Maternal and Child Health Journal

, Volume 17, Issue 4, pp 723–731 | Cite as

Association Between Preterm Delivery and Pre-pregnancy Body Mass (BMI), Exercise and Sleep During Pregnancy Among Working Women in Southern California

  • Sylvia GuendelmanEmail author
  • Michelle Pearl
  • Jessica L. Kosa
  • Steve Graham
  • Barbara Abrams
  • Martin Kharrazi


Little is known about modifiable lifestyle factors beyond quitting smoking that could prevent preterm delivery (PTD, <37 weeks gestation). We examined the individual and joint associations of pre-pregnancy BMI, second trimester exercise and sleep on PTD. We conducted a nested, population-based case–control study interviewing postpartum 344 cases delivering at <37 weeks, as identified by clinical estimate of gestational age from prenatal screening records, and 698 term controls, excluding term low birthweight. Eligible women participated in California’s statewide Prenatal Screening Program, worked during pregnancy, and delivered a singleton birth in Southern California in 2002–2003. Modeled separately, moderate (odds ratio [OR] = 0.90; 95 % confidence interval [CI] = 0.84–0.96—per hour/week) and vigorous (OR = 0.67; 95 % CI = 0.46–0.98 for yes vs. no) exercise during the second trimester were associated with a reduced odds of PTD, and sleep duration was not (OR = 1.09, 95 % CI = 0.80–1.48 for <7 h; OR = 0.88, 95 % CI = 0.57–1.48 for >8 h vs. 7–8 h). When sleep and exercise variables were modeled together along with pre-pregnancy BMI, only moderate exercise (OR = 0.91; 95 % CI 0.85–0.98) continued to be associated with reduced odds of PTD. The benefits of moderate exercise appeared strongest for women with BMI greater than 24 kg/m2 (OR = 0.85; 95 % CI = 0.79–0.93) and weakened with decreasing BMI. No other interactions were found. Moderate exercise is associated with reduced PTD, particularly for women with BMI above the normal range. The results are of public health relevance given that these risk factors are potentially modifiable both pre-conceptionally and during pregnancy and rates of PTD are still high in the United States.


Exercise Sleep duration Obesity Epidemiology Health disparities 



This work was funded in part by the Maternal and Child Health Bureau, Division of Research, Training and Education, grant #R40MV00305-01 to SG. This study was also partially funded by NIH grant #R24MH081797, “Socioeconomic and Neuro-Endocrine Determinants of Perinatal Complications”. We thank Alan Hubbard PhD. for his helpful suggestions for data analysis.

Conflict of interest

None of the authors have competing financial interests in connection with the submitted manuscript.


  1. 1.
    Hamilton, B. E., Martin, J. A., & Ventura, S. J. (2010). Births: Preliminary data for 2009. National vital statistics reports December 21, 59(3). Available at: Accessed 7 April 2011.
  2. 2.
    Institute of Medicine. (2006). Preterm birth: Causes, consequences, and prevention. Google Scholar
  3. 3.
    Bhutta, A. T., Cleves, M. A., Casey, P. H., Cradock, M. M., & Anand, K. J. S. (2002). Cognitive and behavioral outcomes of school-aged children who were born preterm: A meta-analysis. Journal of the American Medical Association, 288, 728–737.PubMedCrossRefGoogle Scholar
  4. 4.
    Morse, S. B., Zheng, H., Tang, Y., & Roth, J. (2009). Early school-age outcomes of late pre- term infants. Pediatrics, 123, e622–e629.PubMedCrossRefGoogle Scholar
  5. 5.
    Savitz, D. A., & Murnane, P. (2010). Behavioral influences on preterm birth: a review. Epidemiology, 21(3), 291–299.PubMedCrossRefGoogle Scholar
  6. 6.
    Weight Gain During Pregnancy. (2009). Re-examining the guidelines. Washington, D. C: Institute of Medicine.Google Scholar
  7. 7.
    ACOG. (2002). Exercise during pregnancy and the postpartum period. ACOG committee opinion N. 267. Obstetrics and Gynecology, 99, 171–1733.CrossRefGoogle Scholar
  8. 8.
    US Department of Health and Human Services. (2008). 2008 Physical activity guidelines for Americans (pp. 1–61) Washington, DC. Accessed 14 April 2011.
  9. 9.
    Borodulin, K., Evenson, K., Monda, K., Wen, F., Herring, A., & Dole, N. (2010). Physical activity and sleep among pregnant women. Paediatric and Perinatal Epidemiology, 24, 45–52.PubMedCrossRefGoogle Scholar
  10. 10.
    Ogden, C. L., Carrol, M. D., Curtin, L. R., McDowell, M. A., Tabak, C. I., & Flegal, K. M. (2006). Prevalence of overweight and obesity in the United states, 1994–2004. Journal of the American Medical Association, 295, 1549–1555.PubMedCrossRefGoogle Scholar
  11. 11.
    Evenson, K., & Wen, F. (2010). National trends in self-reported physical activity and sedentary behaviors among pregnant women: NHANES 1999–2006. Preventive Medicine, 50, 123–128.PubMedCrossRefGoogle Scholar
  12. 12.
    Facco, F., Kramer, J., Ho, K. H., Zee, P. C., & Grobman, W. A. (2010). Sleep disturbances in pregnancy. Obstetrics and Gynecology, 115, 77–83.PubMedCrossRefGoogle Scholar
  13. 13.
    Leiferman, J. A., & Evenson, K. R. (2003). The effect of regular physical activity on birth outcomes. Maternal and Child Health Journal, 7, 59–64.PubMedCrossRefGoogle Scholar
  14. 14.
    Institute of Medicine. (1990). Nutrition during pregnancy. Part I. Weight gain. Washington, DC: National Academy Press.Google Scholar
  15. 15.
    Dietz, P. M., Callaghan, W. M., Cogswell, M. E., Morrow, B., Ferre, C., & Schieve, L. A. (2006). Combined effects of prepregnancy body mass index and weight gain during pregnancy on the risk of preterm delivery. Epidemiology, 17, 170–177.PubMedCrossRefGoogle Scholar
  16. 16.
    Bodnar, L., Siega-Riz, A. M., Simhan, H., Himes, K., & Abrams, B. (2010). Severe obesity, gestational weight gain, and adverse birth outcomes. American Journal of Clinical Nutrition, 91, 1642–1648.PubMedCrossRefGoogle Scholar
  17. 17.
    Aliyu, M. H., Luke, S., Wison, R. E., Saidu, R., Alio, A. P., Salihu, H. M., et al. (2010). Obesity in older mothers, gestational weight gain, and risk estimates for preterm phenotypes. Maturitas, 66:88–93. Epub 2010 Mar 21.Google Scholar
  18. 18.
    Goldenberg, R. L., & Culhane, J. F. (2005). Prepregnancy health status and the risk of preterm delivery. Archives of Pediatrics and Adolescent Medicine, 159, 89–90.PubMedCrossRefGoogle Scholar
  19. 19.
    Hotamisligil, G. S. (2006). Inflammation and metabolic disorders. Nature, 44, 860–867.CrossRefGoogle Scholar
  20. 20.
    Okun, M., Roberts, J., Marsland, A., & Hall, M. (2009). How disturbed sleep may be a risk factor for adverse pregnancy outcomes a hypothesis. Obstetrical & Gynecological Survey, 64, 273–280.CrossRefGoogle Scholar
  21. 21.
    Taheri, S., Ling, L., Austin, D., Young, T., & Mignot, E. (2004). Short sleep duration is associated with reduced liptin elevated ghrelin and increased body mass index. PLOS Medicine, 1, 210–217.CrossRefGoogle Scholar
  22. 22.
    Micheli, K., Komninos, I., Bagkeris, E., Roumeliotaki, T., Koutis, A., Kogevinas, M., et al. (2011). Sleep patterns in late pregnancy and risk of preterm birth and fetal growth restriction. Epidemiology, 22, 738–744.PubMedCrossRefGoogle Scholar
  23. 23.
    Kramer, M. S., & McDonald, S. W. (2006). Aerobic exercise for women during pregnancy. Cochrane Database of Systematic Reivews (3):CD000180. doi: 10.1002/14651858. CD 000180.pub2.
  24. 24.
    Evenson, K. R., Siega-Riz, A. M., Savitz, D., Leiferman, J. A., & Thorp, J. M. (2002). Vigorous leisure activity and pregnancy outcome. Epidemiology, 13, 653–659.PubMedCrossRefGoogle Scholar
  25. 25.
    Mette, J., Andersen, P. K., Olsen, J., Madsen, M., Jorgensen, T., Aagaard, E., et al. (2008). Physical exercise during pregnancy and the risk of preterm birth: A study within the Danish national birth cohort. American Journal of Epidemiology. (advanced e-publication).Google Scholar
  26. 26.
    Phelan, S. (2010). Pregnancy: A “teachable moment” for weight control and obesity prevention. American Journal of Obstetrics and Gynecology, 202(2), 135 el. doi: 10.1016j.ajog.2009.06.008.CrossRefGoogle Scholar
  27. 27.
    Guendelman, S., Kosa, J. L., Pearl, M., Graham, S., Goodman, J., & Kharrazi, M. (2009). Juggling work and breastfeeding: effects of maternity leave and occupational characteristics. Pediatrics, 123, e38–e46.PubMedCrossRefGoogle Scholar
  28. 28.
    Kosa, J., Guendelman, S., Pearl, M., Abrams, B., Graham, S., & Kharrazi, M. (2011). The association between pre-pregnancy BMI and preterm delivery in a diverse Southern California population of working women. Maternal and Child Health Journal, 15, 772–781.PubMedCrossRefGoogle Scholar
  29. 29.
    Guendelman, S., Lang, K. J., Pearl, M., Graham, S., & Kharrazi, M. (2008). Exploring the relationship of second-trimester corticotropin releasing hormone (CRH), chronic stress, and preterm delivery. The Journal of Maternal-Fetal Neonatal Medicine, 21, 788–795.PubMedCrossRefGoogle Scholar
  30. 30.
    Guendelman, S., Pearl, M., Graham, S., Angulo, V., & Kharrazi, M. (2006). Utilization of pay-in antenatal leave in Southern California. Maternal and Child Health Journal, 10(1), 63–73.PubMedCrossRefGoogle Scholar
  31. 31.
    Dietz, P. M., England, L. J., Callaghan, W. M., Pearl, M., Wier, M. L., & Kharrazi, M. (2007). A comparison of LMP-based and ultrasound-based estimates of gestational age using linked California livebirth and prenatal screening records. Paediatric and Perinatal Epidemiology, 21(Suppl 2), 62–71.PubMedCrossRefGoogle Scholar
  32. 32.
    Pearl, M., Wier, M. L., & Kharrazi, M. (2007). Assessing the quality of last menstrual period date on California birth records. Paediatric and Perinatal Epidemiology, 21(Suppl 2), 50–61.PubMedCrossRefGoogle Scholar
  33. 33.
    Gilboa, S. M., Correa, A., & Alverson, C. J. (2008). Use of spline regression in an analysis of maternal prepregnancy body mass index and adverse birth outcomes: does it tell us more than we already know? Annals of Epidemiology, 18, 196–205.PubMedCrossRefGoogle Scholar
  34. 34.
    Evenson, K., & Wen, F. (2010). Measuring physical activity among pregnant women using a structured one-week recall questionnaire: evidence for validity and reliability. International Journal of Behavioral Nutrition and Physical Activity, 7, 21–33.PubMedCrossRefGoogle Scholar
  35. 35.
    Evenson, K. R., & Pompeii, L. A. (2010). Obstetrician practice patterns and recommendations for physical activity during pregnancy. Journal of Women’s Health, 19, 1733–1740.PubMedCrossRefGoogle Scholar
  36. 36.
    Naud, K., Quellet, A., Brown, C., Pasquier, J. C., & Moutquin, J. M. (2010). Is sleep disturbed in pregnancy? JOGC, 32, 28–34.PubMedGoogle Scholar
  37. 37.
    Lobel, M., Dunkel-Schetter, C., & Scrimshaw, S. C. (1992). Prenatal maternal stress and prematurity: A prospective study of socioeconomically disadvantaged women. Health Psychology, 11, 32–40.PubMedCrossRefGoogle Scholar
  38. 38.
    Mamelle, N., & Munoz, F. (1987). Occupational working conditions and preterm birth: A reliable scoring system. American Journal of Epidemiology, 126(1), 150–152.PubMedGoogle Scholar
  39. 39.
    Cleveland, W. S. (1979). Robust locally weighted regression and smoothing scatterplots. Journal of American Statistical Association, 74, 829–836.CrossRefGoogle Scholar
  40. 40.
    Gleeson, M., Bishop, N., Stensel, D., Kindley, M., Mastana, S., & Nimmo, M. (2011). The anti-infammatory effects of exercise: mechanisms and implications for the prevention and treatment of disease. Nature Reviews Immunology, 11, 607–615.PubMedCrossRefGoogle Scholar
  41. 41.
    Rodrigues Domingues, M., Matijasevich, A., & Barros, A. (2009). Physical activity and preterm birth. A literature review. Sports Medicine, 39(11), 961–975.CrossRefGoogle Scholar
  42. 42.
    Fell, D. B., Joseph, K. S., Armson, B. A., & Dodds, L. (2009). The impact of pregnancy on physical activity level. Maternal and Child Health Journal, 13, 597–603.PubMedCrossRefGoogle Scholar
  43. 43.
    Barakat, R., Stirling, J. R., & Lucia, A. (2008). Does exercise training during pregnancy affect gestational age? A randomized controlled trial. British Journal of Sports Medicine, 42, 674–678.PubMedCrossRefGoogle Scholar
  44. 44.
    Hegaard, H. K., Hedegaard, M., Damm, P., Ottesen, B., Petersson, K., & Henriksen, T. B. (2008). Leisure time physical activity is associated with a reduced risk of preterm delivery. American Journal of Obstetrics and Gynecology, 198, 180–185.PubMedCrossRefGoogle Scholar
  45. 45.
    Hatch, M., Levin, S., Shu, X. O., et al. (1998). Maternal leisure-time exercise and timely delivery. American Journal of Public Health, 88(10), 528–533.CrossRefGoogle Scholar
  46. 46.
    Juhl, M., Andersen, P. K., Olsen, J., et al. (2008). Physical exercise during pregnancy and the risk of preterm birth: A study within the Danish National Birth Cohort. American Journal of Epidemiology, 167, 859–866.PubMedCrossRefGoogle Scholar
  47. 47.
    Evenson, K., & Huston, S. L. (2004). Leisure-time physical activity among pregnant women in the USA. Pediatric and Perinatal Epidemiology, 18, 400–407.PubMedCrossRefGoogle Scholar
  48. 48.
    Zhang, J. D., & Savitz, A. (1996). Exercise during pregnancy among US women. Annals of Epidemiology, 6, 53–59.PubMedCrossRefGoogle Scholar
  49. 49.
    Pereira, M. A., Rifas-Shiman, S. L., Kleinman, K. P., Rich-Edwards, J. W., Peterson, K. E., & Gillman, M. W. (2007). Predictors of change in physical activity during and after pregnancy. Project Viva. American Journal of Preventive Medicine, 32, 312–319.PubMedCrossRefGoogle Scholar
  50. 50.
    Petersen, A., Leet, T., & Brownson, R. (2005). Correlates of physical activity among pregnant women in the United States. Medicine and Science in Sports and Exercise, 37, 1748–1753.PubMedCrossRefGoogle Scholar
  51. 51.
    Borodulin, K., Evenson, K. R., Wen, F., Herring, A., & Benson, A. (2008). Physical activity patterns during pregnancy. Medicine and Science in Sports and Exercise, 40, 1901–1908.PubMedCrossRefGoogle Scholar
  52. 52.
    Hutcheon, J. A., Bodnar, L. M., Joseph, K. S., Abrams, B., Simhan, H. N., & Platt, R. W. (2012). The bias in current measures of gestational weight gain. Pediatric and Perinatal Epidemiology, 26, 109–116.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Sylvia Guendelman
    • 1
    Email author
  • Michelle Pearl
    • 2
  • Jessica L. Kosa
    • 1
  • Steve Graham
    • 2
  • Barbara Abrams
    • 1
  • Martin Kharrazi
    • 3
  1. 1.Maternal and Child Health Program, School of Public HealthUniversity of CaliforniaBerkeleyUSA
  2. 2.Sequoia FoundationRichmondUSA
  3. 3.California Department of Public HealthRichmondUSA

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