-05-20T12:04:35Z","timestamp":1558353875000},"page":"460-468","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":26,"title":["Risk of severe maternal morbidity in relation to prepregnancy body mass index: Roles of maternal co\u2010morbidities and caesarean birth"],"prefix":"10.1111","volume":"34","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8213-1319","authenticated-orcid":false,"given":"Stephanie A.","family":"Leonard","sequence":"first","affiliation":[{"name":"Division of Neonatal and Developmental Medicine, Department of Pediatrics and Center for Population Health Sciences, School of Medicine Stanford University Stanford California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Suzan L.","family":"Carmichael","sequence":"additional","affiliation":[{"name":"Division of Neonatal and Developmental Medicine, Department of Pediatrics and Center for Population Health Sciences, School of Medicine Stanford University Stanford California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elliott K.","family":"Main","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, School of Medicine Stanford University Stanford California"},{"name":"California Maternal Quality Care Collaborative Stanford California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Deirdre J.","family":"Lyell","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, School of Medicine Stanford University Stanford California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Barbara","family":"Abrams","sequence":"additional","affiliation":[{"name":"Division of Epidemiology, School of Public Health University of California Berkeley California"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2019,5,20]]},"reference":[{"key":"e_1_2_7_2_1","doi-asserted-by":"publisher","DOI":"10.1097\/AOG.0b013e31826d60c5"},{"key":"e_1_2_7_3_1","unstructured":"CDC.Severe maternal morbidity in the United States;2017.https:\/\/www.cdc.gov\/reproductivehealth\/maternalinfanthealth\/severematernalmorbidity.html#anchor_SMM. 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