Psychosocial predictors of smoking and exercise during pregnancy

A cross-sectional analysis of factors associated with the teachable moment concept and health behaviors during pregnancy

BACKGROUND

Pregnancy is often associated with a change in health behaviors, leading some to suggest that pregnancy could be a teachable moment for lifestyle change. However, the prevalence and underlying mechanism of this phenomenon is not well understood. The aim of this study is to explore the prevalence of a teachable moment during pregnancy, the psychosocial factors that are associated with experiencing such a moment, and its association with actual health behaviors.

METHODS

In this cross-sectional study, 343 pregnant Dutch women completed an online questionnaire. Participants reported on their intentions to change lifestyle due to pregnancy, their current health behaviors, and several psychosocial factors that were assumed to be linked to perceiving a teachable moment during pregnancy: perceived risk, affective impact, changed self-concept, and social support. Multivariable linear and logistic regression were applied to the data analysis.

RESULTS

Results demonstrate that 56% of the women experienced a teachable moment based on intentions to change their health behavior. Multivariate regression analyses revealed that changed self-concept (β = 0.21; CI = 0.11-0.31), positive affect (positive β = 0.28; CI = 0.21-0.48), and negative affect (β = 0.12; CI = 0.00-0.15) were associated with higher intentions to change health behavior. Conversely, more perceived risk was associated with lower intentions to change health behavior (β=-0.29; CI = 0.31 - 0.13). Multivariate regression analyses showed a positive association between intentions to change health behavior and diet quality (β = 0.11; CI = 0.82-1.64) and physical activity (OR = 2.88; CI = 1.66-5.00).

CONCLUSIONS

This study suggests that pregnancy may be experienced as a teachable moment, therefore providing an important window of opportunity for healthcare professionals to efficiently improve health behaviors and health in pregnant women and their children. Results suggest that healthcare professionals should link communication about pregnancy-related health behaviors to a pregnant women's change in identity, affective impact (predominantly positive affective impact) and risk perception to stimulate the motivation to change healthy behavior positively.

The effect of changing pregnancy intentions on preconception health behaviors: a prospective cohort study

PURPOSE

Pregnancy intentions are associated with preconception health behaviors but are understudied among female adolescent and young adult (AYA) cancer survivors. Preconception health is critical for survivors because they face unique risks to fertility and pregnancy from late effects of cancer treatments. This study prospectively assessed the effect of pregnancy intention on physical activity (PA) and smoking behaviors among female AYA survivors.

METHODS

A cohort of 1049 female AYA survivors were recruited between 2013 and 2017. Participants were 18-39 years and had completed primary cancer treatment. Longitudinal mixed effects analysis was conducted on participants who completed at least 2 of 4 questionnaires over 1.5 years. Two measures were used to capture multiple dimensions of pregnancy intention. The pregnancy intention score (PIS) captured wanting and planning dimensions and represented a scaled response of low to high intention. The trying dimension captured urgent intention and ranged from not trying, ambivalent (neither attempting nor avoiding pregnancy), and trying now. Intention change was assessed between each consecutive time points. Final analysis was conducted with multiple imputations.

RESULTS

Survivors with increased intention measured by trying was associated with increased PA over time (adjusted B [95%CI]: 0.3 [0.01, 0.5]) compared to survivors with no changes or decreased trying intention. PIS was not significantly associated with preconception behaviors. No measure of intention was associated with smoking behavior.

CONCLUSIONS

Increasingly urgent pregnancy intention (trying dimension) was associated with higher preconception PA.

IMPLICATIONS FOR CANCER SURVIVORS

Screening for immediate intentions can identify AYA survivors in need of early preconception health promotion.

Health Behaviors and Behavior Change during Pregnancy: Theory-Based Investigation of Predictors and Interrelations

(1) Background: Preventing pregnancy complications and maternal deaths and helping women stay healthy before, during, and after pregnancy by means of sexual health and behavior is imperative. Previous research demonstrated that a lack of social support and perceived discrimination have adverse effects on pregnancy outcomes. These determinants may impact health behavior as an important mediator of pregnancy outcomes. To better understand this relation, the Compensatory Carry-Over Action Model (CCAM) was applied. The research question was: how do predictors of health behavior, specifically intention, planning, self-efficacy, social support, and discrimination, interrelate with different health behaviors during pregnancy? (2) Methods: By means of qualitative interviews with ten pregnant women (20–39 years, mean = 28.6) from different cultural backgrounds, the predictors of health behaviors and experiences with pregnancy, including racial discrimination, were investigated. (3) Results: Not all women changed their unhealthy behaviors even though their higher-level goal was to ensure their baby’s and their own health. This appeared partially due to lack of social support, racial discrimination, and unexpected pregnancy side effects. The women who previously performed health behaviors revealed a healthier pattern with maintaining or even expanding their health behaviors, while those performing no health behavior in the past reported more obstacles with a healthy lifestyle. (4) Conclusions: Pregnant women appear to be having difficulties translating good intentions into behavior. The reasons include lack of support, fear, and insecurity, which impact self-efficacy and planning. Improvements in health behaviors were facilitated by specific circumstances, such as working from home. Policy and practice should take these aspects into account and help mobilize support and overcome discrimination by means of more rights and support for pregnant women while also empowering the individuals.

Association between pregnancy intention and preconception health behaviors

BACKGROUND

Female adolescent and young adult (AYA) cancer survivors face higher infertility and pregnancy risks than peers with no cancer history. Preconception health behaviors such as physical activity (PA), tobacco smoking, and alcohol intake influence reproductive outcomes. In general populations, pregnancy intention is positively associated with healthy preconception behaviors, but it has not been studied among AYA survivors. The authors hypothesized that higher pregnancy intention would be associated with healthier behaviors, especially among AYA survivors with perceived infertility risk.

METHODS

A cross-sectional analysis was conducted with data collected between 2013 and 2017 from 1071 female AYA survivors aged 18 to 39 years who had completed their primary cancer treatment and enrolled in an ovarian function study. Self-reported intention dimensions were measured as a pregnancy intention score (PIS) and trying now to become pregnant. Multivariable linear (PA), binary (smoking), and ordinal (alcohol use) logistic regressions were used to estimate associations between intentions and preconception behaviors, with adjustments made for demographic and cancer characteristics. Effect modification by perceived infertility risk was assessed.

RESULTS

The mean PIS was 1.1 (SD, 0.77) on a 0 to 2 scale (2 = high intention), and 8.9% were attempting pregnancy now. A higher PIS was associated with increased PA (β, 0.08; 95% CI, 0.11-1.04), whereas ambivalence in pregnancy intention was associated with lower alcohol consumption (odds ratio, 0.72; 95% CI, 0.55-0.95). Pregnancy intentions were not associated with smoking. Perceived infertility risk strengthened the relationship between PIS and PA (P < .05).

CONCLUSIONS

Pregnancy intentions were associated with some healthier preconception behaviors in AYA survivors. Medical professionals caring for AYA survivors may consider pregnancy intention screening to guide conversations on preconception health.

'I don't need you to criticise me, I need you to support me'. A qualitative study of women's experiences of and attitudes to smoking cessation during pregnancy

BACKGROUND

Smoking is associated with health inequalities and is the most important modifiable risk factor for poor outcome in pregnancy.

AIM

To explore women's experiences of smoking during pregnancy, examine their attitudes and barriers to smoking cessation, and to discover what support they feel might enable them to have a smoke-free pregnancy in future.

METHODS

A qualitative study was conducted with nineteen women in the United Kingdom who had smoked at some stage in pregnancy during the last five years. Data were collected through in-depth telephone interviews between June and August 2021. The interviews were audio-recorded, transcribed verbatim, and thematically analysed.

FINDINGS

Four key themes were identified: the complex relationship with smoking, being ready to quit, the need for support and understanding, and ideas to support a smoke free pregnancy. The findings revealed that there were two distinct avenues for enabling the support process: encouraging a readiness to quit through identifying individual context, personalised support, and educational risk perception, and, supporting the process of quitting, and offering a range of options, underpinned by a personalised, non-judgemental approach.

CONCLUSION

Smoking in pregnancy is a complex issue resulting from a combination of social, emotional, and physical factors. The findings from this study suggest that a combination of approaches should be made available to enable pregnant women who smoke to select the best options for their individual needs. Irrespective of the practical support offered, there is a need for informed, sensitive, individualised support system that women can identify with.

Women's experiences and perceptions of anxiety and stress during the perinatal period: a systematic review and qualitative evidence synthesis

BACKGROUND

The perinatal period, from pregnancy to the first year postpartum, is a transitional period that can result in anxiety and stress for some women. Perinatal anxiety and stress can adversely impact the physical and psychological health of women and children. Understanding women's lived experiences of perinatal anxiety and stress is essential to better support women. The aim of this qualitative evidence synthesis was to examine women's experiences and perceptions of, and barriers and facilitators to coping with, perinatal anxiety and stress.

METHODS

Databases CINAHL, EMBASE, MEDLINE, PsycINFO and Maternity and Infant Care were searched from inception to June 2020. Eligible studies included women who were pregnant or up to one year postpartum and examined women's experiences of anxiety and/or stress during the perinatal period. Data were synthesised using thematic synthesis.

RESULTS

Of 20,318 identified articles, 13 studies met inclusion criteria and were included in this review. Five key themes emerged: Social support, women's experiences of healthcare, social norms and expectations, factors that impact on coping and mother and baby's health.

CONCLUSION

This review provided a comprehensive synthesis of perinatal anxiety and stress. Findings indicate that increased support for perinatal mental health in antenatal and postpartum care is needed. Addressing unrealistic expectations and conceptualisations of motherhood is also important to better support women. Enhancing women's social support networks and provision of clear and consistent information are also essential to support women and minimise stress and anxiety in the perinatal period.

Variations in Relationships Between Perceived Stress and Birth Outcomes by Immigration Status

INTRODUCTION

Past research shows that stress during pregnancy predicts adverse birth outcomes. These patterns might differ based on immigration status. Our objective was to analyze differences in relationships between perceived stress during pregnancy and birth outcomes by immigration status.

METHODS

We recruited 81 pregnant women in Canada for a prospective longitudinal study of stress during pregnancy and infant development. Participants completed the Perceived Stress Questionnaire at 16-18, 24-26 and 32-34 weeks of pregnancy. Birth records were available for 73 women, including 24 non-immigrants, 18 long-term immigrants (≥ 5 years), and 31 recent immigrants (< 5 years). We used General Linear Models to test relationships between perceived stress and birthweight, birthweight for gestational age Z-scores, and gestational age, and differences based on immigration status.

RESULTS

Controlling for sociodemographic covariates, we observed interactive relationships between immigration status and perceived stress with birthweight at 16-18 (p = 0.032, partial η² = 0.11) and 24-26 weeks pregnancy (p = 0.012, partial η² = 0.15). Results were similar for birthweight for gestational age Z-scores at 16-18 weeks (p = 0.016, partial η² = 0.13) and 24-26 weeks pregnancy (p = 0.013, partial η² = 0.14). Perceived stress predicted smaller birthweight measurements among long-term immigrants. No relation was found between perceived stress, immigration status and gestational age.

DISCUSSION

Risk of adverse health outcomes, including birth outcomes, tends to increase with duration of residence among immigrants. Stress during pregnancy might represent one risk factor for adverse birth outcomes among long-term immigrant women. Promoting psychosocial health screening and care among immigrant women, and assuring continued care with acculturation, might improve both maternal and infant health outcomes.

The Relationship Between Pregnancy Intentions and Diet or Physical Activity Behaviors in the Preconception and Antenatal Periods: A Systematic Review and Meta-Analysis

INTRODUCTION

Healthy preconception and antenatal diet and physical activity behaviors may optimize maternal and offspring outcomes. These behaviors are thought to be linked to pregnancy intentions. The aim of this study was to conduct a systematic review and meta-analysis to determine the association between women's pregnancy intentions and diet or physical activity behaviors in the preconception and antenatal periods.

METHODS

MEDLINE Complete, PsycINFO, CINAHL Complete, Global Health, Embase, and INFORMIT: Health Subset were searched in September 2018 for studies that evaluated relationships between pregnancy intentions and dietary and physical activity behaviors. Risk of bias was assessed, and random effects meta-analyses were conducted for dietary (food groups; energy and macronutrients; diet quality; and caffeine, iodine, and folate intake) and physical activity outcomes.

RESULTS

Of 2623 screened records, 19 eligible studies were identified. The overall risk of bias was moderate to high. Twelve studies measured diet and physical activity behaviors during preconception, 5 during pregnancy, and 2 across both periods. Eleven studies measured pregnancy intention retrospectively, and 8 prospectively measured pregnancy intention. The number of studies available for meta-analyses of individual dietary and physical activity outcomes ranged from 2 to 5. Pregnancy intentions were not associated with preconception fruit, vegetable, or caffeine intake or physical activity. Antenatally, women with intended pregnancies were more likely to report healthier diets, lower caffeine intake, and higher physical activity. Insufficient studies were available to conduct subgroup comparisons for prospective or retrospective assessment.

DISCUSSION

Pregnancy intentions were not associated with preconception diet or physical activity behaviors. In contrast, antenatally, women with intended pregnancies demonstrated better diet and physical activity behaviors. Given the small number of studies available for meta-analyses, further research is needed to consolidate our findings. Meanwhile, health professionals can assess women's pregnancy intentions during preconception and pregnancy and encourage a healthy lifestyle.

Psychosocial Stress, Sedentary Behavior, and Physical Activity during Pregnancy among Canadian Women: Relationships in a Diverse Cohort and a Nationwide Sample

BACKGROUND

Past research shows that psychosocial stress and distress predict sedentary behavior and physical activity, but few studies focus on pregnant women. Our objective was to analyze relationships between psychosocial stress and distress with sedentary behavior and physical activity among pregnant women in Canada.

METHODS

We analyzed objectively-measured sedentary behavior and physical activity at 16-18, 24-26, and 32-24 weeks pregnancy in a sociodemographically diverse cohort of 70 women in Montreal, Canada. Participants completed the Perceived Stress Questionnaire and wore an accelerometer for 3 days that quantified sitting time and steps per day. We used univariate general linear models to analyze relationships between perceived stress with sedentary behavior and physical activity at each evaluation. To assess generalizability, we analyzed relationships between psychological distress with self-reported leisure-time sedentary behavior and daily energy expenditure in transportation and leisure physical activities among a sample representative of 166,095 women in the Canadian Community Health Survey.

RESULTS

In the Montreal cohort, we observed a positive association between perceived stress and sitting time, with small to moderate effect sizes (partial η2 = 0.08-0.16). We observed negative relationships between perceived stress and steps per day at the first two evaluations only, with small to moderate effect sizes (partial η2 = 0.08-0.11). Relationships for sedentary behavior were similar in the nationwide sample, but with smaller effect sizes (partial η2 = 0.02). There were no relationships between distress and physical activity in the nationwide sample.

CONCLUSION

Psychosocial stress represents one risk factor for sedentarity, with relationships evident throughout pregnancy and at the population level. Relationships with physical activity are less consistent, but stress might represent a risk factor for low physical activity in early to mid-pregnancy. Results might guide the development of more comprehensive interventions targeting stress, sedentarity, and physical activity. In particular, integrating psychosocial health into interventions to reduce sedentarity, and including concrete guidelines on sedentary behavior in psychosocial health interventions, might be prioritized.

A systematic mapping review of the associations between pregnancy intentions and health-related lifestyle behaviours or psychological wellbeing

The aim of this study was to conduct a systematic mapping review of the literature that explored associations of pregnancy intentions with health-related lifestyle behaviours and psychological wellbeing before and during pregnancy. Six databases were searched (May 2017) for papers relating to pregnancy intentions, health-related lifestyle behaviours, and psychological wellbeing. The literature was mapped according to the preconception or pregnancy period; prospective or retrospective variable assessment; and reported lifestyle behaviours and psychological wellbeing outcomes. Of 19,430 retrieved records, 303 studies were eligible. Pregnancy intentions were considered during the preconception period in 103 studies (only 23 assessed prospectively), and during the pregnancy period in 208 studies (141 prospectively). Associations between pregnancy intention and preconception behaviours/psychological wellbeing were primarily reported for supplement use (n = 58) and were lacking for diet/exercise, and psychological factors. For behaviours/psychological wellbeing during pregnancy, associations with pregnancy intention were focused on prenatal care (n = 79), depression (n = 61), and smoking (n = 56) and were lacking for diet/exercise. Only 7 studies assessed pregnancy intentions with a validated tool. Despite a large body of literature, there were several methodological limitations identified, namely assessment of pregnancy intentions with non-validated measures and the reliance on retrospective assessment. Future primary studies are needed to fill gaps in our understanding regarding energy-balance-related behaviours. Future studies (including reviews/meta-analyses) should take care to address the noted limitations to provide a comprehensive and accurate understanding of the relationships between pregnancy intentions and health-related lifestyle behaviours and psychological wellbeing before and during pregnancy.

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Reliance on the assessment of pregnancy intentions with non-validated measures

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Reliance on retrospective assessment

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Studies on preconception pregnancy intentions and diet/exercise lacking

Patient-provider communication, maternal anxiety, and self-care in pregnancy

RATIONALE

Favorable relationships with health care providers predict greater patient satisfaction and adherence to provider recommendations. However, the specific components of patient-provider relationships that account for these benefits have not been identified. The potential benefits of strong patient-provider relationships in pregnancy may be especially important, as care providers have frequent, intimate interactions with pregnant women that can affect their emotions and behaviors. In turn, prenatal emotions and health behaviors have potent effects on birth outcomes.

OBJECTIVE

This study investigated whether pregnant women's relationships with their midwives predicted better self-care. Specific components of the patient-provider relationship (communication, integration, collaboration, and empowerment) were examined. We also investigated a mechanism through which these relationship components may be associated with salutary health behaviors: by alleviating women's anxiety.

METHODS

In total, 139 low-risk patients of a university-affiliated midwifery practice in the northeastern United States completed well-validated measures assessing their relationship with midwives, state anxiety, and prenatal health behaviors in late pregnancy; state anxiety was also assessed in mid-pregnancy.

RESULTS

Women's perceptions of better communication, collaboration, and empowerment from their midwives were associated with more frequent salutary health behavior practices in late pregnancy. Controlling for mid-pregnancy anxiety, lower anxiety in late pregnancy mediated associations of communication and collaboration with health behavior practices, indicating that these associations were attributable to reductions in anxiety from mid- to late pregnancy.

CONCLUSION

Results substantiate that benefits of patient-provider relationships in pregnancy may extend beyond providing medical expertise. Some aspects of patient-provider relationships may offer direct benefits to pregnant women in promoting better health practices; other aspects of these relationships may indirectly contribute to better health practices by alleviating negative emotions. The benefits of strong midwife relationships may derive from the reassurance, comfort, and warmth these relationships offer, as well as the information and education that midwives provide to their patients.

Psychometric properties of the Prenatal Health Behavior Scale in mid- and late pregnancy

INTRODUCTION

Psychometrically sound self-report measures are important tools to advance research on health behaviors in pregnancy. The Prenatal Health Behavior Scale (PHBS) has been used in prior studies to quantify health behaviors and examine their associations with relevant variables, but its psychometric properties have not been carefully investigated.

METHODS

In a sample of low-risk women, we examined the factor structure, reliability, and validity of the PHBS at mid- (N = 138) and late (N = 102) pregnancy.

RESULTS

In confirmatory factor analysis, items on the PHBS loaded onto a single reliable factor, but separating health-promoting and health-impairing behavior into two factors had better model fit. The scales defined by these two factors had good internal consistency in mid- and late pregnancy, were only moderately correlated, and were predicted by somewhat different sets of sociodemographic and psychological variables. Pregnancy-specific stress was a robust predictor of health-promoting and health-impairing behavior across time.

DISCUSSION

Results bolster confidence in the reliability and validity of the PHBS and its appropriateness as a self-report tool for investigation of health behaviors among pregnant women. This study is one of the first investigations to examine patterns and predictors of health behavior practices at two time periods of pregnancy.

The London Exercise And Pregnant smokers (LEAP) trial: a randomised controlled trial of physical activity for smoking cessation in pregnancy with an economic evaluation

BACKGROUND

Smoking during pregnancy is the main preventable cause of poor birth outcomes. Improved methods are needed to help women to stop smoking during pregnancy. Pregnancy provides a compelling rationale for physical activity (PA) interventions as cessation medication is contraindicated or ineffective, and an effective PA intervention could be highly cost-effective.

OBJECTIVE

To examine the effectiveness and cost-effectiveness of a PA intervention plus standard behavioural support for smoking cessation relative to behavioural support alone for achieving smoking cessation at the end of pregnancy.

DESIGN

Multicentre, two-group, pragmatic randomised controlled trial and economic evaluation with follow-up at the end of pregnancy and 6 months postnatally. Randomisation was stratified by centre and a computer-generated sequence was used to allocate participants using a 1 : 1 ratio.

SETTING

13 hospitals offering antenatal care in the UK.

PARTICIPANTS

Women between 10 and 24 weeks' gestation smoking five or more cigarettes a day before pregnancy and one or more during pregnancy.

INTERVENTIONS

Participants were randomised to behavioural support for smoking cessation (control) or behavioural support plus a PA intervention consisting of supervised treadmill exercise plus PA consultations. Neither participants nor researchers were blinded to treatment allocation.

MAIN OUTCOME MEASURES

The primary outcome was self-reported, continuous smoking abstinence between a quit date and end of pregnancy, validated by expired carbon monoxide and/or salivary cotinine. Secondary outcomes were maternal weight, depression, birth outcomes, withdrawal symptoms and urges to smoke. The economic evaluation investigated the costs of the PA intervention compared with the control intervention.

RESULTS

In total, 789 women were randomised (n = 394 PA, n = 395 control). Four were excluded post randomisation (two had been enrolled twice in sequential pregnancies and two were ineligible and randomised erroneously). The intention-to-treat analysis comprised 785 participants (n = 392 PA, n = 393 control). There was no significant difference in the rate of abstinence at the end of pregnancy between the PA group (7.7%) and the control group (6.4%) [odds ratio for PA group abstinence 1.21, 95% confidence interval (CI) 0.70 to 2.10]. For the PA group compared with the control group, there was a 33% (95% CI 14% to 56%), 28% (95% CI 7% to 52%) and 36% (95% CI 12% to 65%) significantly greater increase in self-reported minutes of moderate- and vigorous-intensity PA from baseline to 1 week, 4 weeks and 6 weeks respectively. Accelerometer data showed that there was no significant difference in PA levels between the groups. There were no significant differences between the groups for change in maternal weight, depression, withdrawal symptoms or urges to smoke. Adverse events and birth outcomes were similar between the groups except for there being significantly more caesarean births in the control group than in the PA group (28.7% vs. 21.3%; p < 0.023). The PA intervention was less costly than the control intervention by £35 per participant. This was mainly attributable to increased health-care usage in the control group. However, there was considerable statistical uncertainty around this estimate.

CONCLUSIONS

During pregnancy, offering an intervention combining supervised exercise and PA counselling does not add to the effectiveness of behavioural support for smoking cessation. Only 10% of participants had PA levels accessed by accelerometer and it is, therefore, unclear whether or not the lack of an effect on the primary outcome is the result of insufficient increases in PA. Research is needed to identify the smoking populations most suitable for PA interventions and methods for increasing PA adherence.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN48600346.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 84. See the NIHR Journals Library website for further project information.

"It has been a long journey from first knowing": narratives of unplanned pregnancy

Unplanned pregnancies come with risks of various health and financial consequences for women. Understanding such experiences is vital to aiding women in this health context; however, there is little research in this vein, particularly for college-aged young women. Narratives of unplanned pregnancy may help to shed light on the experiences of these women, leading to greater understanding and more congruent and helpful support communication, prevention, and education resources. The present study aimed to identify themes in unplanned pregnancy narratives. Stories for women who had continued their pregnancies differed from those of women who did not continue their pregnancies, and overall, narratives seemed to work toward positively reappraising and making sense of the experience, especially in terms of autonomy, as well as seeking affirmation and support for decisions made. Implications of these results will be discussed in terms of future narrative work in the unplanned pregnancy context.

Psychosocial correlates of health-promoting and health-impairing behaviors in pregnancy

Behaviors during pregnancy including eating, exercise, cigarette smoking, and other substance use affect the health of a pregnant woman and her fetus. However, little is known about what influences pregnant women to engage in these health behaviors. Based upon relevant theory, we hypothesized that because health-promoting behaviors require continuous efforts that may depend upon a reliable, stable set of resources, intrapersonal traits, namely self-esteem and optimism, would be associated with the practice of health-promoting behaviors during pregnancy. In addition, we hypothesized that variables reactive to the more immediate context, pregnancy-specific stress and perceived control over pregnancy, would be associated with the practice of health-impairing behaviors. We distinguished health-promoting and health-impairing behaviors in a diverse sample of 165 pregnant women and investigated whether such behaviors are associated with distinct psychosocial factors. Results supported study hypotheses and provide evidence that even after controlling for maternal age, income, body mass index, and gestation, a stable, self-relevant disposition, self-esteem, is associated with the practice of health-promoting behaviors in pregnancy whereas pregnancy-specific stress, a situationally-evoked factor, is associated with the practice of health-impairing prenatal behaviors. Perceived control over pregnancy, which may reflect stable disposition and situational perceptions, was associated with health-promoting and health-impairing behaviors.

Social support communication in unplanned pregnancy: support types, messages, sources, and timing

Pregnancy is a time of uncertainty and stress for many women, and these aspects are compounded for those facing unplanned pregnancies. Social support communication is considered a vital part of healthy outcomes in pregnancy but is largely unexplored in the unplanned pregnancy context, particularly for college-aged young women. The present study aimed to identify various dimensions of social support in unplanned pregnancy for this population, including support types desired and enacted, sources of support, support types helpful in various stages of this health experience, and message strategies used in helpful support communication. Results of an online semi-structured survey exploring message content and these other elements were analyzed through qualitative and quantitative content analysis as well as statistical analysis. Nurturing support, specifically network support, was found to be most desired in this health context, and the message strategies found in the most helpful support messages differed according to support type. Source and timing of support were also factors in the most helpful types of support in this context. Implications of these results will be discussed in terms of future research in social support in the unplanned pregnancy context.

The effects of stress on physical activity and exercise

BACKGROUND

Psychological stress and physical activity (PA) are believed to be reciprocally related; however, most research examining the relationship between these constructs is devoted to the study of exercise and/or PA as an instrument to mitigate distress.

OBJECTIVE

The aim of this paper was to review the literature investigating the influence of stress on indicators of PA and exercise.

METHODS

A systematic search of Web of Science, PubMed, and SPORTDiscus was employed to find all relevant studies focusing on human participants. Search terms included "stress", "exercise", and "physical activity". A rating scale (0-9) modified for this study was utilized to assess the quality of all studies with multiple time points.

RESULTS

The literature search found 168 studies that examined the influence of stress on PA. Studies varied widely in their theoretical orientation and included perceived stress, distress, life events, job strain, role strain, and work-family conflict but not lifetime cumulative adversity. To more clearly address the question, prospective studies (n = 55) were considered for further review, the majority of which indicated that psychological stress predicts less PA (behavioral inhibition) and/or exercise or more sedentary behavior (76.4 %). Both objective (i.e., life events) and subjective (i.e., distress) measures of stress related to reduced PA. Prospective studies investigating the effects of objective markers of stress nearly all agreed (six of seven studies) that stress has a negative effect on PA. This was true for research examining (a) PA at periods of objectively varying levels of stress (i.e., final examinations vs. a control time point) and (b) chronically stressed populations (e.g., caregivers, parents of children with a cancer diagnosis) that were less likely to be active than controls over time. Studies examining older adults (>50 years), cohorts with both men and women, and larger sample sizes (n > 100) were more likely to show an inverse association. 85.7 % of higher-quality prospective research (≥ 7 on a 9-point scale) showed the same trend. Interestingly, some prospective studies (18.2 %) report evidence that PA was positively impacted by stress (behavioral activation). This should not be surprising as some individuals utilize exercise to cope with stress. Several other factors may moderate stress and PA relationships, such as stages of change for exercise. Habitually active individuals exercise more in the face of stress, and those in beginning stages exercise less. Consequently, stress may have a differential impact on exercise adoption, maintenance, and relapse. Preliminary evidence suggests that combining stress management programming with exercise interventions may allay stress-related reductions in PA, though rigorous testing of these techniques has yet to be produced.

CONCLUSIONS

Overall, the majority of the literature finds that the experience of stress impairs efforts to be physically active. Future work should center on the development of a theory explaining the mechanisms underlying the multifarious influences of stress on PA behaviors.

Physical activity as an aid to smoking cessation during pregnancy (LEAP) trial: study protocol for a randomized controlled trial

BACKGROUND

Many women try to stop smoking in pregnancy but fail. One difficulty is that there is insufficient evidence that medications for smoking cessation are effective and safe in pregnancy and thus many women prefer to avoid these. Physical activity (PA) interventions may assist cessation; however, trials examining these interventions have been too small to detect or exclude plausible beneficial effects. The London Exercise And Pregnant smokers (LEAP) trial is investigating whether a PA intervention is effective and cost-effective when used for smoking cessation by pregnant women, and will be the largest study of its kind to date.

METHODS/DESIGN

The LEAP study is a pragmatic, multi-center, two-arm, randomized, controlled trial that will target pregnant women who smoke at least one cigarette a day (and at least five cigarettes a day before pregnancy), and are between 10 and 24 weeks pregnant. Eligible patients are individually randomized to either usual care (that is, behavioral support for smoking cessation) or usual care plus a intervention (entailing supervised exercise on a treadmill plus PA consultations). The primary outcome of the trial is self-reported and biochemically validated continuous abstinence from smoking between a specified quit date and the end of pregnancy. The secondary outcomes, measured at 1 and 4 weeks after the quit date, and at the end of pregnancy and 6 months after childbirth, are PA levels, depression, self-confidence, and cigarette withdrawal symptoms. Smoking status will also be self-reported at 6 months after childbirth. In addition, perinatal measures will be collected, including antenatal complications, duration of labor, mode of delivery, and birth and placental weight. Outcomes will be analyzed on an intention-to-treat basis, and logistic regression models used to compare treatment effects on the primary outcome.

DISCUSSION

This trial will assess whether a PA intervention is effective when used for smoking cessation during pregnancy.

TRIAL REGISTRATION

ISRCTN48600346.

Factors Associated With Exercise Participation and Attitudes to Exercise Among Pregnant Smokers

Objective: We assessed exercise levels and psychosocial aspects of exercise among pregnant smokers. Methods: A cross-sectional telephone survey of 88 pregnant smokers assessed levels of participation in exercise and psychosocial aspects of exercise; namely, self-efficacy, beliefs, perceived social support, perceived barriers, intentions and stage of change. Results: The women reported slightly higher levels of physical activity than for the general population of young women. The vast majority of women interviewed reported that exercise was important in their pregnancy, that they intended exercising regularly during pregnancy and were interested in exercise classes as an aid to smoking cessation. Fatigue was the most commonly reported barrier to physical activity during pregnancy, followed by ‘it takes too much time’, ‘uncomfortable when I exercise’ or ‘not sure what to do’. The vast majority of women expressed very little confidence and social support towards exercising. Conclusion: The results suggest that there is potential for using physical activity as an aid to smoking cessation during pregnancy. However, such interventions would need to be sufficiently intensive to address perceived barriers to exercise, lack of social support, low self-efficacy and be tailored to different stages of pregnancy.

Physiological regulation in cigarette exposed infants: an examination of potential moderators

The primary purpose of this study was to examine pathways from prenatal cigarette exposure to physiological regulation at 2 months of age. Specifically, we explored the possibility that any association between prenatal cigarette exposure and infant physiological regulation was moderated by fetal growth, prenatal or postnatal environmental tobacco smoke (ETS) exposure or maternal depressive symptomatology during pregnancy. We evaluated whether exposed infants who were also exposed to ETS after birth, were small for gestational age (SGA) or had mothers with higher depressive symptoms during pregnancy had the highest levels of physiological dysregulation. Respiratory sinus arrhythmia (RSA) was obtained from 234 (166 exposed and 68 nonexposed) infants during sleep. As expected, cigarette-exposed infants had significantly lower RSA than nonexposed infants. This association was not moderated by prenatal or postnatal ETS exposure, or maternal depressive symptomatology during pregnancy. However, small for gestational age status did moderate this association such that nonexposed infants who were not small for gestational age had a significantly higher RSA than nonexposed small for gestational age infants and exposed infants. These findings provide additional evidence that prenatal cigarette exposure is directly associated with dysregulation during infancy.

Maternal prenatal stress and cortisol reactivity to stressors in human infants

Early life factors can shape the development of hypothalamic pituitary adrenal (HPA) axis. Maternal prenatal stress might constitute such an early environmental factor. As little is known about the relation between maternal prenatal stress and cortisol reactivity in human offspring, we performed a longitudinal study including four assessments of infant cortisol reactivity to stressful events in a non-clinical population. General and pregnancy-related feelings of stress and anxiety, as well as circadian cortisol levels, were measured in 173 mothers in the last trimester of pregnancy. Infant cortisol reactivity was measured at 5 weeks to a bathing session, at 8 weeks to a vaccination, at 5 months to a stressful mother-infant interaction (still face procedure), and at 12 months to a maternal separation (strange situation procedure). Maternal prenatal fear of bearing a handicapped child was a consistent predictor of infant cortisol reactivity. Although the effects were mild, higher fear was significantly related to higher salivary cortisol reactivity to the bathing session and to decreased cortisol reactivity to vaccination and maternal separation. Thus, pregnancy-specific anxieties predict infant cortisol reactivity in the first year of life, but the direction of the effect depends on infant age and/or the nature of the stressor. While this specific anxiety was a better predictor than stress experience or maternal cortisol concentrations, the underlying mechanisms of these associations remain unclear. Future studies should try to incorporate multiple measures of HPA-axis reactivity during development when studying the long-term consequences of maternal prenatal stress.

Using propensity score modeling to minimize the influence of confounding risks related to prenatal tobacco exposure

INTRODUCTION

Despite efforts to control for confounding variables using stringent sampling plans, selection bias typically exists in observational studies, resulting in unbalanced comparison groups. Ignoring selection bias can result in unreliable or misleading estimates of the causal effect.

METHODS

Generalized boosted models were used to estimate propensity scores from 42 confounding variables for a sample of 361 neonates. Using emergent neonatal attention and orientation skills as an example developmental outcome, we examined the impact of tobacco exposure with and without accounting for selection bias. Weight at birth, an outcome related to tobacco exposure, also was used to examine the functionality of the propensity score approach.

RESULTS

Without inclusion of propensity scores, tobacco-exposed neonates did not differ from their nonexposed peers in attention skills over the first month or in weight at birth. When the propensity score was included as a covariate, exposed infants had marginally lower attention and a slower linear change rate at 4 weeks, with greater quadratic deceleration over the first month. Similarly, exposure-related differences in birth weight emerged when propensity scores were included as a covariate.

CONCLUSIONS

The propensity score method captured the selection bias intrinsic to this observational study of prenatal tobacco exposure. Selection bias obscured the deleterious impact of tobacco exposure on the development of neonatal attention. The illustrated analytic strategy offers an example to better characterize the impact of prenatal tobacco exposure on important developmental outcomes by directly modeling and statistically accounting for the selection bias from the sampling process.

Social support, life stress, and anxiety as predictors of pregnancy complications in low-income women

Prospective repeated measures were used to examine attachment, social support, life stress, anxiety, and psychological wellbeing among low-income women in early and late pregnancy and the relationships of these variables to prenatal, intrapartum, and neonatal complications. One hundred and eleven medically healthy, low-income, Medicaid-eligible women ages 18-35 years, between 14 and 22 weeks of pregnancy were recruited from prenatal clinics. Self-report questionnaires and hospital records were used to collect data. Discriminant analysis was performed. The most important discriminating factors for prenatal complications were state anxiety and total functional social support. The factors for neonatal complications were negative life events and the interaction of emotional support with negative life events.

Sex differences in the relation between prenatal maternal emotional complaints and child outcome

BACKGROUND

Sex differences are found in animal studies concerning the relationship between prenatal maternal stress and outcome of the offspring. Most human studies in this field have not addressed sex differences, although differences between boys and girls may elucidate the biochemical as well as psychological processes involved. Associations between prenatal maternal emotional complaints and behavioural problems of toddlers and preschoolers as assessed by both mothers and fathers are studied separately for boys and girls.

METHODS

Healthy Dutch Caucasian singleton, pregnant women (N=444) answered questionnaires about anxiety and depression in every trimester of pregnancy. When their children (227 boys, 217 girls) were between 14 and 54 months old, both parents reported on their current feelings of depression and anxiety and on the behavioural problems of their children.

RESULTS

Prenatal maternal emotional complaints were found to be associated with child behavioural problems both in boys and in girls, but in different ways. Prenatal maternal emotional complaints during the first trimester were associated with total and internalizing behavioural problems for boys. Emotional complaints during the third trimester were associated with total, internalizing, as well as externalizing behavioural problems for girls.

CONCLUSIONS

Differentiation according to sex and information on timing of emotional complaints during pregnancy is needed in studies concerning the relation between prenatal maternal emotional complaints and child outcome.

The association between prenatal exposure to cigarettes and cortisol reactivity and regulation in 7-month-old infants

We examined the association between prenatal exposure to cigarettes and adrenocortical responses to stress in 7-month-old infants. Cortisol levels were assessed twice prior to and twice following affect-eliciting procedures in 111 (59 exposed and 52 nonexposed) infants. Cortisol reactivity was defined as the difference between the peak poststressor cortisol level and the pretask cortisol level. Higher values indicated higher cortisol reactivity. Exposed infants had higher peak cortisol reactivity than nonexposed infants. There were no differences in pretask cortisol levels. Maternal hostility mediated the association between cigarette exposure and peak cortisol reactivity. Furthermore, infant gender moderated this association such that exposed boys had significantly higher peak cortisol reactivity than nonexposed infants or exposed girls. These findings provide additional evidence that prenatal cigarette exposure is associated with dysregulation during infancy and that early adverse, nonsocial experiences may have relatively long-lasting effects on cortisol reactivity in infants.

Physical activity as an aid to smoking cessation during pregnancy: two feasibility studies

BACKGROUND

Pharmacotherapies for smoking cessation have not been adequately tested in pregnancy and women are reluctant to use them. Behavioural support alone has a modest effect on cessation rates; therefore, more effective interventions are needed. Even moderate intensity physical activity (e.g. brisk walk) reduces urges to smoke and there is some evidence it increases cessation rates in non-pregnant smokers. Two pilot studies assessed i) the feasibility of recruiting pregnant women to a trial of physical activity for smoking cessation, ii) adherence to physical activity and iii) women' perceptions of the intervention.

METHODS

Pregnant smokers volunteered for an intervention combining smoking cessation support, physical activity counselling and supervised exercise (e.g. treadmill walking). The first study provided six weekly treatment sessions. The second study provided 15 sessions over eight weeks. Physical activity levels and continuous smoking abstinence (verified by expired carbon monoxide) were monitored up to eight months gestation.

RESULTS

Overall, 11.6% (32/277) of women recorded as smokers at their first antenatal booking visit were recruited. At eight months gestation 25% (8/32) of the women achieved continuous smoking abstinence. Abstinent women attended at least 85% of treatment sessions and 75% (6/8) achieved the target level of 110 minutes/week of physical activity at end-of-treatment. Increased physical activity was maintained at eight months gestation only in the second study. Women reported that the intervention helped weight management, reduced cigarette cravings and increased confidence for quitting.

CONCLUSION

It is feasible to recruit pregnant smokers to a trial of physical activity for smoking cessation and this is likely to be popular. A large randomised controlled trial is needed to examine the efficacy of this intervention.

A multilevel examination of exercise intention and behavior during pregnancy

Research examining exercising in pregnancy is limited by non-theoretical and cross-sectional assessments that fail to capture the specific physical and psychological demands of the pregnancy trimesters. Drawing on a population in Gainesville, Florida, USA we prospectively examined, within a multilevel design, 61 pregnant women's first and second trimester exercise intention and behavior, and the potential moderating effect of past exercise behavior using the framework of the Theory of Planned Behavior (TPB). Significant cross-sectional associations were found with exercise intention, although the only significant longitudinal effect was the relation between first trimester intention and second trimester changes in exercise behavior. Implications of our findings for study design and exercise intervention development during pregnancy are discussed.

The association between prenatal exposure to cigarettes and infant and maternal negative affect

This study examined the association between prenatal exposure to cigarettes and infant and maternal negative affect. Participants were 115 mother-infant dyads (69 prenatally exposed to cigarettes and 46 nonexposed). Infant and maternal negative affect were both assessed during the neonatal period (2-4 weeks of age) and again at 7 months of infant age. Results indicated that only prenatal exposure to cigarettes predicted infant negative affect. Infants who were prenatally exposed to more cigarettes had higher levels of negative affect at both time points. Furthermore, regression analyses indicated that both infant and maternal negative affect during the neonatal period predicted maternal negative affect at 7 months of age. These results highlight the importance of considering the reciprocal relationship between infant and maternal behavior when examining developmental outcomes among infants prenatally exposed to cigarettes.

Explaining disproportionately high rates of adverse birth outcomes among African Americans: the impact of stress, racism, and related factors in pregnancy

Compared with European Americans, African American infants experience disproportionately high rates of low birth weight and preterm delivery and are more than twice as likely to die during their 1st year of life. The authors examine 5 explanations for these differences in rates of adverse birth outcomes: (a) ethnic differences in health behaviors and socioeconomic status; (b) higher levels of stress in African American women; (c) greater susceptibility to stress in African Americans; (d) the impact of racism acting either as a contributor to stress or as a factor that exacerbates stress effects; and (e) ethnic differences in stress-related neuroendocrine, vascular, and immunological processes. The review of literature indicates that each explanation has some merit, although none is sufficient to explain ethnic disparities in adverse birth outcomes. There is a lack of studies examining the impact of such factors jointly and interactively. Recommendations and cautions for future research are offered.

Are maternal smoking and stress during pregnancy related to ADHD symptoms in children?

BACKGROUND

There are some indications that maternal lifestyle during pregnancy (smoking and stress) contributes to symptoms of ADHD in children. We prospectively studied whether prenatal exposure to maternal smoking and/or stress is associated with ADHD symptoms and diagnostic criteria (according to DSM-IV) in 7-year-olds.

METHODS

Nulliparous Scandinavian women were consecutively recruited at their first prenatal health care visit and assessments of smoking and stress were collected at gestational weeks 10, 12, 20, 28, 32, and 36. Children were followed up at 7 years old. We obtained full data for 72% of the sample: ADHD symptoms were rated by 74% of mothers (n=290) and 96% of eligible teachers (n=208). Attrition analyses showed no differences on key variables between participants and non-participants at follow-up.

RESULTS

Results of multiple regression analyses showed prenatal exposure to smoking (beta=.16, p<.01) and stress (beta=.18, p<.01) were independently associated with later symptoms of ADHD. Results of logistic regression analyses showed that fulfillment of the diagnostic criteria for ADHD was related to exposure to prenatal stress (beta=.68, p<.01) especially in boys. The results were not confounded by sociodemographic factors or birth outcomes.

CONCLUSIONS

This study provides evidence that prenatal exposure to stress and smoking is independently associated with later symptoms of ADHD in human children, particularly for boys. Because stress and smoking are relatively common during pregnancy, and yet preventable, these results are of public health significance.

Psychosocial aspects of selected issues in women's reproductive health: current status and future directions

Emphasizing research published in the past decade, this article presents a summary and evaluation of psychosocial investigations of women's reproductive health, with a focus on selected aspects of menstruation, pregnancy and birth, infertility, and menopause. In some areas, studies have focused on negative physical and psychological concomitants of these health issues. However, research reveals substantial individual variability, with most women adapting well to reproductive health changes. Although methodological and conceptual shortcomings have limited firm conclusions, research has advanced our understanding of the multivariate biological, psychological, and social influences on women's reproductive health and associated outcomes. Understanding and promoting women's reproductive health across the lifespan requires biopsychosocial approaches to research.