Physical activity during pregnancy and maternal-child health (PAMELA): study protocol for a randomized controlled trial

Maternal Physical Activity Patterns in the 2015 Pelotas Birth Cohort: From Preconception to Postpartum

BACKGROUND

Motherhood has been associated with reduced leisure-time physical activity (LTPA) levels. We aim to assess maternal LTPA patterns from preconception to 4 years postpartum.

METHODS

The study was developed with mothers from the Pelotas 2015 Birth Cohort, Southern Brazil (n = 4273). LTPA data were self-reported for preconception, antenatal, and 3, 12, 24, and 48 months postpartum. Information on LTPA referring to preconception (3 mo before pregnancy) and each gestational trimester was retrospectively collected in perinatal. The prevalence of active mothers was calculated according to recommendations (≥150 min/wk). We described changes in LTPA between follow-ups and estimated the probability of mothers being active according to previous LTPA. We used group-based trajectory analysis to identify patterns of LTPA throughout the follow-ups.

RESULTS

The prevalence of active mothers during leisure time decreased in pregnancy and postpartum compared with preconception. At 12 months postpartum, LTPA levels rose again, but at 48 months, the rates of active mothers still had not returned to preconception levels. Prior LTPA engagement was an important determinant of the maintenance of LTPA. Trajectory analysis identified 4 patterns of maternal LTPA, and ∼80% of mothers were allocated to the "always inactive" group. Higher education and income, working outside the home, multiple births, and participating in the PAMELA study intervention were associated with a higher probability of mothers not being included in this predominantly inactive group.

CONCLUSIONS

Motherhood is associated with declining rates of women meeting physical activity recommendations during pregnancy and early postpartum.

Comparative Assessment of Diet Quality and Adherence to a Structured Nutrition and Exercise Intervention Compared with Usual Care in Pregnancy in a Randomized Trial

Background

In trials testing the efficacy of diet and exercise modifications during pregnancy on health outcomes, assessment of participant adherence to interventions of diet and exercise is rarely reported, with few standard methods existing to measure adherence.

Objective

We aimed to assess the maternal diet quality and create an algorithm to evaluate adherence to an intervention of high protein/dairy nutrition and walking exercise from early pregnancy to birth.

Methods

In Be Healthy in Pregnancy randomized trial (NCT01693510), diet quality was measured using scores from an adapted PrimeScreen food frequency questionnaire, nutrient intake assessed by 3-day diet records, and physical activity using accelerometry at 14-17 (early), 26-28 (middle), and 36-38 (late) weeks' gestation. A novel adherence score was derived by combining data for compliance with prescribed protein and energy intakes and daily step counts in the intervention group. Between-group diet quality scores and changes in adherence scores in the intervention group across pregnancy were analyzed using generalized estimating equations adjusted for prepregnancy body mass index and study site.

Results

Diet scores were similar for intervention (n = 55) and control (n = 56) groups at baseline but only the intervention group significantly improved and maintained their scores from early to middle (18.7 ± 7.6 vs. 22.9 ± 6.1; P < 0.001) and late (22.5 ± 6.9; P < 0.008) pregnancy. Protein intake was significantly (P < 0.001) higher but energy intakes were similar in the intervention group compared with those in the control group. Adherence scores for the intervention increased significantly (P < 0.01) from early (1.52 ± 0.70) to midpregnancy (1.89 ± 0.82) but declined from midpregnancy to late (1.55 ± 0.78; P < 0.0005) pregnancy primarily owing to lower step counts.

Conclusions

Adherence to an intervention may decline toward the end of pregnancy, particularly in maintaining physical activity. Creation of adherence scores is a feasible approach to measure combined intervention compliance for diet and physical activity and may increase transparency in interpreting results of randomized trials in pregnancy.This trial was registered at clinicaltrials.gov as NCT01689961 (https://clinicaltrials.gov/ct2/show/NCT01689961?cond=NCT01689961&rank=1; registered on 21 September 2012).

Effects of Regular Exercise During Pregnancy on Early Childhood Neurodevelopment: The Physical Activity for Mothers Enrolled in Longitudinal Analysis Randomized Controlled Trial

BACKGROUND

The aim of this study was to investigate the effect of exercise during pregnancy on early childhood neurodevelopment (cognitive, motor, and language domains).

METHODS

A randomized controlled trial nested into the 2015 Pelotas (Brazil) Birth Cohort was conducted. Healthy pregnant women were enrolled between 16 and 20 weeks of gestation; 424 women and their children (intervention [n = 141]; control [n = 283]) were analyzed. An exercise-based intervention 3 times per week was delivered over 16 weeks. Child neurodevelopment and its domains were assessed at 1, 2, and 4 years. Standardized mean differences and 95% confidence intervals are presented.

RESULTS

No effects of exercise during pregnancy on child neurodevelopment and its domains at age 1 year were observed. Compared with the control group, children from women in the exercise group had higher language score at age 2 years (standardized mean differences = 0.23; 95% confidence intervals, 0.02 to 0.44) and higher cognitive score (standardized mean differences = 0.22; 95% confidence intervals, 0.03 to 0.41) at age 4 years. No effects of exercise during pregnancy were observed in the motor domain at 1, 2, and 4 years.

CONCLUSIONS

No detrimental effects of exercise during pregnancy on child neurodevelopment were observed. In addition, these findings suggest that exercise during pregnancy can result in small benefits for language and cognitive development.

Are leisure-time and work-related activities associated with low back pain during pregnancy?

BACKGROUND

Although working activities are associated with several pregnancy outcomes, there is scarce information regarding the association between working activities and low back pain (LBP) during pregnancy. This study aimed to investigate whether leisure-time and work-related physical activities during pregnancy are associated with LBP.

METHODS

Data from the 2015 Pelotas Birth Cohort study were used. Demographic, socioeconomic, gestational, leisure-time (prior to and during pregnancy) and work-related (days of work, hours of work, standing and heavy lifting) physical activity data were collected at birth. LPB was assessed in the 12-month follow-up period.

RESULTS

Leisure-time physical activity either prior to and during pregnancy was not associated with LBP. Working during pregnancy, days of work and standing position at work were not associated with self-reported LBP during pregnancy. However, working more than 8 h per day and always lifting heavy objects at work increased the odds ratio for LBP (OR 1.30 95%CI: 1.04; 1.63; and OR: 1.39 95%CI 1.08; 1.81, respectively). In addition, women who had lifted heavy objects often/always, reported an increase in pain intensity.

CONCLUSION

Working during pregnancy and days worked per week were not related to experiencing LBP. However, women who worked more than 8 h per day, as well as women who lifted heavy objects at work on a regular basis, were more likely to experience pregnancy-related LBP.

Effects of an exercise program on health of people with epilepsy: A randomized clinical trial

To evaluate the effects of an exercise program on the health of people with epilepsy (PWE) and seizure frequency. A randomized clinical trial was carried out in Pelotas/Brazil. Recruitment was conducted through social media, in local press, and Public Health System facilities. The intervention program was performed at the gym of the Physical Education School/Federal University of Pelotas. A total of 21 people, aged 18-60 years, diagnosed with epilepsy and who were not engaged in systematic physical exercise in the last three months were divided into two groups: (1) exercise (EG) - 12 weeks of a structured physical exercise program; (2) control (CG) - no exercise and maintenance of usual activities. The allocation rate 1:1 was used. The exercise program consisted of two 60-min weekly sessions including warm-up (5-min), aerobic training (15-25 min at 14-17 on Borg scale), resistance training (2-3 sets, 10-15 repetitions), and stretching. Sociodemographic, clinical and health variables (frequency and number of seizures, quality of life, depression, anxiety, and side effects), anthropometrics (weight, height, hip and waist circumferences), cardiorespiratory fitness (VO_2max), and strength (dynamometry) were measured at baseline and after the 12-week intervention. Generalized Estimating Equations (GEE) and Bonferroni posthoc tests were used for the comparison between moments and groups. Eleven participants were randomized to EG and 10 to CG. One EG participant did not complete the study. There was a reduction in frequency of epileptic seizures during the 3-month intervention period in EG (p = 0.010) with no improvement in CG. Improvement in quality of life (p = 0.004), stress levels (p = 0.017) and physical fitness (p = 0.017) were also observed in the EG compared to CG. A structured physical exercise program improved overall health of PWE and decreased seizure frequency.

Parental attendance in two early-childhood training programmes to improve nurturing care: A randomized controlled trial

Parent training programmes have significant potential to improve the quality of children's early environments and thereby their development and life-course outcomes. The aim of this study was to identify and explain the extent to which parents engaged in two group-based training programmes, offered to high-risk families enrolled in a randomized controlled trial study called PIÁ in Southern Brazil. The programmes were: (1) ACT: Raising Safe Kids, a 9-week programme aiming to reduce harsh parenting and maltreatment and improve positive parenting practices; (2) Dialogic book-sharing (DBS), an 8-week programme aiming to promote parental sensitivity and improve child cognitive development and social understanding. Of the 123 mothers randomly allocated to the ACT programme, 64.2% (n = 79) completed the course, and of 124 mothers allocated to DBS, 76.6% (n = 95) completed the course. After the interventions, mothers were very positive about the experience of both programmes but highlighted practical difficulties in attending. In adjusted regression analyses, only two variables significantly predicted ACT course completion (maternal age and distance between the intervention site and household); no significant predictor was found for DBS attendance. We conclude that although high completion rates are possible, there are important challenges to engaging parents of young children in training programmes, and practical difficulties occurring during training courses may be more important for attendance than baseline participant characteristics.

Physical Activity During Pregnancy and Preterm Birth: Findings From the 2015 Pelotas (Brazil) Birth Cohort Study

BACKGROUND

Physical activity (PA) during pregnancy is associated with several benefits in maternal and child outcomes, and its relationship with preterm birth is still conflicting. This study aims to examine the associations between PA during pregnancy and occurrence of preterm birth.

METHODS

PA was assessed by questionnaire (for each trimester) and accelerometry (second trimester) in women enrolled in a birth cohort study that started during pregnancy and included births that occurred between January 1 and December 31, 2015. Gestational age was based on the last menstrual period and ultrasonography. All deliveries before 37 weeks of gestation were considered preterm births. A Poisson regression model was used to measure associations controlling for potential confounders.

RESULTS

PA information was available for 4163 women and 13.8% of births were preterm. A total of 15.8% of women were engaged in PA during pregnancy. Multivariate analysis showed that only PA performed in the third trimester of pregnancy (prevalence ratio = 0.58; 95% confidence interval, 0.36-0.96) was associated with the outcome.

CONCLUSIONS

PA performed in the third trimester of pregnancy was associated with a protection to preterm birth. Pregnant women should be counseled to engage in PA to lower the risk of premature delivery.

Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women

BACKGROUND

About one-third of women have urinary incontinence (UI) and up to one-tenth have faecal incontinence (FI) after childbirth. Pelvic floor muscle training (PFMT) is commonly recommended during pregnancy and after birth for both preventing and treating incontinence. This is an update of a Cochrane Review previously published in 2017.

OBJECTIVES

To assess the effects of PFMT for preventing or treating urinary and faecal incontinence in pregnant or postnatal women, and summarise the principal findings of relevant economic evaluations.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearched journals and conference proceedings (searched 7 August 2019), and the reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised or quasi-randomised trials in which one arm included PFMT. Another arm was no PFMT, usual antenatal or postnatal care, another control condition, or an alternative PFMT intervention. Populations included women who, at randomisation, were continent (PFMT for prevention) or incontinent (PFMT for treatment), and a mixed population of women who were one or the other (PFMT for prevention or treatment).

DATA COLLECTION AND ANALYSIS

We independently assessed trials for inclusion and risk of bias. We extracted data and assessed the quality of evidence using GRADE.

MAIN RESULTS

We included 46 trials involving 10,832 women from 21 countries. Overall, trials were small to moderately-sized. The PFMT programmes and control conditions varied considerably and were often poorly described. Many trials were at moderate to high risk of bias. Two participants in a study of 43 pregnant women performing PFMT for prevention of incontinence withdrew due to pelvic floor pain. No other trials reported any adverse effects of PFMT. Prevention of UI: compared with usual care, continent pregnant women performing antenatal PFMT probably have a lower risk of reporting UI in late pregnancy (62% less; risk ratio (RR) 0.38, 95% confidence interval (CI) 0.20 to 0.72; 6 trials, 624 women; moderate-quality evidence). Antenatal PFMT slightly decreased the risk of UI in the mid-postnatal period (more than three to six months' postpartum) (29% less; RR 0.71, 95% CI 0.54 to 0.95; 5 trials, 673 women; high-quality evidence). There was insufficient information available for the late postnatal period (more than six to 12 months) to determine effects at this time point (RR 1.20, 95% CI 0.65 to 2.21; 1 trial, 44 women; low-quality evidence). Treatment of UI: compared with usual care, there is no evidence that antenatal PFMT in incontinent women decreases incontinence in late pregnancy (very low-quality evidence), or in the mid-(RR 0.94, 95% CI 0.70 to 1.24; 1 trial, 187 women; low-quality evidence), or late postnatal periods (very low-quality evidence). Similarly, in postnatal women with persistent UI, there is no evidence that PFMT results in a difference in UI at more than six to 12 months postpartum (RR 0.55, 95% CI 0.29 to 1.07; 3 trials; 696 women; low-quality evidence). Mixed prevention and treatment approach to UI: antenatal PFMT in women with or without UI probably decreases UI risk in late pregnancy (22% less; RR 0.78, 95% CI 0.64 to 0.94; 11 trials, 3307 women; moderate-quality evidence), and may reduce the risk slightly in the mid-postnatal period (RR 0.73, 95% CI 0.55 to 0.97; 5 trials, 1921 women; low-quality evidence). There was no evidence that antenatal PFMT reduces the risk of UI at late postpartum (RR 0.85, 95% CI 0.63 to 1.14; 2 trials, 244 women; moderate-quality evidence). For PFMT started after delivery, there was uncertainty about the effect on UI risk in the late postnatal period (RR 0.88, 95% CI 0.71 to 1.09; 3 trials, 826 women; moderate-quality evidence). Faecal incontinence: eight trials reported FI outcomes. In postnatal women with persistent FI, it was uncertain whether PFMT reduced incontinence in the late postnatal period compared to usual care (very low-quality evidence). In women with or without FI, there was no evidence that antenatal PFMT led to a difference in the prevalence of FI in late pregnancy (RR 0.64, 95% CI 0.36 to 1.14; 3 trials, 910 women; moderate-quality evidence). Similarly, for postnatal PFMT in a mixed population, there was no evidence that PFMT reduces the risk of FI in the late postnatal period (RR 0.73, 95% CI 0.13 to 4.21; 1 trial, 107 women, low-quality evidence). There was little evidence about effects on UI or FI beyond 12 months' postpartum. There were few incontinence-specific quality of life data and little consensus on how to measure it.

AUTHORS' CONCLUSIONS

This review provides evidence that early, structured PFMT in early pregnancy for continent women may prevent the onset of UI in late pregnancy and postpartum. Population approaches (recruiting antenatal women regardless of continence status) may have a smaller effect on UI, although the reasons for this are unclear. A population-based approach for delivering postnatal PFMT is not likely to reduce UI. Uncertainty surrounds the effects of PFMT as a treatment for UI in antenatal and postnatal women, which contrasts with the more established effectiveness in mid-life women. It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches, and in certain groups of women. Hypothetically, for instance, women with a high body mass index (BMI) are at risk of UI. Such uncertainties require further testing and data on duration of effect are also needed. The physiological and behavioural aspects of exercise programmes must be described for both PFMT and control groups, and how much PFMT women in both groups do, to increase understanding of what works and for whom. Few data exist on FI and it is important that this is included in any future trials. It is essential that future trials use valid measures of incontinence-specific quality of life for both urinary and faecal incontinence. In addition to further clinical studies, economic evaluations assessing the cost-effectiveness of different management strategies for FI and UI are needed.

Female infants are more susceptible to the effects of maternal antenatal depression; findings from the Pelotas (Brazil) Birth Cohort Study

BACKGROUND

We utilised data from the 2015 Pelotas Birth Cohort, a large prospective cohort in southern Brazil, to examine the association of moderate and severe antenatal depression with child birth outcomes and explore interactions with sociodemographic characteristics.

METHODS

Data was available for n = 3046 participants and their infants. We measured antenatal depression using the Edinburgh Postnatal Depression Scale (EPDS, ≥13 for moderate and ≥17 for severe depression). Outcome measures included gestational age, birth weight, length and head circumference, using the Intergrowth-21st standards. We controlled for known confounders including obstetric risk.

RESULTS

We did not find differences in childbirth outcomes by maternal depression status for participants with at least moderate depression, although there was an increased risk for female offspring to be small for gestational age (SGA, OR 2.33[1.37,3.97]). For severe depression (EPDS≥17) we found an increased risk for lower APGAR scores (OR 1.63[1.02,2.60]) and being SGA (OR 1.77[1.06,2.97], with an increased risk for female offspring in particular to be in lower weight centiles (-10.71 [-16.83,-4.60]), to be SGA (OR 3.74[1.89, 7.44]) and in the lower 10th centile for length (OR 2.19[1.25,3.84]).

LIMITATIONS

include the use of a maternal report questionnaire to ascertain depressive symptoms.

CONCLUSIONS

In this recent large longitudinal cohort in Brazil we did not find independent effects of depression on adverse birth outcomes or interactions with sociodemographic characteristics. We found an increased risk of being SGA for female offspring of women with moderate and severe depression, in line with other research suggesting females may be more susceptible to antenatal disturbances.

FUNDING

This work was supported by the Wellcome Trust, United Kingdom (095582), the Brazilian National Research Council (CNPq) and the Coordination for the Improvement of Higher Education Personnel (CAPES). EN was supported by the UK Economic and Social Research Council GCRF Postdoctoral Fellowship (ES/P009794/1).

Maternal perinatal depression and infant sleep problems at 1 year of age: Subjective and actigraphy data from a population-based birth cohort study

This study used data from 2,222 mothers and infants participating in a population-based birth cohort to verify whether maternal depression in the perinatal period was associated with poor infant sleep. Mothers who scored ≥13 points on the Edinburgh Postnatal Depression Scale at 16-24 weeks of gestation and/or 3 months after delivery were considered perinatally depressed. The main outcome variable was poor infant sleep at 12 months of age, defined as >3 night wakings, nocturnal wakefulness >1 hr or total sleep duration <9 hr. Infant sleep data were obtained with the Brief Infant Sleep Questionnaire (BISQ) and 24-hr actigraphy monitoring. Prevalence of perinatal depression in the sample was 22.3% (95% confidence interval [CI], 20.5-24.0). After Poisson regression, infants of depressed mothers showed an adjusted relative risk (RR) of 1.44 (95% CI, 1.00-2.08; p = .04) for >3 night wakings with questionnaire-derived data. When actigraphy data were analysed, no association was found between perinatal depression and poor infant sleep (adjusted RR, 1.20; 95% CI, 0.82-1.74; p = .35). In conclusion, although mothers in the depressed group were more likely to report more night wakings, objective data from actigraphy did not replicate this finding. Dysfunctional cognition, maternal behavioural factors and sleep impairment associated with perinatal depression may affect the mother's impression of her infant's sleep.

Physical exercise and metformin in the prevention of pre-eclampsia: systematic review

Abstract Introduction: Pre-eclampsia is a disorder that may occur during pregnancy but is still unknown and / or multifactorial causes. Objective: To verify whether physical exercise and metformin may be helpful in preventing preeclampsia. Method: This is a systematic review of the literature in PubMed / MEDLINE, Web of Science, Scopus, LILACS and Cochrane. This review followed the critiques of the PRISMA checklist. Bias assessment was used for the Cochrane Handbook for Systematical Reviews of Interventions (Version 5.1.0) for clinical trials and the Downs and Black scale for cohort and case-control studies. Results: 17 studies were within the established criteria. The subjects evaluated were: pre-eclampsia, cardiovascular metabolic factors, physiotherapeutic therapies and the effects of physical exercise and metformin on the circulatory system. Conclusion: There is a need for adapted techniques and new protocols according to the contingencies and complications of pregnancy. During pregnancy, it is suggested a greater interdisciplinarity of knowledge among professionals and that the therapy receives adjustments against the metabolic alterations of the reproductive system. In order to prevent preeclampsia, the study suggests a program of individual exercises that include greater assistance, verification and / or comprehension of possible changes and their limits during pregnancy. As well as, the adjuvant use of metformin of 1000 mg/d in the initial phase, with the purpose of maintaining the effects of the drug due to renal clearance during pregnancy, until reaching a maximum of 1500 mg/d, to avoid side effects of the drug.

Effect of Parental Counseling on Infants' Healthy Sleep Habits in Brazil: A Randomized Clinical Trial

Importance

Poor sleep during early childhood is associated with adverse outcomes, including obesity, cognitive impairment, and mental and behavioral disorders.

Objective

To assess the efficacy of an educational intervention in the promotion of nighttime sleep duration.

Design, Setting, and Participants

This single-blind, intent-to-treat randomized clinical trial included participants in Pelotas, Brazil, aged 3 months who were followed up until age 24 months. Eligibility criteria included healthy infants aged approximately 3 months who slept less than 15 hours per 24 hours. Infants were randomized to the intervention group or control group.

Interventions

Information on sleep characteristics, improvements in the environment, establishment of a nighttime sleep routine, and waiting before attending nocturnal awakenings was delivered to mothers in the intervention group by trained home-visitors at baseline. The intervention group received a telephone call on the first and second day after the intervention and a home visit on the third day after the intervention. The intervention's content was reinforced at health care visits for ages 6 months and 12 months. Mothers allocated to the control group were counseled on the benefits of breastfeeding for the mother's and child's health and given written material with content on breastfeeding.

Main Outcomes and Measures

Nighttime sleep duration was measured by interview and actigraphy at baseline and ages 6, 12, and 24 months and diaries at baseline and age 6 months. At ages 3 and 6 months, nighttime sleep self-regulation was calculated by subtracting nighttime sleep duration recorded by actigraphy from nighttime sleep duration recorded in the diaries and at ages 12 and 24 months by subtracting nighttime sleep duration recorded by actigraphy from nighttime sleep duration obtained by interview.

Results

Among 1812 mother-infant dyads invited to participate, 798 met the inclusion criteria and 586 agreed to participate. The intervention group included 298 infants (154 [52.9%] boys), and the control group included 288 infants (164 [58.2%] boys). At age 6 months, mean (SD) nighttime sleep duration recorded in diaries was 9.80 (1.85) hours in the intervention group and 9.49 (2.07) hours in the control group, a difference of 19 minutes longer for the intervention group. At age 12 months, mean (SD) nighttime sleep duration based on the Brief Infant Sleep Questionnaire was 8.43 (1.35) hours in the intervention group and 8.52 (1.35) hours in the control group, a difference of 5 minutes shorter for the intervention group. At age 24 months, compared with information from the interview, actigraphy records showed that children in the intervention group stayed awake at night without signalizing for a mean (SD) of 0.52 (2.52) hours, whereas children in the control group stayed awake at night without signalizing for a mean (SD) of 0.23 (2.43) hours. There were no statistically significant difference between groups in any of the sleep parameters investigated.

Conclusions and Relevance

This randomized clinical trial found that the educational intervention did not achieve longer nighttime sleep duration among infants in the intervention group.

Trial Registration

ClinicalTrials.gov identifier: NCT02788630.

Physical Activity Before or During Pregnancy and Low Back Pain: Data From the 2015 Pelotas (Brazil) Birth Cohort Study

BACKGROUND

To investigate whether engagement in leisure-time physical activity before or during pregnancy is associated with low back pain (LBP) outcomes during pregnancy and postpartum prevalence of LBP in women who reported LBP during pregnancy.

METHODS

Data from the 2015 Pelotas Birth Cohort Study, were used. Demographic, socioeconomic, and gestational characteristics, as well as physical activity prior to and during pregnancy were recorded at perinatal assessment. LBP outcomes during pregnancy (pain intensity, activity limitation, and care seeking) and postpartum (prevalence of LBP) were collected at the 1-year follow-up.

RESULTS

Pain intensity, care seeking, and prevalence of LBP postpartum period were not associated with physical activity either before or during pregnancy. However, women engaged in physical activity during pregnancy and at least for 2 trimesters had lower odds ratio of activity limitation associated with LBP during pregnancy (odds ratio: 0.60; 95% confidence interval, 0.41 to 0.88; odds ratio: 0.20; 95% confidence interval, 0.04 to 0.86, respectively).

CONCLUSION

Meeting the recommended levels of physical activity during pregnancy is associated with less activity limitation related to LBP during pregnancy. However, physical activity levels, either before or during pregnancy, were not associated with pain intensity, care seeking, and postpartum LBP.

Effects of Maternal Physical Exercise on Global DNA Methylation and Hippocampal Plasticity of Rat Male Offspring

Intrauterine exposure to exercise is beneficial to cognition of the offspring. Although it is advisable to start practicing physical exercise during pregnancy, it is probable that practitioners or sedentary women keep their previous habits during gestation. This study was designed to evaluate the effects of maternal aerobic exercise initiated before and maintained during gestation, or performed in these isolated periods, on cognition and plasticity in the hippocampus of offspring. Groups of male pups were categorized by the exposure of their mothers to: treadmill off (sedentary, SS), pregestational exercise (ES), gestational exercise (SE) or combined protocols (EE). Between postnatal day 20 (P20) and P23 the offspring received one daily 5-bromo-2'-deoxiuridine (BrdU) injection and, from P47 to P51, were evaluated by the Morris water maze task. At P53, hippocampal global DNA methylation, survival of progenitor cells (BrdU), Brain-derived Neurotrophic Factor (BDNF) and reelin levels were measured. The offspring from ES, SE and EE mothers demonstrated improved spatial learning compared to SS, but hippocampal DNA methylation was significantly modified only in the offspring from ES mothers. The offspring from ES and SE mothers presented higher number of BrdU+ and reelin+ hippocampal cells than EE and SS. No differences were observed in the BDNF levels among the groups. The maternal pregestational and gestational isolated exercise protocols showed similar effects for offspring plasticity and spatial cognitive ability, while the combined protocol simply improved their spatial learning. Interestingly, only pregestational exercise was able to induce plasticity in the offspring hippocampus associated with modulation of global DNA methylation.

Water-based exercises in pregnancy: Apparent weight in immersion and ground reaction force at third trimester

BACKGROUND

The morphological alterations during pregnancy may affect the biomechanical loads during exercise practice. Aquatic exercises may suit pregnant women, who are recommended to exercise with low vertical ground reaction force loads. Therefore, the study aimed to determine the apparent weight reduction during immersion and the vertical ground reaction force of three specific water-based exercises in pregnant women at the third trimester.

METHODS

Eleven pregnant women volunteered to take part in the study [32.0 (SD 1.3) weeks, 28.1 (SD 5.7) years, 72.5 (SD 10.1) kg]. The protocol started with the participants immersed to the xiphoid process depth for the apparent weight assessment. Then, three water-based exercises (stationary running, frontal kick and butt kick) were randomly performed at a pre-selected cadence, with 5-min interval. The vertical ground reaction force was measured in each exercise and peak, impulse, contact time and swing time were determined. Repeated measures ANOVA was used (α = 0.05).

FINDINGS

The apparent weight reduction resulted a mean of 82.9 (SD 6.5)% of body weight. Peak, impulse, contact time and swing time revealed no significant difference between exercises (P > 0.05). Values of peak of vertical ground reaction force ranged from 0.67 to 0.72 units of body weight.

INTERPRETATION

Pregnant women at the third trimester can benefit from the apparent weight reduction during immersion for exercising. The three water-based exercises presented similar vertical ground reaction force values, which are considered as low odds for musculoskeletal injuries. Therefore, these findings highlight the safety of the water-based exercise program during pregnancy.

Efficacy of Regular Exercise During Pregnancy on the Prevention of Postpartum Depression: The PAMELA Randomized Clinical Trial

IMPORTANCE

Interventions to reduce postpartum depression have mainly focused on enhancing screening to increase treatment rates among women. Preventive approaches are timely from a population health perspective, particularly in low- and middle-income countries where access to mental health services is limited.

OBJECTIVE

To assess the efficacy of regular exercise during pregnancy on the prevention of postpartum depression.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial examines a prespecified secondary outcome of the Physical Activity for Mothers Enrolled in Longitudinal Analysis (PAMELA) Study, a parallel-group, randomized clinical trial. This trial was nested in the 2015 Pelotas (Brazil) Birth Cohort Study. Between August 27, 2014, and March 14, 2016, pregnant women between 16 and 20 weeks of gestation with no contraindications to exercise were randomized 1:2 to the intervention group or control group via computer-generated randomization using a block size of 9. Data were analyzed from March 7 to May 2, 2018.

INTERVENTIONS

Participants assigned to the intervention were engaged in a 16-week supervised exercise program including aerobic and resistance training delivered in 60-minute sessions 3 times per week.

MAIN OUTCOMES AND MEASURES

Postpartum depressive symptoms were assessed with the Edinburgh Postnatal Depression Scale 3 months after birth. A score of 12 or greater was defined as screening positive for postpartum depression. Primary analysis was performed on a complete case basis (90% of participants who had the primary end point ascertained).

RESULTS

A total of 639 participants (mean [SD] age, 27.1 [5.1] years; mean gestational age, 16.5 [1.5] weeks) were randomly assigned to the intervention group (n = 213) or control group (n = 426). Compliance with the protocol, defined as having engaged in at least 70% of exercise sessions, was low (40.4%). There was no significant difference in mean (SD) scores for postpartum depression between the intervention group (4.8 [3.7]) and the control group (5.4 [4.1]) (mean difference, -0.6; 95% CI, -1.3 to 0.1). There was also no significant difference in rates of postpartum depression between the intervention group (12 of 192 [6.3%]) and the control group (36 of 387 [9.3%]) (odds ratio, 0.65; 95% CI, 0.33-1.28). Instrumental variable analysis indicated that noncompliance may have attenuated the effect estimates obtained in the primary analysis.

CONCLUSIONS AND RELEVANCE

Moderate-intensity exercise during pregnancy did not lead to significant reductions in postpartum depression. However, noncompliance to the intervention protocol was substantial and may have led to underestimations of the possible benefits of exercise. The point estimates for this study are in the same direction as the previous randomized clinical trial on this topic. Future studies on how to promote regular exercise during pregnancy to improve compliance, particularly targeting young and less educated women, are warranted before further trials are undertaken.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02148965.

Correlates of accelerometer-assessed physical activity in pregnancy-The 2015 Pelotas (Brazil) Birth Cohort Study

Objective methods to measure physical activity (PA) have become available and widely used given the high degree of precision to evaluate PA. However, few studies have used accelerometers to measure PA during pregnancy, especially in low‐ and middle‐income countries. We assessed overall PA, moderate, vigorous, and moderate‐to‐vigorous physical activity (MVPA) objectively measured among pregnant women and their correlates in a population‐based study. PA was assessed for seven consecutive days using a raw triaxial wrist‐worn accelerometer in women interviewed around 16 and 24 weeks of gestation in the 2015 Pelotas (Brazil) Birth Cohort Study. The average acceleration, which expresses overall PA, was presented in milli‐g (1 mg = 0.001 g), and average time (min/day) spent in MVPA (>100 mg) was also analyzed in 5‐ and 10‐min bouts. Analyses were performed using linear regression. In total, 2317 women were included in the analyses. Overall PA was 27.6 mg. Pregnant women spent on average 14 min/day in MVPA and 0.4 min in vigorous PA. Time spent in MVPA and total PA were inversely associated with years in school and income, and were lower among women receiving advice to not exercise. MVPA was also inversely associated with age, lower among women living with a partner, and higher among non‐white women. The study indicated low levels of PA among pregnant women. The identified correlates may provide a framework to better understand factors influencing PA during pregnancy and thus inform future interventions.

Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women

BACKGROUND

About one-third of women have urinary incontinence and up to one-tenth have faecal incontinence after childbirth. Pelvic floor muscle training (PFMT) is commonly recommended during pregnancy and after birth for both prevention and treatment of incontinence.This is an update of a review previously published in 2012.

OBJECTIVES

To determine the effectiveness of pelvic floor muscle training (PFMT) in the prevention or treatment of urinary and faecal incontinence in pregnant or postnatal women.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register (16 February 2017) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised trials in pregnant or postnatal women. One arm of the trial included PFMT. Another arm was no PFMT, usual antenatal or postnatal care, another control condition, or an alternative PFMT intervention.

DATA COLLECTION AND ANALYSIS

Review authors independently assessed trials for inclusion and risk of bias. We extracted data and checked them for accuracy. Populations included: women who were continent (PFMT for prevention), women who were incontinent (PFMT for treatment) at randomisation and a mixed population of women who were one or the other (PFMT for prevention or treatment). We assessed quality of evidence using the GRADE approach.

MAIN RESULTS

The review included 38 trials (17 of which were new for this update) involving 9892 women from 20 countries. Overall, trials were small to moderate sized, and the PFMT programmes and control conditions varied considerably and were often poorly described. Many trials were at moderate to high risk of bias. Other than two reports of pelvic floor pain, trials reported no harmful effects of PFMT.Prevention of urinary incontinence: compared with usual care, continent pregnant women performing antenatal PFMT may have had a lower risk of reporting urinary incontinence in late pregnancy (62% less; risk ratio (RR) for incontinence 0.38, 95% confidence interval (CI) 0.20 to 0.72; 6 trials, 624 women; low-quality evidence). Similarly, antenatal PFMT decreased the risk of urinary incontinence in the mid-postnatal period (more than three to six months' postpartum) (29% less; RR 0.71, 95% CI 0.54 to 0.95; 5 trials, 673 women; moderate-quality evidence). There was insufficient information available for the late (more than six to 12 months') postnatal period to determine effects at this time point.Treatment of urinary incontinence: it is uncertain whether antenatal PFMT in incontinent women decreases incontinence in late pregnancy compared to usual care (RR 0.70, 95% CI 0.44 to 1.13; 3 trials, 345 women; very low-quality evidence). This uncertainty extends into the mid- (RR 0.94, 95% CI 0.70 to 1.24; 1 trial, 187 women; very low-quality evidence) and late (RR 0.50, 95% CI 0.13 to 1.93; 2 trials, 869 women; very low-quality evidence) postnatal periods. In postnatal women with persistent urinary incontinence, it was unclear whether PFMT reduced urinary incontinence at more than six to 12 months' postpartum (RR 0.55, 95% CI 0.29 to 1.07; 3 trials; 696 women; very low-quality evidence).Mixed prevention and treatment approach to urinary incontinence: antenatal PFMT in women with or without urinary incontinence (mixed population) may decrease urinary incontinence risk in late pregnancy (26% less; RR 0.74, 95% CI 0.61 to 0.90; 9 trials, 3164 women; low-quality evidence) and the mid-postnatal period (RR 0.73, 95% CI 0.55 to 0.97; 5 trials, 1921 women; very low-quality evidence). It is uncertain if antenatal PFMT reduces urinary incontinence risk late postpartum (RR 0.85, 95% CI 0.63 to 1.14; 2 trials, 244 women; low-quality evidence). For PFMT begun after delivery, there was considerable uncertainty about the effect on urinary incontinence risk in the late postnatal period (RR 0.88, 95% CI 0.71 to 1.09; 3 trials, 826 women; very low-quality evidence).Faecal incontinence: six trials reported faecal incontinence outcomes. In postnatal women with persistent faecal incontinence, it was uncertain whether PFMT reduced incontinence in the late postnatal period compared to usual care (RR 0.68, 95% CI 0.24 to 1.94; 2 trials; 620 women; very low-quality evidence). In women with or without faecal incontinence (mixed population), antenatal PFMT led to little or no difference in the prevalence of faecal incontinence in late pregnancy (RR 0.61, 95% CI 0.30 to 1.25; 2 trials, 867 women; moderate-quality evidence). For postnatal PFMT in a mixed population, there was considerable uncertainty about the effect on faecal incontinence in the late postnatal period (RR 0.73, 95% CI 0.13 to 4.21; 1 trial, 107 women, very low-quality evidence).There was little evidence about effects on urinary or faecal incontinence beyond 12 months' postpartum. There were few incontinence-specific quality of life data and little consensus on how to measure it. We found no data on health economics outcomes.

AUTHORS' CONCLUSIONS

Targeting continent antenatal women early in pregnancy and offering a structured PFMT programme may prevent the onset of urinary incontinence in late pregnancy and postpartum. However, the cost-effectiveness of this is unknown. Population approaches (recruiting antenatal women regardless of continence status) may have a smaller effect on urinary incontinence, although the reasons for this are unclear. It is uncertain whether a population-based approach for delivering postnatal PFMT is effective in reducing urinary incontinence. Uncertainty surrounds the effects of PFMT as a treatment for urinary incontinence in antenatal and postnatal women, which contrasts with the more established effectiveness in mid-life women.It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches and in certain groups of women. Hypothetically, for instance, women with a high body mass index are at risk factor for urinary incontinence. Such uncertainties require further testing and data on duration of effect are also needed. The physiological and behavioural aspects of exercise programmes must be described for both PFMT and control groups and how much PFMT women in both groups do, to increase understanding of what works and for whom.Few data exist on faecal incontinence or costs and it is important that both are included in any future trials. It is essential that future trials use valid measures of incontinence-specific quality of life for both urinary and faecal incontinence.

A randomized controlled trial of exercise during pregnancy on maternal and neonatal outcomes: results from the PAMELA study

BACKGROUND

Women are encouraged to be physically active during pregnancy. Despite available evidence supporting antenatal physical activity to bring health benefits for both the mother and child, the most effective way to prevent some maternal and fetal outcomes is still unclear. The purpose of this study was to evaluate the efficacy of an exercise intervention to prevent negative maternal and newborn health outcomes.

METHODS

A randomized controlled trial (RCT) nested into the 2015 Pelotas (Brazil) Birth Cohort Study was carried-out with 639 healthy pregnant women, 213 in the intervention group (IG) and 426 in the control (CG) group. An exercise-based intervention was conducted three times/week for 16 weeks from 16-20 to 32-36 weeks' gestation. The main outcomes were preterm birth and pre-eclampsia. Gestational age was calculated based on several parameters, including routine ultrassounds and/or last menstrual period and categorized as < 37 weeks and ≥ 37 weeks for evaluation of preterm birth. Pre-eclampsia was self-reported. Secondary outcomes were gestational weight gain, gestational diabetes, birth weight, infant length, and head circumference. Analyses were performed by intention-to-treat (ITT) and per protocol (70% of the 48 planned exercise sessions). Odds ratio were derived using unconditional logistic regression.

RESULTS

The IG and CG did not differ at baseline regarding their mean age (27.2 years ± 5.3 vs. 27.1 years ± 5.7) and mean pre-pregnancy body mass index (25.1 ± 3.9 vs. 25.2 ± 4.1 kg/m2). The mean adherence to the exercise intervention was 27 ± 17.2 sessions (out of a potential 48) with 40.4% attending > = 70% of the recommended exercise sessions. A total of 594 participants (IG:198; CG: 396) were included in the ITT and 479 (IG: 83; CG: 396) were included in the per protocol analyses. There were no significant differences in the incidence of preterm birth and pre-eclampsia between groups in the ITT and per protocol analysis. There were also no differences between the two groups in mean gestational weight gain, gestational diabetes, birth weight, infant length, and head circumference.

CONCLUSIONS

While the RCT did not support the benefits of exercise performed during pregnancy on preeclampsia and preterm birth, the exercise program also did not present adverse impacts on newborn health. Our findings may contribute to promote intervention strategies that motivate health providers to encourage pregnant women to be more physically active.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02148965 , registered on 22 May 2014.

Measuring Adherence to a Nutrition and Exercise Lifestyle Intervention: Is Program Adherence Related to Excessive Gestational Weight Gain?

To identify adherence required to achieve target health outcome(s) in nutrition and/or exercise interventions, a measurement tool that tracks objective and self-reported measures of adherence is necessary. The purpose of this study was to design an adherence measurement tool and test it retrospectively on the Nutrition and Exercise Lifestyle Intervention Program (NELIP; Ruchat et al., Medicine and Science in Sports and Exercise, 44(8), 1419-1426, 2012; Mottola et al., Medicine and Science in Sports and Exercise, 42(2), 265-272, 2010), designed to prevent excessive gestational weight gain (EGWG). The tool was based on the goals of the NELIP and included a grading system for each behavior (exercise and nutrition). It was used to determine whether adherence scores could differentiate excessive versus acceptable weight gain during pregnancy across pre-pregnancy body mass index (BMI) categories. Results showed irrespective of pre-pregnancy BMI, women with acceptable weight gain had significantly higher adherence (p < 0.05) than women with excessive weight gain. It is recommended that this adherence tool be included in future prospective lifestyle intervention studies.

Changes in leisure-time physical activity among Brazilian pregnant women: comparison between two birth cohort studies (2004 - 2015)

BACKGROUND

Low levels of leisure-time physical activity (LTPA) during pregnancy have been shown in studies conducted worldwide. Surveillance is extremely important to monitor the progress of physical activity patterns over time and set goals for effective interventions to decrease inactivity among pregnant women. The aim of this study was to evaluate time changes in LTPA among Brazilian pregnant women in an 11-year period (2004-2015) by comparing data from two birth cohort studies.

METHODS

Two population-based birth cohort studies were carried out in the city of Pelotas, southern Brazil, in 2004 and 2015. A total of 4244 and 4271 mothers were interviewed after delivery. Weekly frequency and duration of each session of LTPA in a typical week were reported for the pre-pregnancy period and for each trimester of pregnancy. Trends in both recommended LTPA (≥150 min/week) and any LTPA (regardless of weekly amount) were analysed overtime. Changes were also calculated separately for subgroups of maternal age, schooling, family income, parity, pre-pregnancy body mass index and pre-pregnancy LTPA.

RESULTS

The proportion of women engaged in recommended levels of LTPA pre-pregnancy increased from 11.2% (95%CI 10.0-12.2) in 2004 to 15.8% (95%CI 14.6-16.9) in 2015. During pregnancy, no changes were observed over the period for the first (10.6 to 10.9%) and second (8.7 to 7.9%) trimesters, whereas there was a decrease from 3.4% (95%CI 2.9-4.0) to 2.4% (95%CI 1.9-2.8) in the last trimester. Major decreases in LTPA in the last trimester were observed among women who were younger, with intermediate to high income, high schooling, primiparous, pre-pregnancy obese and, engaged in LTPA before pregnancy. Changes in any LTPA practice followed the same patterns described for recommended LTPA.

CONCLUSIONS

Despite the increase in the proportion of women engaged in LTPA before pregnancy between 2004 and 2005, LTPA levels remained stable during the first and second trimesters of pregnancy and declined during the third gestational trimester over the period. Interventions to encourage the maintenance of LTPA practice throughout pregnancy are urgently needed.

Infant sleep hygiene counseling (sleep trial): protocol of a randomized controlled trial

BACKGROUND

Sleep problems in childhood have been found to be associated with memory and learning impairments, irritability, difficulties in mood modulation, attention and behavioral problems, hyperactivity and impulsivity. Short sleep duration has been found to be associated with overweight and obesity in childhood. This paper describes the protocol of a behavioral intervention planned to promote healthier sleep in infants.

METHODS

The study is a 1:1 parallel group single-blinded randomized controlled trial enrolling a total of 552 infants at 3 months of age. The main eligibility criterion is maternal report of the infant's sleep lasting on average less than 15 h per 24 h (daytime and nighttime sleep). Following block randomization, trained fieldworkers conduct home visits of the intervention group mothers and provide standardized advice on general practices that promote infant's self-regulated sleep. A booklet with the intervention content to aid the mother in implementing the intervention was developed and is given to the mothers in the intervention arm. In the two days following the home visit the intervention mothers receive daily telephone calls for intervention reinforcement and at day 3 the fieldworkers conduct a reinforcement visit to support mothers' compliance with the intervention. The main outcome assessed is the between group difference in average nighttime self-regulated sleep duration (the maximum amount of time the child stays asleep or awake without awakening the parents), at ages 6, 12 and 24 months, evaluated by means of actigraphy, activity diary records and questionnaires. The secondary outcomes are conditional linear growth between age 3-12 and 12-24 months and neurocognitive development at ages 12 and 24 months.

DISCUSSION

The negative impact of inadequate and insufficient sleep on children's physical and mental health are unquestionable, as well as its impact on cognitive function, academic performance and behavior, all of these being factors to which children in low- and middle-income countries are at higher risk. Behavioral interventions targeting mothers and young children that can be delivered inexpensively and not requiring specialized training can help prevent future issues by reducing the risk to which these children are exposed.

TRIAL REGISTRATION

ClinicalTrial.gov NCT02788630 registered on 14 June 2016 (retrospectively registered).