Routine Physical Activity and Healthy Pregnant Women's Self Reports of
Psychological Distress: A Literature Review
Amanda Staton
B.Sc.N., University of Victoria, 2002

Project Submitted in Partial Fulfillment of
The Requirements for the Degree of
Master of Science

In
Nursing
(Family Nurse Practitioner)

The University of Northern British Columbia
August 2009
© Amanda Staton, 2009

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BRITISH COLUMBIA
LIBRARY

Prince George, B.C.

Physical Activity in Pregnancy ii
Abstract
Psychological distress is identified as a common experience during pregnancy, and a risk
factor for negative maternal and fetal health outcomes. Physical activity contributes to
physical and emotional health in non-pregnant subjects. The same may be true for pregnant
women. The purpose of this project is to conduct a critical examination of the literature and
provide recommendations to guide nurse practitioners in working with prenatal clients. The
following question was designed to guide this process:
In healthy pregnant women, does physical activity at least three times weekly, as compared
to remaining sedentary, decrease self reports of psychological distress?
For the purpose of this project, psychological distress is defined women's self reported
feelings of anxiety, depressed mood, or concerns with body image. The studies included in
the literature review were obtained from a series of online database searches. Research
studies, literature reviews, or clinical practice guidelines published after 1999 and written in
English were included. The final yield was nine studies and three clinical practice guidelines.
The evidence suggests participation in physical activity decreases over the course of
pregnancy, and that women who routinely participate in physical activity during pregnancy
tend to feel more positive about body image and report less feelings of anxiety and depressed
mood compared to women who do not regularly engage in physical activity. Due to the
limited number of studies found on this topic and the design and methodology limitations of
these studies, further research is warranted.

Physical Activity in Pregnancy iii
Table of Contents
Abstract

11

Table of Contents

lll

Introduction
Literature Search Methodology
Approach to the Project

2

Background and Context
Psychological Health During Pregnancy
Physical Activity, Physiological Health, and Psychological Health
Relevance To The Clinical Practice ofNurse Practitioners in BC
Depressed Mood and Feelings of Anxiety During Pregnancy
Causes
·
Prevalence during pregnancy
Outcomes
Detection and Treatment
Body Image During Pregnancy
Association Between Physical Activity and Physical and
Psychological Health During.Pregnancy

3
3

Literature Review
Physical Activity During Pregnancy
Trends
Physical Activity and Depressed Mood During Pregnancy
Physical Activity and Feelings of Anxiety During Pregnancy
Physical Activity and Body Image During Pregnancy

4

6

6

8
8

9

10
12
14

14
15
17
20

22
23

Discussion
Limitations or Biases in the Reviewed Literature
Relevance of Findings to Nurse Practitioners' Clinical Practice

26
26
28

Conclusion
Implications and Recommendations for Nurse Practitioner
Clinical Practice

28

References

32

Appendix A
Analysis of Research Studies Addressing Physical Activity
Patterns During Pregnancy

40

Physical Activity in Pregnancy iv
Appendix B
Analysis of Research Studies Addressing Physical Activity
Patterns and Body Image During Pregnancy

42

Appendix C
Analysis of Research Studies Addressing Physical Activity Patterns and
Feelings of Anxiety and/or Depressed Mood During Pregnancy

47

Appendix D
Analysis of SOGC/CSEP Clinical Practice Guidelines

52

Appendix E
Analysis of RCOG Clinical Practice Guidelines

54

Appendix F
Analysis of ACOG Clinical Practice Guidelines

56

Physical Activity in Pregnancy 1
ROUTINE PHYSICAL ACTIVITY AND SELF REPORTS
OF PSYCHOLOGICAL DISTRESS IN HEALTHY PREGNANT WOMEN:
A LITERATURE REVIEW
The purpose of this practice-based project is to conduct a critical examination and
synthesis of knowledge in an area of concern to nurse practitioner practice. The result is a
literature review and position paper that concludes with evidence-informed recommendations
for nurse practitioners in primary care practice. The critical examination and synthesis of
knowledge is designed to address the following clinically significant question:
In healthy pregnant women, does physical activity at least three times weekly, as compared
to remaining sedentary, decrease self reports of psychological distress?

Literature Search Methodology
The research question was designed based on a method of inquiry in which a research
question includes a specific population of interest ('P'), a proposed intervention ('I'), a
comparison intervention ('C'), and a measurable outcome ('0'). The components of this
'PICO question' form the framework for a search process used to gather data in an attempt to
answer the question and reduce uncertainty on the topic (Melnyk & Fineout-Overholt, 2005).
The PICO question of inquiry designed for this paper is comprised of the following
components. The population of interest (P) is healthy pregnant women. The intervention of
interest (I) is physical activity at least three times weekly during pregnancy, and the
comparison of interest (C) is remaining sedentary during pregnancy. The measurable

Physical Activity in Pregnancy 2
outcome of interest (0) is decreased self reports of psychological distress. For the purposes
of this review, psychological distress is defined as women's self reported feelings of anxiety,
depressed mood, or concerns about body image. This paper is presented under the following
headings: introduction; approach to the project; background and context; literature review;
discussion; conclusion; and appendices.

Approach to the Project
This paper examines the relationship, as documented in the contemporary literature,
between physical activity and healthy pregnant women's self reports of psychological
distress. The appendices contain summaries of the studies and guidelines included in the
literature review (see Appendices A, B, C, D, E, and F). Associations between physical

.··.

:.

activity and feelings of anxiety, depressed mood, and concerns about body image are
addressed. Trends in physical activity during pregnancy are also investigated. Few prior
investigations have addressed the relationship between physical activity and these aspects of
psychological distress in pregnancy. This paper will review these investigations and
synthesize the existing knowledge in order to propose evidence-informed recommendations
for nurse prctitioner clinical practice (see Appendices A, B, and C for complete analyses).
Canadian (Appendix D), British (Appendix E), and American (Appendix F)
recommendations on physical activity during pregnancy are also assessed to gain a clear
understanding of current practice guidelines. Due to the scope and length limitations, this
project concentrates only on American, British, and Canadian guidelines. Any follow up
investigations would benefit from addressing guidelines from countries such as Australia,

.

Physical Activity in Pregnancy 3
New Zealand, Japan, and Scandinavia, where sound recommendations are also published.
The studies included in the literature review were obtained from a series of online
database searches using components of the PICO question of inquiry as keywords. The
databases included Medline Ovid, Medline Ebsco, the Cochrane database of systematic
reviews, Health Sciences: a SAGE full-text collection, and Biomedical reference collection
comprehensive. Studies published after the year 1999 were included in the literature review.
This topic is addressed in the literature prior to the year 2000, however, due to scope and
word length restrictions of the project only studies published in and subsequent to the year
2000 were included. Studies that did not directly address the research question or were
written in languages other than English were excluded. Journal articles other than research
studies or literature reviews were also excluded. The final yield was nine studies (See
Appendices A, B, and C). Clinical practice guidelines for Canadian, British, and American
Societies of Obstetricians and Gynaecologists were also retrieved (see Appendices D, E, and
F for complete analyses).

Background and Context

Psychological Health During Pregnancy
The psychological health of women during pregnancy is a critical aspect of the overall
health and well-being of pregnant women (Bowen &Muhajarine, 2006). Historically, much
emphasis has been placed on the importance of physical maternal health during pregnancy.
More recently, there has also been a growing recognition about the importance of maternal

Physical Activity in Pregnancy 4
psychological health during pregnancy (Davies, Wolfe, Mottola, & MacKinnon, 2003).
Psychological distress is shown to be a common experience during pregnancy, and is
identified as a risk factor for less than optimal maternal and fetal health outcomes such as
inadequate maternal weight gain, low birth weight (Bennett, Einarson, Taddio, Koren, &
Einarson, 2004a), preterm birth (Bennett et al., 2004a; Glynn, Robel, Dunkel Schetter, &
Sandman, 2008), lower levels of maternal-fetal attachment (Alhusen, 2008), and increased
risk of postpartum depression (Bennett et al., 2004a; Bowen & Muhajarine, 2006). Despite
growing awareness, it is noted that health care providers' detection of psychological distress
during pregnancy remains low (Bennett et al., 2004a; Coleman, Carter, Morgan, & Schulkin,
2008). Additionally, the effectiveness of commonly prescribed treatment regimes, such as
pharmacotherapy or psychotherapy, is frequently reported as being sub-optimal (Marcus &
Flynn, 2007).

Physical Activity, Physiological Health, and Psychological Health
It has been well documented that routine participation in physical activity contributes to

physical and emotional health (Centre for Disease Control and Prevention, 1999). A review
of eleven trials found that pregnant women who engage in physical activity improved or
maintained their physical fitness (Kramer & McDonald, 2008). Physical activity is
recommended as an integral part of maternal and fetal health (American College of
Obstetricians and Gynaecologists [ACOG], 1994; ACOG, 2002; Davies et al., 2003; Royal
College of Obstetricians and Gynaecologists [RCOG], 2006), and in most cases is safe for
both mother and fetus (ACOG, 1994; ACOG, 2002; RCOG, 2006).

Physical Activity in Pregnancy 5
Concerns associated with physical activity during pregnancy such as hyperthermia and
the teratogenic effects in the first trimester of human pregnancy (ACOG, 1994; ACOG,
2004; Davies et al., 2003) or a shortened gestation (Kramer & McDonald, 2008) have not
been supported in the literature (Davies et al., 2003; Kramer & McDonald, 2008). The
contemporary literature agrees that maternal physiologic adaptations to pregnancy, such as
raised minute ventilation and increased skin blood flow, aid in dissipating heat and thereby
reducing the risk ofhyperthermia (ACOG, 1994; RCOG, 2006). It is also agreed that women
who engage in physical activity during pregnancy are not at increased risk of preterm labour.
Their pregnancies are the same length as those who remain sedentary (Kramer & McDonald,
2008). According to ACOG (1994), "There has been no demonstrated increase in neural tube
defects or other birth defects in infants of women who continue to perform even vigorous
exercise during early pregnancy"(p. 1259).
In addition to the physiological benefits, physical activity also improves mental health
and feelings of well-being (Callaghan, 2004). In non-pregnant women, physical activity has
been shown to lessen the effects of psychological health issues such as depressed mood and
feelings of anxiety (Poudevigne & O'Connor, 2006). It has also been shown to improve body
image and self-esteem in non-pregnant subjects (Fox, 1999). The same may apply to
pregnant women. As is argued in this paper, physical activity is an effective intervention that
nurse practitioners can recommend to all healthy pregnant women as a way of helping to
decrease self reports of anxiety, depressed mood, or decreased body image. There is an
assumption that self reports of psychological distress reflect occurrence; therefore, a decrease
in self reports of anxiety, depressed mood, or decreased body image is likely to reflect a

Physical Activity in Pregnancy 6
decrease in occurrence.

Relevance To The Practice ofNurse Practitioners in BC
In the province of British Columbia nurse practitioners manage the treatment of women

with uncomplicated pregnancies well into the second trimester of pregnancy. Focusing on
health promotion and disease prevention through primary, secondary, and tertiary levels of
prevention is a cornerstone of nurse practitioner care. For example, implementing
interventions such as education and counselling, immunizations, tobacco, drug, and/or
alcohol cessation, screening for diseases and disorders, early diagnosing of diseases or
disorders, and prescribing necessary treatments are components of the care that a nurse
practitioner may provide to a pregnant woman (College of Registered Nurses ofBC
[CRNBC], no date). As I will argue in this review, routine physical activity during pregnancy
can help to enhance the health and well-being of pregnant women by minimizing the
occurrence and self reports of depressed mood, feelings of anxiety, or concerns about body
image. The evidence supports nurse practitioners and other primary care providers discussing
the psychological and physical benefits of routine physical activity during pregnancy with
clients at every appropriate opportunity.

Depressed Mood and Feelings ofAnxiety During Pregnancy
:

Pregnancy is a normal event in life. It is also a time requiring substantial adjustments
for all involved. During a relatively short period of time, expectant mothers experience

.•..

Physical Activity in Pregnancy 7
significant psychological and physiological changes to body size and shape, hormones,
emotions, relationships, and lifestyle (Varney, Kriebs & Gegor, 2004). Generally, pregnancy
is a time of positive emotions for women; however, this is not true for all women. Feelings of
anxiety (Andersson, Sundstrom-Poromaa, Wulff, Astrom, & Bixo, 2006; Radecki Breitkopf,
Primeau, Levine, Olson, Wu, & Berenson, 2006), depressed mood (Andersson et al., 2006),
and concerns about body image (Clark, Skouteris, Wertheim, Paxton, & Milgram, 2009) are
common and can have lasting negative effects for both the mother and baby (Misri and
Kendrick, 2007). Furthermore, feelings of anxiety, depressed mood, or negative body image
during pregnancy often go undetected by healthcare providers (Bowen and Muhajarine,
2006). The treatment regimes for these disorders during pregnancy are controversial and
frequently sub-optimal (Koren, Matsui, Einarson, Knoppert, & Steiner, 2005), inaccessible to
women due to lack of client or system resources, or are never initiated by the patient due to
fetal health concerns (Marcus and Flynn, 2007; Misri and Kendrick, 2006). Further research
of these issues is warranted to develop evidence-informed recommendations that inform
nurse practitioners in primary care practice. The following is a general overview of these
disorders.
Depression and anxiety are common and non-discriminant disorders that affect men
and women of all socio-economic levels in every country of the world. The rates of
depression in Canada and the United States are reported at 8.2% and 8.7% ofthe general
population, respectively (Vasiliadis, Lesage, Adair, Wang, & Kessler, 2007). Bennett et al.
report similar international rates ranging from 7%-13% (2004b). Women appear to be at
increased vulnerability. Statistics Canada (2002) reports that Canadian women have higher

Physical Activity in Pregnancy 8
reported prevalence rates for depression than men: 5.9% of women were found to meet the
criteria for major depressive episode compared to 3.7% of men. Women oflower socioeconomic status are reported to be even more vulnerable (Bennett, et al., 2004b; Faisal-Cury
& Rossi Menezes, 2007). Anxiety disorders are also seen at least twice as often in women as

in men (Andersson et al., 2006). The reported lifetime prevalence of anxiety in women is as
high as 30% (Andersson et al., 2006; Bowen, Bowen, Maslany, & Muhajarine, 2008). The
literature reports that both anxiety and depression are prevalent in women of childbearing
age (Andersson et al., 2006; Faisal-Cury & Rossi Menezes, 2007; Goebert, Morland,
Frattarelli, Onoye, & Matsu, 2007) .

Causes
The causes of depression and anxiety remain unknown, however it is thought that a
combination of biological factors, environmental and social factors, and a genetic
predisposition are involved (Bennett et al., 2004a). In women, hormonal changes associated
with the reproductive cycle may also play an integral role. As pregnancy is a period
involving substantial hormonal changes, pregnant women are at increased risk (Misri and
Kendrick, 2007).

Prevalence during pregnancy
The reported prevalence rates of depression and anxiety during pregnancy range
considerably. A systematic review by Bennett et al. (2004b) reports prevalence rates of

Physical Activity in Pregnancy 9
depression in women from a variety of developed countries to be 7.4%, 12.8%, and 12.0% in
the first, second, and third trimesters of pregnancy, respectively. The reported rates of
depression during the second and third trimesters of pregnancy are nearly double the rate
observed in the general female population. The authors point out that these rates may be
conservative due to various limitations found in the studies included for analysis (Bennett et
al., 2004b). Another study reported a prevalence rate of 19.6% based on a cross-sectional
study of Brazilian women (Faisal Curry and Rossi Menezes, 2007), and Andersson et al.
(2006) found that 14.5% of the participants in their Swedish population-based sample were
experiencing minor depressive disorders. Further, Goebert et al. (2007) report a prevalence
rate for probable major depression of 31% with an additional 5% at risk of having moderate
depression. This was based on a study comparing Asian, Caucasian, and Native Hawaiian
women in Hawaii.
Anxiety during pregnancy would appear to be as common as depression during
pregnancy. Prevalence rates of anxiety are reported in the literature as 18.4% (Andersson et
al., 2006), 39% (Adewuya, Ola, Aloha, and Mapayi, 2006), and 59.5% (Faisal-Cury and
Rossi Menezes, 2007). Radecki Breitkopf et al. (2006) found that anxiety scores among
women of lower socioeconomic status were lower in the postpartum period than during
pregnancy. Comorbidity is also common. Andersson et al. (2006) report that 20.5% of the
women in their study suffered from both depression and anxiety. It is critical for healthcare
providers to understand the prevalence of depression and anxiety during pregnancy due to
the myriad of negative maternal and fetal outcomes associated with these disorders if left
untreated.

Physical Activity in Pregnancy 10

Outcomes
The outcomes associated with depression and anxiety during pregnancy are
significant to mother, fetus, and, neonate. In pregnant women these include: altered maternalfetal attachment (Alhusen, 2008; Lindgren, 2001); decreased participation in health practices
during pregnancy (Lindgren, 2001 ); increased maternal somatic symptoms; inadequate
maternal weight gain; pre-eclampsia; substance use and addictions (including tobacco, drugs,
and alcohol); increased risk of suicide (Bennett et al., 2004a); and increased risk of
postpartum depression and/or psychosis (Bowen, & Muhajarine, 2006; Milgrom, Gemmi1,
Bilszta, Hayes, Bernett, Brooks et al., 2008). The outcomes associated with maternal
depression during pregnancy on the fetus/neonate include: increased risk of pre-term birth
(<37 weeks) and low birth-weight (<2500g) (Bennett et al., 2004a); less breast-feeding;
lower health scores at birth; failure to thrive; increased admissions to the Neonatal Intensive
Care Unit (Bowen, & Muhajarine, 2006); and, possible altered neurobehavioral functioning
in the neonate (Bennett et al., 2004a).

Detection and treatment

Until the last decade, much emphasis has been placed on the detection and treatment
of depression in the postpartum period whereas studies addressing depression during
pregnancy have been noticeably lacking from the contemporary literature. Since the early
1990s, however, published studies have increased awareness ofthe issue and provided
opportunity for enhanced prevention, detection, and treatment.
Detection of depression and anxiety in pregnant women has proven marginally

Physical Activity in Pregnancy 11
successful; as many as 50% of pregnant women who experience depression go unrecognized
by their healthcare providers (Bennett et al., 2004a). This may be because many of the
somatic symptoms associated with depression and anxiety during pregnancy are similar to
common symptoms of pregnancy, and are therefore attributed to the pregnancy rather than a
psychological origin (Bennett et al., 2004b). Such symptoms may include sleep and appetite
disturbances, fatigue, emotional lability, physical aches and pains, or lack of interest in sex
(BC Reproductive Care Program, 2003). Also, feelings of depression and anxiety may be
negatively impacted by the progression of pregnancy. Without ongoing assessment
throughout the course of the pregnancy depression and anxiety in pregnant women may be
missed (Bennett et al., 2004a). Another reason why feelings of anxiety or depressed mood
may go unrecognized is a lack of screening by care providers. A study by Coleman et al.
(2008) found that only 20% of physician respondents screen for anxiety during pregnancy.
The primary barrier identified for this lack of screening is perceived inadequate education
about the disorder. Similarly, the same may be true regarding screening for depressed mood
and body image concerns during pregnancy.
The current interventions for depressed mood and feelings of anxiety during
pregnancy are similar to those for depression and anxiety in the general population:
pharmacotherapy and psychotherapy (Bennett et al. , 2004a; Bowen and Muhajarine, 2006;
Misri and Kendrick, 2007). Psychotherapy has proven to be beneficial (Bowen &
Muhajarine, 2006) but due to high costs, extensive need for resources, and lack of available
therapists in most areas this option is often difficult for women to access or totally
unavailable (Bennett et al., 2004a). Pharmacotherapy generally involves tricyclic

Physical Activity in Pregnancy 12
antidepressants (TCAs), selective serotonin re-uptake inhibitors (SSRis) (Marcus & Flynn,
2007; Misri and Kendrick, 2007), serotonin norepinephrine reuptake inhibitors (SNRis), or
atypical antidepressants (Misri and Kendrick, 2007). There is a great deal of controversy
regarding the use of antidepressants during pregnancy due to the potential of harm to the
developing fetus (Marcus & Flynn, 2007; Misri and Kendrick, 2007). Both TCAs and SSRis
are proven to cross the placenta (Bennett et al., 2004a). For this reason, many healthcare
providers and pregnant women have strong aversions to their use during pregnancy (Bennett
et al., 2004a). Several complementary or adjunct therapies have also been investigated for
treating depression and/or anxiety during pregnancy. Due to the concerns regarding lack of
access to psychotherapy and possible side effects of pharmacotherapy, further investigation
into complementary and adjunct therapies is warranted.

Body Image During Pregnancy
Another aspect of psychological distress reported by pregnant women is concern
about body image (Clark et al., 2009) . Thompson, Heinberg, Altabe, and Tanleff-Dunn
defme body image as " ... one's internal representation of one's outer appearance, and includes
cognitive, perceptual, and attitudinal components" (as cited in Clark et al., 2009, p. 28).
During pregnancy women experience exceptional changes in their body size, shape, and
composition over a relatively short period of time (Varney et al., 2004). These rapid physical
changes may increase pregnant women's likelihood of experiencing negative body image.
This is a concern because impaired body image during pregnancy is associated with maternal
actions or issues that may impact negatively upon maternal and fetal health such as altered

Physical Activity in Pregnancy 13
eating behaviours, smoking, decreased participation in physical activity, and depression
(Duncombe, Wertheim, Skouteris, Paxton, & Kelly, 2008).
The body image of pregnant women changes over the course of pregnancy (Goodwin,
Astbury, & McMeeken, 2000; Boscaglia, Skouteris, and Wertheim, 2003). There is a lack of
consensus in the literature as to whether these changes are generally in a positive or negative
direction. Duncombe et al. (2008) report that the body image of the pregnant women in their
study remained relatively stable across pregnancy, and that they were able to adjust to the
rapid physical changes of pregnancy. These findings are consistent with those reported by
Clark et al. (2009) and Boscaglia et al. (2003). Duncombe et al. (2008) also found that
women with a positive body image at the beginning of pregnancy continued with a positive
body image throughout the pregnancy while women with negative body image tended to
remain concerned for the duration of the pregnancy. A study by Goodwin et al. (2000) and
another by Smith and Michel (2006) found that body image for women in the control groups
(no physical activity) moved in a negative direction from early pregnancy to late pregnancy.
In contrast, positive changes in body image were noted for women in the physical activity
group (Smith & Michel, 2006).
Although there is no absolute consensus regarding the nature of these changes, it is
documented that some women experience negative changes to body image during pregnancy
(Goodwin et al., 2000). These feelings may impact both the woman's and her baby's health.
More research is necessary to investigate interventions that may help women to maintain or
increase their positive body image during pregnancy.

Physical Activity in Pregnancy 14
Association Between Physical Activity and Physical and
Psychological Health During Pregnancy

Maternal participation in health practices, such as physical activity, healthy nutrition,
maintaining good dental and personal hygiene, and abstaining from tobacco, drugs, and
alcohol, have been associated with a reduced feelings of anxiety and depression and
increased positive body image in pregnant women (Haas, Jackson, Fuentes-Afflick, Stewart,
Dean, Barawsky, et al., 2005; Lindgren, 2001; Poudevigne & O'Connor, 2005 ; Poudevigne &
O'Connor, 2006). Of these health practices, routine physical activity has the potential to
benefit the participant both physically and psychologically (Davies et al., 2003). Physical
activity also has reportedly no adverse effects, is inexpensive, and can be done in groups or
individually depending on the social needs of the participant. It is feasible to argue that
routine physical activity is an effective intervention for decreasing or preventing feelings of
anxiety, depressed mood, or decreased body image in healthy pregnant women. Due to the
lack of published studies on this topic and to the many design and methodology limitations
of these studies (Poudevigne & O'Connor, 2006), more investigation is necessary.

Literature Review
Four themes related to physical activity and psychological distress during pregnancy
emerged from the literature review: physical activity during pregnancy; the relationship
between physical activity and self reports of depressed mood during pregnancy; the
relationship between physical activity and self reported feelings of anxiety during pregnancy;
and, the relationship between physical activity and self reports of concerns about body image

Physical Activity in Pregnancy 15
during pregnancy.

Physical Activity During Pregnancy

Three clinical practice guidelines included in this review speak to the topic of
physical activity during pregnancy: the Canadian guidelines developed jointly by the Society
of Obstetricians and Gynaecologists of Canada and the Canadian Society for Exercise
Physiology (SOGC/CSEP) (Davies et al., 2003); the American guidelines developed by the
American College of Obstetricians and Gynaecologists (ACOG) (1994, 2002); and the
British guidelines developed by the Royal College of Obstetricians and Gynecologists
(RCOG) (2006). The three guidelines concur that all healthy women should participate in
routine physical activity throughout their entire pregnancy to maintain cardiorespiratory and
muscular fitness.
Although the guidelines focus on the physiological benefits of physical activity during
pregnancy, all three mention a psychological benefit as well: ACOG suggests routine
physical activity may enhance women's overall feelings of well-being (1994, 2002); RCOG
states that active women experience less stress, anxiety, and depression (2006); and
SOGC/CSEP supports that women who do not engage in routine physical activity during
pregnancy may develop concerns about body image (Davies et al., 2003).
The three guidelines agree that the beginning frequency for physical activity during
pregnancy is at least three times weekly, and all encourage four to seven sessions per week as
tolerated. The recommended duration per session is at least 30 minutes; previously sedentary
women should begin with 15 minutes and build up to 30 minutes and more. The

Physical Activity in Pregnancy 16
recommended intensity of physical activity during pregnancy is at a moderate level (ACOG,
1994; Davies et al., 2003; RCOG, 2006).
To measure the level of intensity of physical activity, SOGC/CSEP (Davies et al., 2003)
and RCOG (2006) recommend using the 'talk test', the Borg scale of perceived exertion, or
modified heart rate zones for use in pregnancy. ACOG ( 1994) recommends pregnant women
should modify the intensity based on how they feel. The 'talk test' implies a woman is
exercising at an appropriate level if she is able to carry on a conversation during exercise.
The level of intensity should be decreased if this is not possible (Davies et al., 2003; RCOG,
2006). The Borg scale of perceived exertion is another subjective way of measuring how one
is feeling during activity. It is based on the individual's physical sensations of heart rate,
respiration rate, and muscle fatigue. The scale ranges from 6-20, with 6 being very, very light
perceived exertion and 20 being very, very hard perceived exertion (Borg as cited by CDC,
2009). A rating of 12-14 is identified as somewhat hard perceived exertion and is an
appropriate level for most pregnant women (Davies et al., 2003; RCOG, 2006). Due to
normal alterations of women's resting and maximal heart rates during pregnancy,
conventional heart rate zones for aerobic exercise are not recommended for use in pregnant
women (Davies et al., 2003; RCOG, 2006). Instead, SOGC/CSEP (Davies et al., 2003) and
RCOG (2006) recommend following modified heart rate zones as outlined in their
guidelines; women aged less than 20 years should aim for 140-155 beats per minute (bpm);
women aged 20-29 should aim for 135-150 bpm; women aged 30-39 should aim for 130-145
bpm; and women aged 40 or greater should aim for 125-140 bpm (Davies et al., 2003;
RCOG, 2006).

Physical Activity in Pregnancy 17

It is well documented that routine physical activity during pregnancy, defined as at least
thirty minutes of moderate intensity activity three or more times weekly, contributes to
physical health. The contribution to psychological health is also documented in the literature
(Davies et al., 2003; RCOG, 2006). Despite this awareness, decreased participation in
physical activity during pregnancy is common (Poudevigne & O'Connor, 2006). Five of the
studies included in the literature review report on trends in physical activity during
pregnancy.

Trends
In a prospective longitudinal study, Goodwin et al. (2000) used a self-report
questionnaire to gather data on physical activity during pregnancy. They found that 80% of
the 72 women in their convenience sample were exercising before pregnancy and at the
beginning of the second trimester of pregnancy. Sixty percent maintained a consistent level
of exercise throughout pregnancy, and 40% decreased their level of exercise. Limitations of
this investigation included the lack of evidence for the validity of the exercise history
questionnaire, a small sample size, and the possibility of recall error.
Data from 28 retrospective, non-experimental, or quasi-experimental studies included in
a literature review by Poudevigne and O'Connor (2006) also determined that physical
activity consistently decreases during pregnancy. The intensity, duration, and frequency of
physical activity decreases from pre-pregnancy to the first trimester, and from the first to the
third trimester. Limitations inherent to many of the studies included in the review are as
follows: the use of physical activity measures with no documented evidence of their

Physical Activity in Pregnancy 18
reliability or validity; weak measures of physical activity, such as recall; lack of a clear
definition of physical activity; lack of empirical testing, such as the maximum amount of
oxygen an individual can use during intense exercise (V02 max), to confirm verbal reports
(Quinn, 2008); and too few measures over time (Poudevigne & O'Connor, 2006).
Da Costa, Rippen, Dritsa, & Ring (2003) found similar results. The monthly frequency
of physical activity decreased from the first to the third trimester. Interestingly, the monthly
frequency of physical activity increased from pre-pregnancy to the first trimester. The
duration of exercise sessions decreased from pre-pregnancy to the second trimester but
increased slightly in the third trimester. Physical activity was assessed by asking participants
to recall their participation in activities not associated with work (DaCosta et al., 2003).
These results are limited due to the self-reporting of physical activity by the participants, no
inclusion of a test of fitness to confirm verbal reports, and the use of a non-validated measure
of physical activity.
Poudevigne and O'Connor (2005) used a 7-day diary, interviewer-administered 7-day
physical activity recall, and a 3-day motion sensor recording to measure physical activity
throughout the duration of their prospective investigation. The results from the pregnant
participants were compared to an equal number of matched non-pregnant subjects. The
results of the diary and recall showed that overall physical activity decreased over the course
of the pregnancy with a slight increase at 24 weeks. The results of the motion sensor
recording showed a significant decrease of motion in pregnant women: 23% from gestational
weeks 12-36 compared with only a 5% decrease in non-pregnant women (Poudevigne &
O'Connor, 2005). Limitations are a small sample size of only 12 pregnant women and the

Physical Activity in Pregnancy 19
lack of generalizability of the results to those from socio-economic and ethnic backgrounds
other than middle-class Caucasian women.
Schmidt, Pekow, Freedson, Markenson, and Chasan-Taber's (2006) cross sectional
study of 233 prenatal care patients found that the median total energy expenditure was
similar among women in the first and second trimesters and lower among women in the third
trimester. While the other studies in this literature review address only physical activity in
term of exercise-type activities, this study included household/caregiving, occupational,
leisure, and sport/exercise in the definition of physical activity. Household/caregiving
activity was found to be the largest contributor of total energy expenditure in each trimester.
Sport/exercise activity contributed very little to the overall energy expenditures but increased
from the first to the second trimester, and then decreased substantially in the third. These
results are in general agreement with the previously mentioned studies (DaCosta et al., 2003;
Goodwin et al., 2000; Poudevigne & O'Connor, 2005). A small sample size, recall bias, and
the use of a non-validated physical activity measurement tool may influence these results.
Five studies addressed physical activity during pregnancy (see Appendices A, B, and C
for complete analyses of these studies). The available evidence suggests that participation in
physical activity decreases from the first to the third trimester of pregnancy. Additional
research into this topic is warranted due to the design and methodology inadequacies of the
existing studies.

Physical Activity in Pregnancy 20
Physical Activity and Depressed Mood During Pregnancy

Maternal participation in physical activity during low risk pregnancies has been reported
as safe and beneficial to maternal physical and psychological health, and to fetal and
neonatal health (Davies et al. , 2003). Five of the nine studies included in the literature review
address the relationship between depressed mood and physical activity during pregnancy.
Limiting factors include the number of different tools used to evaluate depressive symptoms
and their lack of validation for use with pregnant women.
Goodwin et al. (2000) found no significant difference for depression during pregnancy
(mean score= 0.56 +/- 1.00 for exercisers vs. 0.61 +/- 1.24 for non-exercisers; p value not
significant) when the exercise group was compared with the non-exercise group. The 28-item
General Health Questionnaire (GHQ-28) was used to gain information about the subjects'
mental state at 30 weeks' gestation. The authors report the GHQ-28 has not been validated
for use with pregnant women (Goodwin et al., 2000). This lack of validation limits the
reliability of this data. Additional limitations involve the data being reported only once
during pregnancy and the lack of randomization of subjects into groups.
Alternatively, Poudevigne and O'Connor (2006) report on six studies whose evidence
suggests that decreased aerobic exercise was associated with low mood, including increased
symptoms of depression. Due to the lack of published research and design and methodology
limitations found in the studies, these authors recommended additional research into this
topic.
DaCosta et al. (2003) also found that pregnant women who were not exercising in the
first and second trimesters reported significantly more symptoms of depression than their

Physical Activity in Pregnancy 21
exercising counterparts. The Lubin Depressive Adjective Checklist Form C (DACL) was
used to assess symptoms of depression. No information was provided regarding the
reliability or validity of this tool. In the first trimester, 33 .1% of non-exercising pregnant
women were considered depressed compared to 15.1% of exercising pregnant women
(p=0.02). In the second trimester, 18.9% of non-exercising pregnant women were considered
depressed compared to 5.7% of pregnant women who were exercising regularly (p=0.02).
There were no group differences for the third trimester (DaCosta et al. , 2003). A limitation
of this study is the authors' failure to account for possible confounding factors in the
relationship between physical activity and symptoms of depression.
Poudevigne and O'Connor (2005) also found associations between changes in physical
activity and mood (including depression) during pregnancy using the 65-item Profile of
Mood States (POMS) questionnaire. The authors report using this questionnaire due to the
extensive evidence supporting its reliability and validity, including data from large samples
of pregnant women. A strong test of the relationship was not possible due to the tiny
magnitude of the changes. Additional limitations include a small sample size and recall bias.
In a large observational multi-ethnic cohort study, the prevalence of depressive

symptoms increased over the course of pregnancy (Haas et al., 2005). In this study physical
activity was measured by recall from the previous month, and depressive symptoms were
screened for using the short-form Center for Epidemiologic Studies-Depression Scale (CBSD). Of the many demographic, medical, and obstetrical characteristics addressed in the study,
a lack of exercise during pregnancy was consistently associated with depressive symptoms
(Haas et al., 2005). Due to the observational nature of this study, it is not possible to identify

Physical Activity in Pregnancy 22
causal relationships. Recall bias may also interfere with these findings . This was a larger
sample size than most of the studies reviewed, which may reduce bias.
Five studies addressed the relationship between physical activity and depressed mood
during pregnancy (see Appendix C for complete analyses of these studies). The available
evidence suggests that decreased physical activity during pregnancy is associated with
increased depressive symptoms during pregnancy. More research is necessary due to the lack
of published papers on the topic and the design and methodology inadequacies of the existing
studies such as recall bias, small sample sizes, and the lack of accounting for confounding
factors.

Physical Activity and Feelings ofAnxiety During Pregnancy

As reported, feelings of anxiety during pregnancy appear to be as common, or even
more common, than depressed mood (Adewuya et al., 2006; Andersson et al., 2006; Da
Costa et al., 2003; Faisal-Cury and Rossi Menezes, 2007). Two of the nine studies included
in this literature review specifically address the relationship between physical activity and
feelings of anxiety during pregnancy.
DaCosta et al. (2003) used the state-trait anxiety inventory (STAI) to measure state
anxiety of the participants. The scale was completed monthly beginning in the third month of
pregnancy. The results indicate that anxiety was lower in every trimester for women who
reported engaging in leisure time physical activity compared to non-exercising women.
Based on the data, it is difficult to identify causal relationships. Also, small sample sizes and
lack of generalizability of the results to non-Caucasian pregnant women limit the reliability

Physical Activity in Pregnancy 23
of these results.
Similarly, Goodwin et al. (2000) report that women in their non-exercise group scored
higher on the 28-item General Health Questionnaire (GHQ-28) for anxiety than women in
the exercise group (mean score = 6.22 =/- 3.81 vs. 4.42 =/- 2.58; p= 0.03). As previously
mentioned, the GHQ-28 has not been validated for use during pregnancy which may limit the
validity of the results. The lack of measures over time and the self selection of subjects into
groups are also limiters.
In summary, the available evidence suggests that women who routinely participate in
physical activity during pregnancy report less feelings of anxiety compared to women who
do not regularly engage in physical activity (see Appendix C for complete analyses of the
studies). Further research is warranted due to the limited number of papers found on this
topic and the outlined design and methodology limitations of the available studies.

Physical Activity and Body Image During Pregnancy
It is well documented that women experience changes in body image during pregnancy

(Chang, Chao, & Kenney, 2006; Clark et al. , 2009 ; Duncombe et al. , 2008). Although there
is a lack of absolute consensus regarding the general trend ofthis change, it has been shown
that negative body image during pregnancy may contribute to negative maternal health
behaviors and depression (Clark et al., 2009). Four of the nine studies included in this
literature review address the relationship between routine physical activity and body image
during pregnancy.
Boscaglia, Skouteris, & Wertheim (2003) address changes in body satisfaction during

Physical Activity in Pregnancy 24
pregnancy using a 10-item version of the Body Cathexis Scale (test-retest reliability= 0.71 ;
Cronbach's alpha = 0.85-0.88.). The results of high exercising and low exercising pregnant
women were compared at 15-22 weeks' gestation and at 23-30 weeks' gestation. The results
indicate that at 15-22 weeks' gestation, the high exercisers were significantly more satisfied
with their bodies compared to the low exercisers, t(69)=-2.89; p=0.005; d=0.69. No other
significant differences were found (Boscaglia et al., 2003). The authors report that while the
majority of pregnant women in this study were able to adapt to their changing body without a
negative shift in body image, women who regularly participated in physical activity adapted
to these changes earlier in pregnancy (Boscaglia et al., 2003). These results may be limited
by participant self-selection into groups and the recall method of data retrieval.
Similar results were found in a two-group quasi-experimental, pre-test/post-test study by
Smith and Michel (2006). This study looked at the effects of aquatic exercises on
discomforts in pregnancy, which included perception of body image (2006). Body image was
measured using the 34-item Pregnancy Body Shape Questionnaire (PBSQ) (Cronbach's
alpha=.86). Higher scores on this tool indicate lower body image. The body image scores of
the non physical activity group were compared to those from the group participating in
aquatic exercise three times weekly. The results indicate that there was no statistically
significant difference between the groups for body image at the pretest (mean score = 65.5
+/- 23 .6 (activity group) vs. 59.1 +/- 27.5 (non-activity group); p=.03). At the posttest,
pregnant women who participated in the aquatic physical activity program reported
significantly higher positive body image (lower scores) compared to the non physical activity
group (mean score = (activity group) 56.0 +/- 23.7 vs. (non-activity group) 80.1 +/- 34.5,

Physical Activity in Pregnancy 25
p=.03) (Smith & Michel, 2006). Participant self-selection into groups and the small sample
size may contribute to bias in this study. Also, there is a possible lack of generalizability of
results to pregnant women who participate in physical activity other then aquatic exercises or
who are less than 19 weeks gestation.
Goodwin et al. (2000) compared body image of exercising and non-exercising pregnant
women. The Body Cathexis Scale was used to measure attitude about body image at 14-20
weeks' gestation and at 27-30 weeks' gestation. The results show no significant difference
between the two groups. However, the scores for the non-exercising women became less
positive over the course of pregnancy (34.67 vs. 33.78) while the scores for the exercising
women became more positive (35.12 vs. 36.88) (Goodwin et al., 2000). These results may be
limited by the self selection of subjects into groups, as well as the lack of clearly defmed
criteria for the exercise and non-exercise groups.
Marquez-Sterling, Perry, Kaplan, Halberstein, and Signorile (2000) also used the Body
Cathexis Scale to examine the effects of routine physical activity on body image in 15
previously sedentary primigravidae. The results show no changes in the body image of the
women in the non-physical activity group, indicating that their body image remained stable
over the course of pregnancy. The women who participated in the three times weekly
physical activity sessions showed an increase in positive body image over the course of
pregnancy (Marquez-Sterling et al., 2000). These results may be limited by the small sample
size and the lack of generalizability of the results to the general population.
Four studies addressed the relationship between routine physical activity and body
image during pregnancy (see Appendix B for complete analyses of these studies). Based on

Physical Activity in Pregnancy 26
the available evidence, it can be argued that women who participate in routine physical
activity during pregnancy are more likely to have a positive body image throughout the
course of pregnancy compared to women who do not participate in physical activity. Due to
the limited number of published articles on this topic and the design and methodology
limitations of the available studies, additional research is warranted.

Discussion
Limitations or Biases in the Reviewed Literature

The evidence gathered for this review supports the argument that regular participation in
physical activity during pregnancy is likely to decrease self reports of psychological distress,
such as feelings of anxiety, depressed mood, or concerns about body image. The limited
search time-line for this preliminary review and the subsequent possibility of missing
seminal works on the topic will be best addressed in a follow up study to ensure all relevant
contemporary literature is included. The findings of this review must also be interpreted with
caution due to the lack of published studies found on this topic and the numerous limitations
of the available studies. Small sample sizes, self-selection into groups, lack of experimental
designs, too few measures over time, and use of recall to gather information may introduce
confounding variables. Also, other factors may be unaccounted for and there is a frequent
lack of empiric testing to confirm verbal accounts. Comparison of the findings between
studies is difficult due to the inconsistent definitions of what constitutes physical activity and
the varying methods of measuring levels of physical activity. The various types of
measurement tools used in the different studies, some of which have no published evidence

Physical Activity in Pregnancy 27
of reliability or validity for use with pregnant women, also make comparison of the findings
difficult. Further investigations using rigorous methods and validated measures that are
appropriate for pregnant women would confirm or challenge these findings.
Based on the findings of this literature review, there is cautious support for an
association between routine physical activity during pregnancy and pregnant women's
experiences and self reports of psychological distress; however, there is insufficient evidence
to provide reliable correlational evidence. It is unclear if pregnant women report less
symptoms of psychological distress when they regularly participate in physical activity or if
pregnant women participate in physical activity because they are experiencing fewer
symptoms of psychological distress. Additional research using rigorous designs and
validated measures that are relevant for pregnant women would verify any potential
correlational relationships.
An interesting outcome of this review which warrants further investigation is a finding

by DaCosta et al. (2003). The pregnant women in this study experienced psychological
benefits of physical activity, even though many were exercising less frequently and at a
lower intensity than is recommended by the Society of Obstetricians and Gynecologists and
the Canadian Society for Exercise Physiology (Davies et al. , 2003) and the Royal College of
Obstetricians and Gynecologists (2006). As these recommendations focus primarily on the
physical benefits of aerobic exercise during pregnancy and less on the psychological
benefits, it is possible that a lower frequency and intensity of physical activity during
pregnancy has similar protective benefits to psychological health than do the higher
frequency and duration to physical health. More focussed research would shed light on the

Physical Activity in Pregnancy 28
optimal frequency and duration of aerobic exercise during pregnancy to achieve decreased
self reports of psychological distress.

Relevance of Findings to the Clinical Practice ofNurse Practitioners

Despite the limitations or biases in the literature and the need for further investigations,
the findings of these studies are valuable in the context of clinical practice. Nurse
practitioners care for diverse populations with diverse health concerns. Providing evidenceinformed treatments and recommendations is a necessity and expectation of the role. A
substantial difficulty for NPs, and all health professionals, is wading through the masses of
research and frequently conflicting information to gain an understanding of the optimal
treatments and recommendations for each individual client. In this case, it is encouraging that
the overall findings of the studies are consistent in stating that routine physical activity tends
to decrease self reports of psychological distress in healthy pregnant women. It is also
encouraging that self reports of psychological distress were not found to increase with
routine physical activity during pregnancy. This knowledge, paired with the fact that physical
activity during pregnancy benefits maternal physical health (Davies et al., 2003) and has
shown no adverse effects to either mother or fetus (RCOG, 2006), presents a sound basis for
effective clinical discussions between primary care providers and pregnant clients.

Conclusion
Contemporary literature reports that women's participation in physical activity is
reduced during pregnancy (Poudevigne & O'Connor, 2006). For women who continue to

Physical Activity in Pregnancy 29
regularly participate in physical activity during pregnancy, trends show decreasing levels as
the pregnancy progresses (Schmidt et al., 2006). Evidence supports that among healthy
pregnant women, increased participation in physical activity is associated with a decrease in
self reports of psychological distress (Boscaglia et al., 2003; DaCosta et al., 2003; Goodwin
et al., 2000; and Poudevigne & O'Connor, 2006). The current recommendations encourage at
least thirty minutes of moderate intensity physical activity three or more days every week
throughout pregnancy (ACOG, 1994; Davies et al., 2003; RCOG, 2006); however, even low
intensity physical activity during pregnancy is associated with decreased self reports of
psychological distress (DaCosta et al., 2003). Pregnant women who routinely participate in
physical activity are also more likely to report positive feelings about body image earlier in
pregnancy (Boscaglia et al., 2003), and to maintain these positive feelings over the course of
the pregnancy (Marquez-Sterling et al., 2000) compared to pregnant women who do not
participate in regular physical activity. In addition to psychological health benefits, evidence
also demonstrates that this intervention can improve maternal physical health and contribute
to the prevention of pre-eclampsia, gestational diabetes, and excessive weight gain during
pregnancy (RCOG, 2006).

Implications and Recommendations for Nurse Practitioner Clinical Practice
These findings have implications for nurse practitioners' clinical practice. Firstly, as
levels of physical activity are shown to decrease during pregnancy, especially in the third
trimester (Poudevigne & O'Connor, 2006), it is important for NPs to consider actions to
encourage regular physical activity prior to and throughout pregnancy. Secondly, NPs must

Physical Activity in Pregnancy 30
consider the physical and psychological effects decreased physical activity has on maternal
health, and monitor both appropriately throughout the gestational period. Thirdly, as the
evidence from this review is inconclusive in terms of demonstrating causal relationships, it is
necessary for NPs to consider that psychological distress may contribute to decreased
physical activity during pregnancy just as decreased physical activity may contribute to self
reports of psychological distress. It is useful for the NP to consider both possible associations
when working with a prenatal client who is experiencing psychological distress and to plan
the care accordingly.
When considering the implications of these fmdings for nurse practitioner clinical
practice, the social context of women's lives also deserves full recognition. It is an area that
is not well represented in the biomedical paradigm. Women's lived experiences are unique,
and can greatly impact actions and choices. Pregnant women's social contexts have the
potential to contribute to psychological distress, and may also facilitate or impede
participation in physical activity during pregnancy. It is important for NPs to consider the
greater determinants of health, which combine to create the social context within which
pregnant women live, when planning and implementing care. Having a clear understanding
of community services available to pregnant women, and ensuring adequate time to explore
the client's lived experiences and social context may aid NPs when addressing psychological
distress and physical activity during pregnancy.
Due to the dearth of available contemporary studies on this topic and the limitations of
these studies, additional investigations using rigorous methods and validated measures
relevant for pregnant women would be a beneficial contribution to NP clinical practice. NPs

Physical Activity in Pregnancy 31
could lead this research to ensure its relevance for their practices. Firstly, there is scope for
NPs to pursue research that is congruent with, and which explores, the social, emotional, and
spiritual contexts of women's lives, as well as the physical context. The literature review also
reveals additional research topics with direct relevance to clinical practice that may be of
interest to NPs. For example, an investigation into the reliability and validity of screening
tools which have no such published evidence may be an area of interest. A follow up study
to this preliminary review would be relevant to capture any seminal work not included due to
the limited search time-line.
Based on the fmdings from this review, it is recommended that NPs discuss the physical
and possible psychological benefits of routinely participating in physical activity during
pregnancy with their pre-conception and prenatal clients at every appropriate opportunity.
NPs routinely screen expectant clients for signs of physical illnesses, such as hypertension or
urinary tract infections, using validated measures. In light of these findings, NPs may also
choose to routinely screen for signs of psychological distress, such as feelings of anxiety,
depressed mood, or concerns about body image, using validated screening tools. It is
recommended that NPs encourage at least 30 minutes of moderate intensity physical activity
three or more times weekly for all healthy, pregnant women, with a view to optimizing
physical health and decreasing potential for self reports of psychological distress during the
gestational period.

Physical Activity in Pregnancy 32
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Radecki Breitkopf, C., Primeau, L., Levine, R., Olson, G., Wu, H., & Berenson, A. (2006).
Anxiety symptoms during pregnancy and postpartum. Journal ofPsychosomatic

Obstetrics and Gynecology, 27(3), 157-162. DOl: 10.1080/01674820500523521.
Royal College of Obstetricians and Gynaecologists (2006). Exercise in pregnancy: statement
no. 4. Retrieved June 28, 2008, from the World Wide Web: http://www.rcog.org.uk.
Schmidt, M ., Pekow, M., Freedson, P., Markenson, G., & Chasen-Taber, L. (2006). Physical
activity patterns during pregnancy in a diverse population of women. Journal of

Women's Health, 15(8), 909-918. Retrieved April20, 2009, from Medline Ebsco
database.
Smith, S., & Michel, Y. (2006). A pilot study on the effects of aquatic exercise on
discomforts of pregnancy. Journal of Obstetric, Gynecologic, and Neonatal Nursing,
35(3), 315-23. Retrieved June 27, 2008, from Medline Ebsco database.

Statistics Canada (2002). Table 105-1100: Mental health and wellbeing profile, canada

community health survey (CCHS), by age group and sex, Canada and provinces,
occasional, 2002. Retrieved April27, 2009, from the World Wide Web:
http://cansim2.statcan.gc.ca/cgi-winlcnsmcgi.pgm.
Varney, H., Kriebs, J., & Gegor, C. (2004). Normal pregnancy database: Adaptations of the
mother, development and growth of the embryo and the fetus, and the placenta.

Varney's Midwifery (4th ed.). Mississauga, ON: Jones and Barlett.

Physical Activity in Pregnancy 39
Vasiliadis, H., Lesage, A., Adair, C., Wang, P., & Kessler, R. (2007). Do Canada and the
United States differ in Prevalence of depression and utilization of services?

Psychiatric Services, 58(1), 63-71. Retrieved April27, 2009 from the World Wide
Web: http://psychservices.psychiatryonline.org/cgi/reprint/58/1/63
Whatley Blum, J. , Beaudoin, C., & Caton-Lemos, L. (2004). Physical activity patterns and
maternal well-being in postpartum women. Maternal and Child Health Journal, 8(3),
163-9. Retrieved June 27, 2008, from Medline Ebsco database.

Physical Activity in Pregnancy 40
Appendix A
Analysis of Research Study Addressing Physical Activity Patterns During Pregnancy
Author(s) & Date of Schmidt, M ; Pekow, P; Freedson, P; Marken son; G; Chasan-Taber,
L.
Publication
2006
Title

Physical activity patterns during pregnancy in a diverse population
of women

Conceptual or
Theoretical
Framework

none given

Study Design

cross-sectional study

Major Variables
Studied

a. total physical activity: household/caregiving; occupational;
leisure; sports/exercise; transportation

Sample Description

233 prenatal care patients from first, second and third trimesters; all
recruited from a tertiary care hospital in western Massachusetts; > 16
yrs < 40 yrs; uncomplicated pregnancies

a. interviewers used standardized open-ended forms to record
Measurement
Instruments for Each detailed descriptions of every activity performed by participants
during a 24 hr period x 3
Variable
b. activity-specific intensity codes (Compendium of physical
activities) assigned to each activity recorded in the recalls; in form of
METs
Data Analysis Used

Statistical analysis performed using Statistical Analysis System
version 9.1
- mean, median, and interquartile energy expenditure values
calculated by activity type and intensity across trimesters and
categories: age, race, education, income, parity, and pre-pregnancy
BMI
- statistical significance of differences in estimates across trimesters
assessed with Kruskal-Wallis test of rank order differences.
- logistic regression: ORs, 95% CI for high level of combined
moderate /vigorous, total, and type-specific energy expenditure.
- multivariate logistic regression used to statistically adjust for
covariates found to be statistically significantly associated with high
level of activity in unadjusted models at p<O.OS
- tests of trend: calculated by modeling ordinal subject characteristics
as continuous variables.
- effect modification by trimester evaluated in inspection of stratumspecific ORs and by evaluating significance of interaction terms via

Physical Activity in Pregnancy 41
chi-square likelihood ratio tests
Study Findings

- activity intensity and type varied significantly across women in
different trimesters
- mean energy expenditure in moderate intensity activity was similar
between women in the first and second trimesters, and approximately
45% lower among women in the third trimester.
- mean household/caregiving energy expenditure: much higher
among women in later pregnancy.
- sports/exercise activity: very little contribution to total energy
expenditure

Strengths and
Weaknesses

- clearly written and organized.
- clinical implications and future research outlined.
- authors acknowledged the limitations of the study and emphasized
the necessity of more rigourous research.
- lit review good
- nature and small sample size: may contribute to bias.
- generalizability of results - no

a two-group, quasiexperimental,
pretest/posttest
a. body image
b. participation in healthpromoting behaviours
c. level of physical
discomfort
d. mobility

Study Design

Major Variables
Studied

a. physical characteristics:
wt, ht, skin-fold
measurements.
b. body image
c. aerobic fitness : HR,
BP, lactates.

experimental - RCT

Pender's Health Promtion none g1ven
Model (HPM), grounded
in social cognitive theory.

Conceptual or
Theoretical
Framework

2000

Astbury, J;
McMeeken, J.

a. body image
b . exercise activity over
last 4 weeks: type,
duration, perceived level
of exertion, heart rate
during activity
c. psychological well-

prospective longitudinal
study

none given

Physical and
body image and
psychological changes
psychological well-being
with vigourous exercise in in pregnancy. A
sedentary primigravidae
comparison of exercisers
and non-exercisers.

A pilot study on the
effects of aquatic
exercises on discomforts
of pregnancy

January 2000

A; Kaplan T; Halberstein
R;
Signorile J

IMarquez-Sterling S; Perry Goodwin, A;

Title

May-June 2006

Author(s) & Date of ISmith SA;
Publication
Michel Y

Analysis of Research Studies Addressing Physical Activity Patterns and Body Image During Pregnancy

AppendixB

Physical Activity in Pregnancy 42

a. body image

partial prospective
approach

none given

Changes in body image
satisfaction during
pregnancy: a comparison
of high exercising and low
exerc1smg women

2003

Boscaglia, H; Skouteris,
H; Wertheim, E.

Measurement
Instruments For
Each Variable
a. Pregnancy Body Shape
Questionnaire Cronbach's alpha =.86
b. Pender's Health
Promotion Lifestyle
Profile (HPLP) - subscale
reliabilities .70-.90;
Cronbach's alpha =.92.
c. Smith's Pregnancy
Discomfot Index (SPDII)

a. Detecto balance scale, a. Body Cathexis Scale
b. self-report exercise
stadiometer attached to
history questionnaire
scale, Lange skin-fold
c. 28 item General Health
caliper.
Questionnaire(GHQ-28)
b. Body Cathexis Scale
c. Polar Vantage XL heart
rate monitor,
sphygmomanometer with
cuff, 2300 Stat Glucose/LLactate Analyser

a. Body Cathexis Scale test-retest reliability =
0.71 ; Cronbach's alpha=
0.85-0.88.

Sample Description a convenience sample of - subjects randomly
convenience sample of 72 71 healthy pregnant
40 non-exercising
assigned to either the
volunteers recruited from women; high sociopregnant women; at least Control or Exercise
a community and hospital economic status;
19 wks gestation; greater intervention group (C= 6; based pre-natal classes.
then 18 yrs; taller than or E=9) (5 diced)
- nulliparous; 20-40 yrs;
equal to 5ft; permission to - recruited from radio and 14-20 wks pregnant;
participate from health
newspaper ads
- healthy; no
care provider (HCP).
-all subjects: completed
contraindications to
Excluded: those with
medical questionnaire,
exercise; BMI <30; read
mutiple pregnancies, hx of provided a fetal
and write English.
pre-term birth, placenta
sonogram, classified as
previa or gestational
low risk, permission to
participate by HCP,
hypertension, or both.
approved to participate by
60% of sample was
medical director of study,
African-American.
and had not exercised on a
regular basis x 1 yr prior
to conception

being: anxiety; dep.

Physical Activity in Pregnancy 43

'

I

Study Findings
- ---

Women who participated
in the aquatic exercise
program reported less

--

----

Exercising subjects
experienced significant
improvements in aerobic

- no significant difference - at 15-22 wks gest. the
high exercisers were
in body cathexis scores
significantly more
between early preg (17

Data Analysis Used Statistical analysis
Students t-test performed -statistical analyses
-analyses performed
performed using SPSS
for independent samples performed using Mac
using SPSS for Windows,
version 12
to compare physical
StatView Student data
version 10.05 .
- demographic and clinical characteristics of subjects analysis prog.
- two-tailed t-tests used to
characteristics evaluated at beginning of study
- t-test and two-factor
ensure no differences b/w
at initiation of study and - a repeated measures
repeated measure analysis exercisers and nonduring post-testing.
ANOVA performed to find of variance (ANOVA) for exercisers (groups differed
Distributional
significant differences in analysis of parametric
on parity status).
characteristics of outcome PWC 150 time and lactate data.
- mixed ANOVA
variables examined.
accumulation b/w groups - for analysis of nonconducted on body
Internal consistency
before and after 15 wk
parametric variables chi- cathexis scores: group as
estimates (Cronbach's
program
square test for categorical bw subjects indep.
alpha) evaluated for each - a Students t-test for
variables and Mann
variable, parity as
instrument. Independent independent samples used Whitney U for single
blocking indep variable;
time as within subjects
t-tests analysed for all
to compare groups in
items on the Body
indep variable (P = 0.04)
instruments and sub-scales pregnancy outcome
Cathexis Scale .
- simple linear regression - simple main effects
of the HPLP. Post-test
measures and
and a multiple regression analyses using t-tests bw
scale and sub-scale scores psychological variables.
and within groups (alpha=
evaluated by ANCOVA.
anal. to predict
relationships b/t
0.01 to reduce type 1
alpha set at < or= .05 .
independent variables and errors); effect sizes
calculated
dependent variables.
(Cohen's d).

-reliability =.89
d. Timed Get Up and Go
Test - reliability =.92-.96

Physical Activity in Pregnancy 44

I

physical discomfort,
improved mobility, and
improved body image and
health-promoting
behaviours compared to
the women who did not
participate in the aquatic
exerctse program.

satisfied with their bodies
fitness, lactate
wks) and late preg (30
hemodynamics, and
wks)
compares to low
psychological measures of - no significant difference exercisers, t(69)= -2.89,
health and well-being that in total body cathexis
P=0.005, d=0.69.
were not observed in the scores b/w the exercise
No other significant
and non-exercise groups
differences found b/w
non-exercising group.
however, scores for the
groups.
Recommendation:
sedentary primigravidae
non-exercise group
- high exercisers:
with low risk pregnancies became less positive over significantly more
can participate in
time while the scores for satisfied with their bodies
at 15-22 wks gest. , and
vigourous exercise
the exercisers remained
tended
to be more
programs when run by
relatively stable.
- exercise group compared satisfied at 23-30 wks
certified instructors in a
to the non-exercise group gest. , compared to 6 mo.
supervised setting.
pre-pregnancy
at late pregnancy: a
significant difference was -low exercisers: no
significant difference in
found for overall
body
image scores
psychological well-being
indicating that the body
and for the subscales of
image of the non or low
anxiety and insomnia
exercisers remained
(4.70 +/- 4.68 for
exercisers vs. 7.33+/- 4.19 relatively stable from prepregnancy to late
for non-exercisers;
pregnancy.
p=0.04). No significant
difference was found for
depression (0.56+/- 1.00
for exercisers vs. 0.61 +/1.24 for non-exercisers; p
NS).

Physical Activity in Pregnancy 45

Strengths and
Weaknesses

- self-selection into groups
- clearly written and
- limitations outlined by
- limitations outlined by
organized.
authors
authors
- small sample size.
- clinical implications and - groups randomly
- clearly written and well
future research outlined.
assigned : decreased bias organized
- authors acknowledged
- clearly written and
-self-selection of subjects
the limitations of the study organized
and emphasized the
- selection bias
- lack of definition for
necessity of more
- nature and size of
exercise vs. non-exercise
rigourous research.
sample: possible bias,
decreased generalizability groups
- lit review good
- lack of measurement
- large number of tests
points
performed increased
- participant self-selection possibility ofType 1 error. - GHQ only used in late
pregnancy
of group assignments:
- GHQ not validated for
may be a confounding
use with pregnant women
variable and contribute to
bias.
-small sample size: may
contribute to bias.
? generalizability - ext.
validity?

Physical Activity in Pregnancy 46
1

a. physical activity
patterns
b. body weight
c. mood

Major Variables a. self reported LTPA
Studied
patterns during each
trimester of pregnancy
b. depressive symptoms
c. pregnancy-specific

none given

two group quasiexperimental
(longitudinal prospective
approach)

none given

Conceptual or
Theoretical
Framework

Jan 2005

Haas JS; Jackson RA;
Fuente-Afflick E; Stewart
AL; Dean ML; Brawarsky
P; Escobar GJ
2006

Poudevigne M; O'Connor
P.

a. poor physical function
b. poor vitality
c. poor or fair health
d. depressive symptoms

non-experimental
(observational cohort)

none given

During pregnancy:
a. physical activity changes
b. mod changes
c. relationship b/w
physical activity and self-

systematic review

none given

Physical activity and mood Changes in health status of A review of physical
during pregnancy
women during and after
activity patterns in
pregnancy.
pregnant women and their
relationship to
psychological health

August 2005

Poudevigne M;
O'ConnorP.

Study Design

Self-reported leisure- time
physical activity (LTPA)
during pregnancy and
relationship to
psychological well-being

2003

DaCosta, D; Rippen, N;
Dritsa. M; Ring, A

Title

Author(s) &
Date of
Publication

-- - - -

Analysis of Research Studies Addressing Physical Activity Patterns and Feelings of Anxiety and/or Depressed Mood During
p

Appendix C

Physical Activity in Pregnancy 47

I

180 pregnant women; first
trimester (8-14 wks);
recruited from five
OBGYN offices in
Montreal area. 19-40 yrs,
stable relationship;
conceived naturally;
read/understand
English/French.

12 pregnant women aged
1809 pregnant women
samples of studies
18-40; first trimester ;
from 1 of 6 sites in the San reviewed varied
uncomplicated pregnancy. Francisco area. These sites immensely:
Read and understand
were chosen for a previous - size 18- >9000
English. All were paid $70 longitudinal cohort study
- majority were
for their time. Recruited
(Project WISH) due to their convenience samples
through newspaper ads,
socio-economic and ethnic
flyers at women clinics and diversity.
OBGYN offices, and at
All participants:
maternity related
received prenatal care at
businesses.
one of the six sites before
The control group was
16 wks gestation; at least
made up of 12 race18 yo; spoke English,
matched non-pregnant,
Spanish or Cantonese;
non-lactating women.
could be contacted by
phone

esteem;
In general population:
d. relationship b/w physical
activity and mood

- -

- - --

Measurement
Generally, well validated
a. 3 structured interviews
a. diary of daily physical
Medical Outcome Study
Instruments For developed for study (1 for activities; 7-day physical
Short Form-36 (SF-36) a-c: measures not used in the
Each Variable
reviewed studies: lack of
each trimester); includes
activity recall; and the MTI a. physical function- 10
assessment ofLTPA in the accelerometer.
items
precise, well-validated
previous-month- specific b. double balance beam
b. vitality- 4 items
measures of physical
c. self-rated
activity, data gathered too
activity; frequency/month; scale
average duration/session
c. 65-item Profile of Mood health:excellent, very good, infrequently;
b. Lubin depression
good, fair, poor.
States (POMS)
adjective checklist- form C questionnaire
d. short-form Centre for

Sample
Description

stressors and concerns
d. state anxiety
e. fluctuations in stress due
to minor daily stressors

Physical Activity in Pregnancy 48

Data Analysis
Used

Epidemiological Studies
Depression Scale- 10 items

- descriptive stats: means, Statistical analysis
3 sets of multivariate
medians, standard
performed using SPSS
logistic regression models
deviation (SD) for all
version 11.5
examined: health status
variables.
- assumptions for analysis prior to pregnancy, health
- independent sample tof variance were tested;
status during pregnancy,
and postpartum health
tests for continuous
degrees of freedom were
variables and chi-square
adjusted using the Huynh- status.
for dichotomous variables Feldt adjustments when
sphericity wasn't met. A
for group differences on
study variables for each
box plot analysis was done
for the variables.
trimester
- daily energy expenditure Hypotheses 1&2 : Pearson
est. for all the self-reported correlations were
computed;
LTPA in which women
reported having engaged in Hypothesis 3 tested with a
- expressed in kilocalories mixed model ANOVA.
Spearman correlations
expended per kg of body
performed for hypothesis 4
weight per hour. The av.
daily energy expenditure
for the activity
(Kcal/kg/day) was
estimated by dividing by
30.

(DACL)
c. Pregnancy Experiences
Questionnaire (PEQ)
d. sate-trait anxiety
inventory (STAI)
e. Hassels Scale (revised)

Physical Activity in Pregnancy 49

Overall, the review failed
to prove the credibility of
the results identified from
the included studies

majority of studies
reviewed used percentages
or Pearson's r correlation
to compare groups. Some
used mean , standard
deviation, and Cohen's d.
- No degrees of freedom or
p-values given

Strengths and
Weaknesses

Study Findings

-

-

- physical activity is
- prevalence of exercise
evidence of the validity of Limitations in physical
behaviours: prior to
the 7-day physical activity function, restrictions in
reduced during pregnancy;
pregnancy 40%; 1st and
recall and the
vitality, and the prevalence - available evidence
2nd trimesters 29%, 3rd
suggests that inactivity is
accelerometer as measures of depressive symptoms
trimester 21 %.
of physical activity in
increased over the course
associated with worse
mood;
- a significantly greater
pregnancy; may be valid
of pregnancy.
I
number of women who
tools. Pregnant group may Of the many demographic, however, the literature was
were not exercising in the have had less fatigue, more medical, and obstetric
limited due design and
first trimester were
characteristics examined,
methodology limitations of
energy, and more stable
depressed (33.1 %)
insufficient money for food the existing studies
mood due to their above
- additional research is
average physical activity
and housing, and lack of
compared to exercisers
(15 .1%). Similar in 2nd
although conclusions can't exercise were strongly and necessary
(18.9% vs. only 5.7%). No be drawn. More research consistently associated
with poor health status on
is necessary
group differences were
all indicators before,
shown for the 3rd.
during, and after
- state anxiety was lower
pregnancy.
for exercisers in each
trimester compared to nonexerctsers
- limitations of studies
- limitations outlined by
- limitations outlined by
- limitations outlined by
discussed and the need for
authors
authors
authors
further, more rigourous,
- clearly written and well
- clearly written and well
- clearly written and
research outlined
organized
organized
organized
- majority of studies used
-observed
relationships
- small sample of self-nature and size of
were
fairly recent
may not be causal
selected participants;
sample: possible bias,
- organization of report
- possible recall bias
decreased generalizability fmdings may not
slightly confusing at times
- no comparison group
- no test of cardiovascular generalize to other
failed to prove the
observed
samples;
possible
sample
fitness to confirm exercise
of the results
credibility
bias; Type II errors; recall
adherence to reported

Physical Activity in Pregnancy 50

link

exercise regimens
- findings suggest
association but no causal

method may be unreliable

Physical Activity in Pregnancy 51
given from the included
studies

Physical Activity in Pregnancy 52
Appendix D
Analysis of SOGC/CSEP Clinical Practice Guidelines
joint SOGC/CSEP Clinical Practice Guideline No 129, June 2003
source and date of
publication
title

Exercise in pregnancy and the postpartum period

scope and purpose

Overall objective specifically described: Yes. To design
Canadian guidelines advising obstetric care providers of the
maternal, fetal , and neonatal implications of aerobic and
strength-conditioning exercises in pregnancy.
Clinical question specifically described: Yes. What are the
relative merits of aerobic and strength conditioning in pregnancy
and the postpartum period?
Patients to whom the guidelines are mean to apply: Canadian
women

stake-bolder
involvement

Guideline development group includes individuals from all
relevant professional groups: reviewed by the Clinical Practice
Obstetrics Committee and approved by the Executive and
Council of the Society of Obstetricians and Gynaecologists of
Canada, and approved by the Board of Directors of the Canadian
Society for Exercise physiology.
Patient's views and preferences sought: not mentioned in
guidelines
Target users of guidelines: Canadian women and their care
providers
Piloted among target users: not mentioned in guidelines

rigour of development

Systematic methods used to search for evidence: Yes.
MEDLINE search from 1996-2002 for English language articles
related to studies of maternal aerobic and strength conditioning in
a previously sedentary population, maternal aerobic and strength
conditioning in a previously active population, impact of aerobic
and strength conditioning on early and late pregnancy outcomes,
and impact of aerobic and strength conditioning on neonatal
outcomes, as well as for review articles and meta-analyses related
to exercise in pregnancy.
Criteria for selecting evidence clearly described: Yes. See
above.
Methods used for formulating the recommendations clearly
described: No.
Health benefits, side effects, and risks considered in formulating
the recommendations: Yes.
Explicit link b/w the recommendations and the supporting

Physical Activity in Pregnancy 53
evidence: Yes. the quality of evidence reported was described
using the Evaluation of Evidence criteria outlined in the Report
of the Canadian Task Force on the Periodic Health Exam. All
recommendations are preceded by a discussion of the literature
on the subject.
Expert external reviewers prior to publication: No. The
guidelines state that they were reviewed and approved by the
Clinical Practice Obstetrics Committee, the Executive and
Council ofthe Society of Obstetricians and Gynaecologists of
Canada (which are later stated to be the same committee), and the
Canadian Society for Exercise Physiology - sounds like external
reviewers but then it is stated that these groups are also the
sponsors of the guidelines. Also, two ofthe authors are listed as
members of the reviewing committees.
Procedure for updating the guideline is provided: no
clarity and
presentation

Recommendations (specific and unambiguous): Yes.
Various options for management presented: Yes. ie
contraindications
Key recommendations easily identifiable: Yes. In bold, offset,
and numbered 1-6.
Tools to support application of guideline: Yes. Borg's Rating of
Perceived Exertion and resources clients and care providers can
refer to.

application

Organizational barriers to applying recommendations discussed:
No
Cost implications of applying the recommendations considered:
No
Key review criteria for monitoring and/or audit purposes: No

editorial independence Editorially independent from the funding body: No. The review
committees are also the sponsors.
Conflicts of interest recorded: no conflicts of interest of guideline
development members was recorded in the guidelines

Physical Activity in Pregnancy 54
Appendix E
Analysis of the RCOG Clinical Practice Guidelines
source and date of
RCOG Statement No. 4, January 2006
publication
title

Exercise in pregnancy

scope and purpose

Overall objective specifically described: yes
Clinical question specifically described: no question identified
but objective clear
Patients to whom the guidelines are mean to apply: pregnant
women

stake-holder
involvement

Guideline development group includes individuals from many
relevant professional groups : physician from BC, Canada;
physician consultant for the British Olympic Association;
Community Development Officer; Chairman of Association of
physiotherapists in Women's health; RCOG Consumer's Forum
Patient's views and preferences sought: No; although Consumer's
Forum consulted
Target users of guidelines: women and their care providers
Piloted among target users: No

rigour of development

Systematic methods used to search for evidence: Yes.
Criteria for selecting evidence clearly described: Yes: databases;
timelines; search words
Methods used for formulating the recommendations clearly
described: No
Health benefits, side effects, and risks considered in formulating
the recommendations: Yes
Explicit link b/w the recommendations and the supporting
evidence: Yes- evidence described but not rated
Expert external reviewers prior to publication: yes
Procedure for updating the guideline is provided: no

clarity and
presentation

Recommendations (specific and unambiguous): yes
Various options for management presented: yes
Key recommendations easily identifiable: yes - numbered and
bulleted
Tools to support application of guideline: Yes. Borg's Rating of
Perceived Exertion, modfied heart rate target zones, and resources
clients and care providers can refer to.

application

Organizational barriers to applying recommendations discussed:
no
Cost implications of applying the recommendations considered:
no

Physical Activity in Pregnancy 55
Key review criteria for monitoring and/or audit purposes: no

editorial independence Editorially independent from the funding body: no
Conflicts of interest recorded: not mentioned

Physical Activity in Pregnancy 56
Appendix F
Anatysts
1 . o fACOGCrmtca
. lP racttce Gm·dermes

source and date of
publications

ACOG Technical Bulletin no. 189, February 1994
ACOG Committee Opinion No. 267, Jan. 2002

title

Exercise during pregnancy and the postpartum period

scope and purpose

Overall objective specifically described: yes
Clinical question specifically described: no but intent clear
Patients to whom the guidelines are mean to apply: pregnant
women

stake-holder
involvement

Guideline development group not mentioned
Patient's views and preferences sought: not mentioned in
guidelines
Target users of guidelines: American women and their care
providers
Piloted among target users: not mentioned in guidelines

rigour of development Systematic methods used to search for evidence: not provided
Criteria for selecting evidence clearly described: no
Methods used for formulating the recommendations clearly
described: no
Health benefits, side effects, and risks considered in formulating
the recommendations: yes
Explicit link b/w the recommendations and the supporting
evidence: evidence explained; not rated
Expert external reviewers prior to publication: not mentioned
Procedure for updating the guideline is provided: no
clarity and
presentation

Recommendations (specific and unambiguous): Yes.
Various options for management presented: Yes. ie.
contraindications
Key recommendations easily identifiable: yes - bulleted
Tools to support application of guideline: no

application

Organizational barriers to applying recommendations discussed:
no
Cost implications of applying the recommendations considered:
no
Key review criteria for monitoring and/or audit purposes: no

editorial independence Editorially independent from the funding body: no
Conflicts of interest recorded: no conflicts of interest of guideline
development members was recorded in the guidelines