Low-Income African American Women’s Beliefs Regarding Exercise during Pregnancy

Impact of health literacy on pregnancy outcomes in socioeconomically disadvantaged and ethnic minority populations: A scoping review

BACKGROUND

Health literacy, influenced by sociodemographic characteristics such as ethnicity, economic means and societal factors, affects the ways in which pregnant women maintain their health; this in turn may increase risk of adverse pregnancy outcomes.

OBJECTIVE

To explore what is known about the impact of personal health literacy on prevention of stillbirth and related adverse outcomes in pregnant women of low socioeconomic status or from ethnic minority backgrounds.

SEARCH STRATEGY

MEDLINE, CINAHL, PsychINFO, and CENTRAL were searched as well as reference lists of included studies and gray literature.

SELECTION CRITERIA

Included studies focused on personal health literacy and stillbirth prevention in women from low socioeconomic or ethnic minority backgrounds in the perinatal period.

DATA COLLECTION AND ANALYSIS

A meta-summary approach was adopted for qualitative, observational, descriptive, and audit studies. Findings of intervention studies were extracted, and meta-analyses were conducted where possible. The primary outcome was stillbirth; maternal mortality and neonatal mortality were secondary outcomes.

MAIN RESULTS

Forty-one studies were included from diverse geographical settings. The meta-summary synthesized five abstracted statements. These recognized lower personal health literacy and greater difficulty interacting with healthcare services in the studied populations, primarily as the result of limited health knowledge, lack of positive perception towards health services, language barriers, illiteracy, and relying on friends or family members for health information. Meta-analysis of intervention studies revealed no association between current interventions that aimed to increase personal health literacy and the risk of stillbirth (relative risk [RR] 1.04, 95% confidence interval [CI] 0.96-1.12), neonatal mortality (RR 0.88, 95% CI 0.75-1.03), and maternal mortality (RR 0.87, 95% CI 0.63-1.22).

CONCLUSIONS

Various factors suggest lower personal health literacy in women of low socioeconomic status or ethnic minority, which can increase the risk of stillbirth. However, this review identified no significant impact of current health education interventions on the risk of stillbirth, or neonatal or maternal mortality. Although not directly measured, the health education interventions were anticipated to increase personal health literacy. Further research on the topic of this scoping review is warranted, particularly in lower-resource settings and regarding the potential role of e-literacy and organizational health literacy to improve pregnancy outcomes. To address deficits in health literacy, efforts must be made to provide pregnant women with health information in novel, accessible ways.

In search of the 'like-minded' people: pregnant women's sense-making of their physical activity-related social experiences

AIMS/BACKGROUND

Social factors are increasingly recognised as influential on antenatal physical activity. While pregnant women describe the people and support they require to remain physically active, little is known about how pregnant women select and make sense of their social experiences throughout pregnancy. This study followed pregnant women's sense-making of their physical activity-related social experiences as pregnancy progressed, and physical activity declined.

DESIGN/METHODS

This study used a qualitative design. Four pregnant women were recruited in their second trimester, participated in three individual semi-structured interviews and submitted diary entries throughout trimesters two and three. Data were analysed using longitudinal interpretative phenomenological analysis.

RESULTS

To facilitate physical activity, pregnant women were 'searching for the "like-minded" people who motivate, share and understand', namely pregnant women and prenatally trained exercise professionals. When making sense of social experiences, pregnant women were 'grading and critiquing the quality and paucity of "active pregnancy" information', and'cherry-picking social experiences necessary for "nesting", obtaining support and protecting self-esteem as physical activity declined'. This involved disengaging from social experiences, and consequently, some pregnant women found themselves 'lamenting interactions with the "like-minded" people, contending with grief and inner conflict'.

CONCLUSION

Pregnant women proactively seek and make sense of social experiences to facilitate physical activity. In an increasingly digitalised society, interventions should support pregnant women to utilise social media constructively and safely to access 'like-minded' people, provide in-person and virtual networks to meet individual support needs throughout pregnancy and encourage health professionals to demonstrate interest in the 'active pregnancy' to maximise influence.

Barriers and facilitators to healthy gestational weight gain amongst pregnant women from ethnic minority groups: A systematic search and narrative synthesis

BACKGROUND

Excessive weight gain can be detrimental to the health and wellbeing of both mother and child. There is evidence that women from ethnic minority groups are more likely to gain excessive weight during pregnancy. For the purpose of this review, ethnic minority women are defined as those with different national or cultural traditions from the main population.

AIM

Our aim was to identify barriers and facilitators to healthy gestational weight gain in pregnant women in ethnic minority groups.

METHODS

Databases searched were MEDLINE, CINAHL, PsycInfo and PsycArticles between 2011 and 2022. Inclusion criteria were empirical studies of any method considering gestational weight gain in ethnic minority women published in English. Data were extracted according to aim, participants, methods, and findings in relation to barriers and facilitators. Included papers were assessed for quality according to relevant Joanna Briggs Institute checklists.

FINDINGS

Twenty-six studies were identified. Five themes were revealed: (1) knowledge and beliefs, (2) cultural and social influences, (3) confidence, (4) physical experiences, and (5) personal and environmental factors.

DISCUSSION

Some barriers and facilitators were relevant to all groups and others were more specific to ethnic minority groups. The latter included social and cultural influences, which were reported extensively. Our search was comprehensive, although it is possible we may not have captured all relevant papers.

CONCLUSION

We recommend that the barriers and facilitators identified here are considered in designing future, or adjusting current, health care practitioner mediated interventions to support healthy gestational weight gain in ethnic minority women.

Pregnant and Postpartum Women's Perceptions of Barriers to and Enablers of Physical Activity During Pregnancy: A Qualitative Systematic Review

INTRODUCTION

Physical activity throughout pregnancy has been shown to have health benefits for the pregnant person, including reductions in the risk of preeclampsia and gestational weight gain and improvements in blood pressure regulation. Despite the benefits, many pregnant women do not meet the guidelines for physical activity throughout pregnancy. Therefore, it is important to determine what influences women's activity levels during pregnancy. This systematic review of the qualitative literature aimed to determine pregnant and postpartum women's perceptions of barriers to and enablers of physical activity, specifically during pregnancy.

METHODS

MEDLINE, PsycINFO, CINAHL, and Embase were searched systematically to identify qualitative studies investigating pregnant or postpartum women's perceptions of barriers to and enablers of physical activity during pregnancy. Included studies were limited to populations of pregnant or postpartum women, the majority of whom were aged 18 to 40 years, and studies published from 1985 onward. Data quality was assessed using the Critical Appraisal Skills Programme Qualitative Studies Checklist. Data were extracted using NVivo software and subsequently mapped on the COM-B framework.

RESULTS

Twenty-five qualitative studies were included in this systematic review. Sixteen themes were identified that mapped onto 6 components of the COM-B framework. Commonly reported barriers to physical activity during pregnancy included pregnancy symptoms, lack of knowledge of what constitutes safe activity, and the opinions of women's social circles. Commonly reported enablers of physical activity during pregnancy were social support and the experienced benefits, including physiologic, psychological, and social benefits.

DISCUSSION

The results of this systematic review have clinical implications for perinatal care providers, as the overall benefits of physical activity during pregnancy have been well documented in previous studies. The authors recommend clinicians aim to explore pregnant women's perspectives on physical activity during pregnancy in order to be able to address their perceived barriers to and enablers of physical activity during pregnancy.

Timeliness and Adequacy of Prenatal Care Among Department of Veterans Affairs-Enrolled Veterans: The First Step May Be the Biggest Hurdle

INTRODUCTION

Little is known about access to and use of prenatal care by veterans using U.S. Department of Veterans Affairs (VA) maternity benefits. We compared the timeliness and adequacy of prenatal care by veteran status and payor.

STUDY DESIGN

We used VA clinical and admistrative data linked with California vital statistics patient discharge data to identify all births to VA-enrolled veterans and non-veterans between 2000 and 2012. Births were categorized based on veteran status and payor (non-veterans with Medicaid, non-veterans with private insurance, VA-enrolled veterans using VA maternity care benefits, and VA-enrolled veterans with other payor). Outcomes were timeliness of prenatal care (initiation before the end of the first trimester) and adequacy of prenatal care as measured by the Kotelchuck Index (inadequate, intermediate, adequate). Covariates included demographic, health, and pregnancy characteristics. We used generalized linear models and multinomial logistic regression to analyze the association of veteran status and payor with timeliness of prenatal care and adequacy of prenatal care, respectively.

RESULTS

We identified 6,196,432 births among VA-enrolled veterans (n = 17,495) and non-veterans (n = 6,178,937). Non-veterans using Medicaid had the lowest percentage of timely prenatal care (78.1%; n = 2,240,326), followed by VA-enrolled veterans using VA maternity care benefits (82.8%; n = 1,248). VA-enrolled veterans using VA maternity care benefits were the most likely to receive adequate prenatal care (92.0%; n = 1,365). Results remained consistent after adjustment.

CONCLUSIONS

This study provides key baseline data regarding access to and use of prenatal care by veterans using VA maternity benefits. Longitudinal studies including more recent data are needed to understand the impact of changing VA policy.

Changes in Physical Activity and Television Viewing From Pre-pregnancy Through Postpartum Among a Socioeconomically Disadvantaged Perinatal Adolescent Population

STUDY OBJECTIVE

Adolescent pregnancy contributes to accelerated trajectories of adiposity and cardiometabolic diseases. Two potentially low-cost prevention strategies include promoting physical activity (PA) and limiting television (TV) viewing. Few studies have explored these behavior patterns in perinatal adolescents. This study sought to characterize PA and TV viewing in a socioeconomically disadvantaged perinatal adolescent population.

DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS

A cross-sectional, retrospective, 10-item survey was used to explore behavior patterns in 79 predominantly Black (86%) postpartum adolescents.

MAIN OUTCOME MEASURES

Outcomes included self-reported changes in PA from pre-pregnancy through pregnancy, and 7-day recall of PA and TV viewing in postpartum.

RESULTS

The majority of adolescents (66%) reported being active on ≥3 days/week in pre-pregnancy; however, many reported low PA (≤2 days/wk) in their first (59%), second (66%), and third (54%) trimesters. Adolescents who reported being active on ≥5 days/wk in pre-pregnancy (19%) experienced first trimester PA decline, which subsequently plateaued. This group remained the most active throughout pregnancy. In postpartum, over half (54%) of all adolescents reported low PA and irrespective of PA, spent considerable time watching TV (median = 1680.0 minutes, inerquartile range = 2940).

CONCLUSION

Interventions promoting PA coupled with reducing TV viewing during pregnancy and in postpartum may benefit perinatal adolescents. The findings from this study suggest that PA history is a predictor of gestational PA, and low PA and high TV viewing in postpartum underscore the need for behavioral intervention. Conducting a brief assessment of PA history in early gestation may offer important insight.

Obstetric Patients and Healthcare Providers Perspectives to Inform Mobile App Design for Physical Activity and Weight Control During Pregnancy and Postpartum in a Rural Setting

Background

Mobile health technology offers the opportunity for women to engage with physical activity promotion programs without many of the barriers commonly associated with exercise during and after pregnancy (eg, childcare concerns, rigid schedules, fear of doing harm to fetus or self, access to fitness facilities, uncomfortable with body in front of others) which may be particularly useful in under-resourced rural environments. We conducted the first known study on perspectives of pregnant women, postpartum women, and obstetric healthcare providers in a rural setting on needs related to the development of a mobile app designed to increase physical activity during pregnancy and postpartum.

Methods

Focus groups and in-depth face-to-face personal interviews were conducted with 14 pregnant women, 13 postpartum women, and 11 healthcare providers in a rural community. Semi-structured questions utilizing constructs of the Health Belief Model were used to identify barriers, facilitators, and other influences on physical activity during pregnancy and postpartum. Recordings of all in-depth interviews and focus groups were transcribed and standard content analyses for qualitative data were conducted.

Results

Rural women and healthcare providers expressed several key perspectives about and recommendations to promote physical activity during and after pregnancy. Broadly, these perspectives encapsulated two main themes: 1) physical activity as critical for weight control and 2) the need for evidence-based exercise information. Key desired features of this app identified include goal setting/progress tracking, evidence-based exercise guidance tailored to specific time points of pregnancy and postpartum, social support via community-based forum, symptom tracking, time-efficient workouts, and push notifications.

Conclusion

The perspectives identified by participants should be utilized when designing mobile health physical activity mobile apps for pregnant and postpartum women in rural areas.

Factors Influencing Pregnancy and Postpartum Weight Management in Women of African and Caribbean Ancestry Living in High Income Countries: Systematic Review and Evidence Synthesis Using a Behavioral Change Theoretical Model

Background: Women of black African heritage living in high income countries (HIC) are at risk of obesity and weight-related complications in pregnancy. This review aimed to synthesize evidence concerning attitudes to weight management-related health behaviors in pregnancy and postpartum, in women of black African ancestry, living in high-income countries. Methods: A systematic review of the literature and thematic evidence synthesis using the Capability-Opportunity-Motivation Behavioral change theoretical model (COM-B). Databases searched included MEDLINE, EMBASE, Web of Science, and Scopus. The CASP tool was used to assess quality. Results: Twenty-four papers met the selection criteria, most of which were from the US. Motivational factors were most commonly described as influencers on behavior. Normative beliefs about "eating for two," weight gain being good for the baby, the baby itself driving food choice, as well as safety concerns about exercising in pregnancy, were evident and were perpetuated by significant others. These and other social norms, including a cultural acceptance of larger body shapes, and daily fast food, created a challenge for healthy behavior change. Women also had low confidence in their ability to lose weight in the postpartum period. Behavior change techniques, such as provision of social support, use of credible sources, and demonstration may be useful to support change. Conclusions: The women face a range of barriers to engagement in weight-related health behaviors at this life-stage. Using a theoretical behavior change framework can help identify contextual factors that may limit or support behavior change.

Structural Model of Maternal Behavior in Community Setting to Prevent Low Birth Weight in East Nusa Tenggara, Indonesia

Low birth weight (LBW) is still a magnitude problem in Indonesia with a multifactorial causes. Studies revealed that one of cause of LBW-infants birth is mother's behavior in treating her pregnancy, including traditional pregnancy care practices. The purpose was to develop the structural model on community setting that might describe the LBW infants-birth. A case-control study on 50 post-partum mothers with LBW and 50 with normal birthweight infants was held in Kupang, East Nusa Tenggara, Indonesia, November 2016 - May 2017. Mother who have spontaneous birth, singleton, and received integrated ANC were inlcuded. Several data such as maternal characteristics, pregnancy knowledge, perceived behavioral control (PBC), maternal health status, obedience to traditional pregnancy care, were collected using questionnaire and medical records tracing. Statistical analysis was performed using path analysis from SmartPLS 3.2.7 and considered significant path when the coefficients were not zero with P value <0.05. Outer and inner model analysis showed two significant paths, both are come from maternal characteristic that influence the LBW infants-birth through pregnancy knowledge (0.489, P=0.000) and PBC (0,425, P=0,000). In the first path, PBC affect maternal health status (0.217, P=0.021) which in turn will cause LBW (0.201, P=0.001). The second path, PBC affect the obedience to traditional pregnancy care (0.474, P=0.000) and then influence to LBW (0.316, P=0.000). As conclusion, maternal characteristics, pregnancy knowledge, PBC, maternal health status, and obedience to traditional pregnancy care are key points that might be used as a significant variables in preventing LBW-infants birth.

The Evidence Base in Exercise Knowledge of Pregnant Women: A Latent Class Analysis

BACKGROUND

Exercise has many benefits for women with uncomplicated pregnancies. However, poor exercise knowledge may contribute to problems or barriers that reduce a woman's level of exercise after becoming pregnant.

AIM

This study was performed to identify pregnancy exercise knowledge among pregnant women using latent class analysis and to examine the relationship between pregnancy exercise knowledge patterns and sociodemographic characteristics.

DESIGN

A descriptive, cross-sectional approach was used in this study.

METHODS

Participants were recruited from the prenatal outpatient departments of two hospitals and a certified prenatal center in Taipei, Taiwan. A total of 618 participants completed a pregnancy exercise knowledge test. The data were analyzed using WINMIRA and SPSS 20.0 software.

RESULTS

Two latent classes were identified based on exercise knowledge among pregnant women. The Accurate Knowledge group (n = 543, 87.9%), which had a higher latent trait for exercise knowledge (M = 1.31, SD = 0.94), was larger than the Limited Knowledge group (n = 75, 12.1%), which had a lower latent trait (M = -0.22, SD = 1.14). The principles of exercise for pregnant women, particularly the appropriate intensity and duration, may be difficult items for women in the Limited Knowledge group to understand. Women with Limited Knowledge had significantly lower education levels and greater rates of unemployment, multiparity, and miscarriage than women in the Accurate Knowledge group.

LINKING EVIDENCE TO ACTION

A two-class system for interpreting exercise knowledge among pregnant women is statistically supported. We believe that this study has evidence-based potential to help healthcare providers improve pregnant women's exercise knowledge as part of routine prenatal care to promote exercise.

Patient and obstetric provider communication regarding weight gain management among socioeconomically disadvantaged African American women who are overweight/obese

To examine the communication between obstetric providers and their socioeconomically disadvantaged, African American patients who are overweight and obese during pregnancy, and whether this communication relates to outcomes. Pregnant patients and their obstetric providers were surveyed between October 2012 and March 2016 at Washington University School of Medicine in St. Louis, MO. Percent agreement between patients' and obstetric providers' survey responses was analyzed and measured (κ coefficient). Descriptive and multilevel logistic regression analyses aimed at identifying the relation of perceived communication between providers and patients to gestational weight gain, diet, and exercise during pregnancy. A total of 99 pregnant women and 18 obstetric providers participated in the study. Significant lack of agreement was observed between patients and obstetric providers regarding communication about weight gain recommendations, risk factors associated with excessive weight gain, what constitutes adequate exercise per week, exercise recommendations, dietary recommendations, and risk factors associated with a poor diet. Our findings suggest patients were not receiving intended messages from their obstetric providers. Thus, more effective patient-obstetric provider communication is needed regarding gestational weight gain, exercise and dietary recommendations among overweight/obese, socioeconomically disadvantaged, African American women.

The Impact of Symptoms of Depression and Walking on Gestational Age at Birth in African American Women

BACKGROUND

Symptoms of depression have been related to lower gestational age and preterm birth (<37 completed weeks gestation). Leisure time physical activity may have protective effects on preterm birth; however, less has been published with regard to other domains of physical activity such as walking for a purpose (e.g., for transportation) or the pathways by which symptoms of depression impact gestational age at birth.

METHODS

This was a secondary analysis of available data of African American women. Women were interviewed within 3 days after birth. We proposed a model in which walking for a purpose during pregnancy mediated the effects of symptoms of depression (measured by the 20-item Center for Epidemiologic Studies-Depression [CES-D] scale) on gestational age at birth in a sample of 1,382 African American women.

RESULTS

Using structural equation modeling, we found that the direct effect of CES-D scores of 23 or greater, which have been correlated with major depression diagnosis, on gestational age at birth was -4.23 (p < .001). These results indicate that symptoms of depression were associated with a decrease in gestational age at birth of 4.23 days. Walking for a purpose mediated the effect of CES-D scores of 23 or greater on gestational age at birth.

CONCLUSIONS

Compared with African American women without symptoms of depression, African American women who had symptoms of depression walked less for a purpose during their pregnancy and delivered infants with lower gestational age at birth. If not medically contraindicated, clinicians should incorporate walking as part of prenatal care recommendations and reassure women about safety of walking during pregnancy.

"Just because you're pregnant, doesn't mean you're sick!" A qualitative study of beliefs regarding physical activity in black South African women

Background

Despite the benefits of physical activity during pregnancy, the physiological and psychological changes that occur during this unique period may put women at greater risk of being sedentary. Lifestyle and environmental transitions have left black South African women at increased risk of physical inactivity and associated health risks. Therefore, the aim of this qualitative study was to describe the beliefs regarding physical activity during pregnancy in an urban African population.

Methods

Semi-structured interviews (n = 13) were conducted with pregnant black African women during their third trimester. Deductive thematic analysis was completed based on the Theory of Planned Behaviour. Coding and analysis was completed with the assistance of ATLAS.ti software.

Results

Participants had a mean age of 28 (19–41) years, and a mean BMI of 30 (19.6–39.0) kg/m². Although the majority of women believed that physical activity was beneficial, this did not appear to translate into behaviour. Reported reasons for this included barriers such as pregnancy-related discomforts, lack of time, money and physical activity related education, all of which can contribute to a reduced perceived control to become active. Opportunities to participate in group exercise classes was a commonly reported facilitator for becoming active. In addition, influential role players, such as family, friends and healthcare providers, as well as cultural beliefs, reportedly provided the women with vague, conflicting and often discouraging advice about physical activity during pregnancy.

Conclusions

This study provides new theoretical insight on the beliefs of urban South African pregnant women regarding physical activity. Findings from this study suggest a holistic approach to improve physical activity compliance during pregnancy, inclusive of physical activity education and exercise opportunities within a community setting.

This study presents critical formative work upon which contextually and culturally sensitive interventions can be developed.

Obesity in Pregnancy: A Qualitative Approach to Inform an Intervention for Patients and Providers

To investigate perceptions of minority pregnant women and providers about obesity and gestational weight gain (GWG), and to explore strategies to improve management of obesity in pregnancy with an emphasis on group prenatal care. Sixteen primarily non-Hispanic black pregnant women with a body mass index ≥ 30 kg/m(2) and 19 prenatal care providers participated in focus groups. Discussion topics included GWG goals, body image, health behaviors, and group prenatal care with additional emphasis on provider training needs. Women frequently stated a GWG goal >20 lbs. Women described a body image not in line with clinical recommendations ("200 pounds is not that big."). They avoided the term "obese". They were interested in learning about nutrition and culturally-acceptable healthy cooking. Women would enjoy massage and exercise in group settings, though definitions of "exercise" varied. Family members could help, but generational differences posed challenges. Most had to "encourage myself" and "do this for me and the baby". Providers expressed discomfort discussing GWG and difficulty finding the right words for obesity, which was partially attributed to their own weight. They noted the challenges they faced during prenatal care including time constraints, cultural myths, and system issues. Providers considered a group setting with social support an ideal environment to address health behaviors in obese women. Culturally-tailored programs that use acceptable terms for obesity, provide education regarding healthy eating and safe exercise, and encourage support from social networks may be effective in addressing GWG in obese minority women. Provider training in communication skills is necessary to address obesity in pregnancy.

Benefits of exercise during pregnancy

There is a direct link between healthy mothers and healthy infants. Exercise and appropriate nutrition are important contributors to maternal physical and psychological health. The benefits and potential risks of exercise during pregnancy have gained even more attention, with a number of studies having been published after the 2002 American College of Obstetrics and Gynecologists guidelines. A review of the literature was conducted by using PubMed, Scopus, and Embase to assess the literature regarding the benefits of exercise during pregnancy. The search revealed 219 publications, which the authors then narrowed to 125 publications. The purpose of this review is to briefly summarize the known benefits of exercise to the mother, fetus, and newborn.