Physical activity during pregnancy and maternal-child health outcomes: a systematic literature review

Impact of maternal posture on fetal physiology in human pregnancy: a narrative review

In numerous medical conditions, including pregnancy, gravity and posture interact to impact physiology and pathophysiology. Recent investigations, for example, pertaining to maternal sleeping posture during the third trimester and possible impact on fetal growth and stillbirth risk highlight the importance and potential clinical implications of the subject. In this review, we provide an extensive discussion of the impact of maternal posture on fetal physiology from conception to the postpartum period in human pregnancy. We conducted a systematic literature search of the MEDLINE database and identified 242 studies from 1991 through 2021, inclusive, that met our inclusion criteria. Herein, we provide a synthesis of the resulting literature. In the first section of the review, we group the results by the impact of maternal posture at rest on the cervix, uterus, placenta, umbilical cord, amniotic fluid, and fetus. In the second section of the review, we address the impact on fetal-related outcomes of maternal posture during various maternal activities (e.g., sleep, work, exercise), medical procedures (e.g., fertility, imaging, surgery), and labor and birth. We present the published literature, highlight gaps and discrepancies, and suggest future research opportunities and clinical practice changes. In sum, we anticipate that this review will shed light on the impact of maternal posture on fetal physiology in a manner that lends utility to researchers and clinicians who are working to improve maternal, fetal, and child health.

Replacement of watching television with physical activity and the change in gestational diabetes mellitus risk: A case-control study

OBJECTIVE

To evaluate the effect of replacing 1 h/week of watching television with 1 h/week of light to moderate (LMPA) or vigorous physical activity (VPA) before and during pregnancy on the risk of gestational diabetes mellitus (GDM).

METHODS

A case-control study was conducted in pregnant women. Physical activity and television watching before and during pregnancy were assessed using the Paffenbarger Physical Activity Questionnaire. Each type of activity was classified according to intensity (metabolic equivalent of task; MET): less than 6 METs is LMPA, 6 METs or more is VPA. The duration of physical activity and watching television was calculated, and logistic regression models were used to estimate adjusted odds ratios (aOR) and 95% confidence intervals for their association with GDM risk. The isotemporal substitution model was used to calculate the effect of replacing 1 h/week of watching television with the same duration of physical activity.

RESULTS

The GDM cases (n = 290) spent less time performing VPA than controls without GDM (n = 1175) and more time watching television during pregnancy (P < 0.05). During pregnancy, the risk of GDM increased for each hour of watching television (aOR = 1.02; 95% confidence interval 1.00-1.03). Women who spent more time watching television during pregnancy were likely to develop GDM (aOR>14 h/week vs. 0-6 h/week  = 2.03; 95% confidence interval 1.35-3.08). Replacing 1 h/week of watching television with 1 h/week of VPA during pregnancy could decrease the chance of developing GDM (aOR = 0.66; 95% confidence interval 0.43-1.00).

CONCLUSIONS

A simple change of 1 h/week of watching television for 1 h/week of VPA in pregnant women may reduce the risk of GDM considerably.

Why are pregnant women physically inactive? A qualitative study on the beliefs and perceptions about physical activity during pregnancy

This study aimed to describe the beliefs and perceptions of pregnant women and healthcare providers about physical activity during pregnancy. Using a qualitative approach, 30 pregnant women and the 14 healthcare providers caring for them were interviewed in the second trimester of pregnancy. We included women who maintained, decreased, or stopped physical activity since becoming pregnant. They were divided into low (≤ 8 years) and high schooling (> 8 years). Semi-structured, in-depth interviews were conducted and guided by three key questions: (1) When does physical activity during pregnancy start to be considered a wrong behavior?; (2) What are the main barriers (biological or others) to physical activity?; and (3) Do the actions of healthcare providers and people close to pregnant women reinforce barriers? Interviews were audio recorded, transcribed, and analyzed based on recurring themes. All women changed their physical activity behavior (decreased or stopped) when they discovered their pregnancy. Fear of miscarriage, contractions, bleeding, and of causing malformations in the baby were the most reported reasons for decreasing or stopping physical activity. Participants also lacked access to consistent information and healthcare providers' support on the benefits of physical activity. Despite the current international recommendations to regular physical activity during pregnancy, uncertainty regarding its benefits remains. Interventions to promote physical activity during this period should include the training of healthcare providers so they can advise and discard ideas contrary to mother-child health benefits.

A narrative review of exercise dose during pregnancy

The current recommendations for prenatal exercise dose align with those from the American College of Sports Medicine; 150 min of moderate intensity every week of pregnancy. However, recent works suggest there may be a dose-dependent beneficial effect for mother and offspring; maternal and offspring health outcomes respond differently to low, medium, and high doses of prenatal exercise. It is, therefore, our aim to summarize the published evidence (years 1950-2023) for five metrics of prenatal exercise training commonly reported, that is, "FITT-V": Frequency (number of sessions), Intensity (metabolic equivalents "METs"), Time (duration of sessions), Type (exercise mode), Volume (exercise MET*mins). The target audience includes clinicians and health care professionals, as well as exercise professionals and physiologists. Data suggest that moderate exercise frequency (3-4 times weekly) appears safe and efficacious for mother and offspring, while there is contradictory evidence for the safety and further benefit of increased frequency beyond 5 sessions per week. Moderate (3-6 METs) and vigorous (>6 METs) intensity prenatal exercise have been shown to promote maternal and offspring health, while little research has been performed on low-intensity (<3 METs) exercise. Exercise sessions lasting less than 1 hr are safe for mother and fetus, while longer-duration exercise should be carefully considered and monitored. Taken together, aerobic, resistance, or a combination of exercise types is well tolerated at medium-to-high volumes and offers a variety of type-specific benefits. Still, research is needed to define (1) the "minimum" effective dose of exercise for mother and offspring health, as well as (2) the maximum tolerable dose from which more benefits may be seen. Additionally, there is a lack of randomized controlled trials addressing exercise doses during the three trimesters of pregnancy. Further, the protocols adopted in research studies should be more standardized and tested for efficacy in different populations of gravid women.

Physical Activity as a Modern Intervention in the Fight against Obesity-Related Inflammation in Type 2 Diabetes Mellitus and Gestational Diabetes

Diabetes is one of the greatest healthcare problems; it requires an appropriate approach to the patient, especially when it concerns pregnant women. Gestational diabetes mellitus (GDM) is a common metabolic condition in pregnancy that shares many features with type 2 diabetes mellitus (T2DM). T2DM and GDM induce oxidative stress, which activates cellular stress signalling. In addition, the risk of diabetes during pregnancy can lead to various complications for the mother and foetus. It has been shown that physical activity is an important tool to not only treat the negative effects of diabetes but also to prevent its progression or even reverse the changes already made by limiting the inflammatory process. Physical activity has a huge impact on the immune status of an individual. Various studies have shown that regular training sessions cause changes in circulating immune cell levels, cytokine activation, production and secretion and changes in microRNA, all of which have a positive effect on the well-being of the diabetic patient, mother and foetus.

Prevalence and Factors Associated with Cardiovascular Lifestyle Risk Factors among Pregnant Women in Burkina Faso: Evidence from a Cross-Sectional Study

Data on lifestyle risk factors for cardiovascular diseases, such as smoking, alcohol consumption, inadequate physical activity, and insufficient consumption of fruits and vegetables, in pregnant women in Africa, are scarce. This study aimed to estimate the prevalence of cardiovascular lifestyle risk factors among pregnant women in Burkina Faso and identify their associated factors. Pregnant women who attended antenatal care services between December 2018 and March 2019 were included in this study. A modified Poisson regression model was used to estimate adjusted prevalence ratios (aPR) with a 95% confidence interval. A total of 1027 pregnant women participated in this study. The prevalence of alcohol consumption, tobacco use, inadequate physical activity, and insufficient consumption of fruits and vegetables were 10.2% [8.5-12.2], 3.0% [2.1-4.3], 79.4% [76.9-81.8], and 53.5% [50.5-56.6], respectively. The prevalence of more than one cardiovascular lifestyle risk factor in pregnant women was 50.9% [48.0-54.0]. The predictors significantly associated with more than one cardiovascular lifestyle risk factor were women over 30 years old aPR 1.26; 95% CI [1.03-1.53]), women living in fourth wealth index households (aPR 1.23; 95% CI [1.06-1.42]), in semi-urban areas (aPR 5.46; 95% CI [4.34-6.88]), and women with no occupation (aPR 1.31; 95% CI [1.18-1.44]). The prevalence of more than one cardiovascular lifestyle risk factor was high during pregnancy in Burkina Faso. Women of childbearing age should be advised on how healthy behaviors can lead to improved pregnancy outcomes.

Physical exercise in pregnancy: benefits, risks and prescription

OBJECTIVES

The aim of this article is to provide a comprehensive literature review, gathering the strongest evidence about the risks and benefits and the prescription of physical exercise during pregnancy.

CONTENT

Regular physical exercise during pregnancy is associated with numerous benefits. In general women are not adequately advised on this matter. Along with their concerns regarding the potential associated risks, it contributes to the abandonment or refusal to start exercising during pregnancy. A systematic review was conducted in MEDLINE including articles considered to have the highest level of scientific evidence. Fifty-seven articles, including 32 meta-analysis, 9 systematic reviews and 16 randomized controlled trials were included in the final literature review.

SUMMARY

Exercise can help preventing relevant pregnancy related disorders, such as gestational diabetes, excessive gestational weight gain, hypertensive disorders, urinary incontinence, fetal macrosomia, lumbopelvic pain, anxiety and prenatal depression. Exercise is not related with an increased risk of maternal or perinatal adverse outcomes. Compliance with current guidelines is sufficient to achieve the main benefits, and exercise type and intensity should be based on woman's previous fitness level.

OUTLOOK

Exercise in pregnancy is safe for both mother and fetus, contributing to prevent pregnancy related disorders. Exercise type and intensity should be adapted to woman's previous fitness level, medical history and characteristics of the ongoing pregnancy.

Baby Steps: Using Intervention Mapping to Develop a Sustainable Perinatal Physical Activity Healthcare Intervention

While the benefits of physical activity (PA) during and after pregnancy have been established, many women do not reach the recommended PA levels during this time. A major barrier found in the literature is a lack of counselling by healthcare providers (HCPs), which is partly caused by the limited knowledge on the topic. The aim of this study was to develop an intervention to improve the promotion of PA by HCPs. We used Intervention Mapping (IM), a theory-based framework to develop an intervention, called "Baby steps", in a high-income (Austria) and a low-to-middle-income country (South Africa). We applied the following IM steps: (1) A needs assessment to determine the barriers and enablers of PA promotion by HCPs, including a scoping literature review and community needs assessments (qualitative interviews, questionnaires, and focus groups with midwives, obstetricians, and community health workers) to determine the desired outcomes of the intervention. (2) Performance and change objectives were formulated, describing the behaviors that need to change for the intervention to succeed. (3) Based on these objectives, theory-based behavior change techniques were selected, and practical applications were developed. (4) The applications were combined into two evidence-based interventions tailored to each country's needs. Step (5) and (6) consist of an implementation and evaluation plan, respectively. The intervention is aimed at HCPs, such as midwives and community health workers, consisting of a two-day training course, including practical resources. Combining didactic and interactive education, it addresses both PA knowledge and the skills needed to transfer knowledge and facilitate behavior change. In the future, the intervention's effect on women's activity levels during and after pregnancy needs to be studied.

Influence of gestational exercise practice and litter size reduction on maternal care

Mother-pup interactions are extremely important to offspring survival and growth. The goal of this study was to evaluate the influence of prenatal and neonatal interventions on maternal care, analyzing the effect of maternal exercise, as a healthy intervention, and also the litter size reduction, a model that has been widely used to study early overfeeding in rats. Female Wistar rats were divided into 1) sedentary, and 2) swimming exercise for four weeks, starting one week before mating (5 days/week, 30 min/session). One day after birth, the litter was culled to 8 pups (normal) or 3 pups (small) per dam, yielding control and overfed subgroups for each maternal group, respectively. From postnatal days 2-9 the litter was observed 5 periods a day, to evaluate maternal behavior. Litter reduction caused important alterations in maternal behavior, reducing the total time out of the nest and increasing the frequency of maternal care and lactation in several observation periods, justifying the increased pup's weight gain already demonstrated by this animal model. The practice of maternal exercise did not prevent, but cause the less intensive frequency of non-maternal behavior and lactation in arched-back position, induced by the reduction of litter size. These data demonstrated that small litter size altered maternal behavior, and gestational exercise does not influence significantly these changes.

Testing the Multiple Pathways of Residential Greenness to Pregnancy Outcomes Model in a Sample of Pregnant Women in the Metropolitan Area of Donostia-San Sebastián

Residential greenness may positively impact diverse human health indicators through the reduction of air pollution, the improvement of psychological health, and the promotion of physical activity. Previous studies indicate a weak but positive association with pregnancy outcomes. Our aim was to test the multiple pathways from residential greenness to pregnancy outcomes model, using residential NO₂ concentrations, psychological health, and moderate-to-vigorous physical activity (MVPA) during the first trimester of pregnancy, in a sample of 440 pregnant women residing in Donostia, Spain. Three metrics of residential greenness were calculated around each participant’s home address: normalized difference vegetation index (NDVI) within 300 m, and green space (>5000 m²) availability within 300 and 500 m. Residential NO₂ concentrations, psychological health, and MVPA were explored as mediators of the associations between these metrics and the following pregnancy outcomes: birth weight (BW), low birth weight (LBW), prematurity, small for gestational age (SGA), and large for gestational age (LGA). Educational attainment, parity, and body mass index (BMI) were treated as covariates. Counterfactual mediation analyses showed very low to null statistical support for an association between any of the greenspace metrics and pregnancy outcomes in the full sample. Green space availability (300 m) was associated with lower BW and showed a marginal protective effect against LGA.

Effects of High-Fat Diet and Exercise Intervention on the Metabolism Regulation of Infant Mice

Maternal exercise is crucial for promoting the health of the offspring. Previous studies showed that long-term maternal exercise improves energy metabolism during pregnancy. Whether swimming exercise can reverse the metabolic disorders caused by high-fat exposure in the early life of the offspring is yet to be elucidated. Three-week-old C57BL/6 female mice were randomly assigned to the standard chow diet group (SC), standard chow diet and exercise group (SC-Ex), high-fat diet group (HFD), and high-fat diet and exercise group (HFD-Ex). After swimming intervention for 13 weeks, male and female mice were caged, and the exercise intervention lasted until delivery. Then, the mothers were fed standard chow diet. A total of 8 offsprings/group were randomly selected after 4 weeks of lactation for GTT and ITT. After body composition analysis, the mice were sacrificed to obtain specimens. The levels of metabolism factors and IL-6 were measured by suspension microarray. Subsequently, 15 min after starting the GTT and ITT, the curve detected significant difference between the HFD and other groups. The body fat percentage of the HFD-Ex offspring was significantly lower than that of HFD offspring (p < 0.05) irrespective of the gender. The levels of IL-6 and TG in the male offspring in the HFD-Ex group were improved significantly (p < 0.05). Compared to the HFD offspring, serum glucose and GIP in the female offspring in the HFD-Ex group was significantly reduced (p < 0.05). Long-term exercise of the mother effectively improved the metabolic disorder caused by high-fat exposure in the infant offspring. Thus, the metabolic inheritance of the offspring is gender-dependent; the maternal metabolism can make male offspring genetically susceptible.

Impact of physical activity and traumatic exposure on occurrence of gestational hypertension: a survey of pregnant women in an armed-conflict region in Nigeria

OBJECTIVE

To compare physical activity level and traumatic exposure between normotensive and hypertensive pregnant women in an armed conflict region of Nigeria.

METHODS

130 normotensives and hypertensive pregnant women comprising of 65 participants per group participated in the study. Harvard Trauma Questionnaire and Pregnancy Physical Activity Questionnaire were used to assess traumatic events and physical activity respectively.

RESULTS

Significant difference was observed on total traumatic event (p = 0.008) and all domains and intensities of physical activity except inactivity and sedentary (p > 0.05). Household activities (OR: 0.989; 95% CI: 0.981-0.996), occupational activities (OR: 0.936; 95%CI: 0.879-0.996) and sport/exercise activities (OR: 0.898; 95%CI: 0.832-0.969) were associated with a decrease hypertensive pregnancy.

CONCLUSION

Despite exposed to traumatic events, physical activity is associated with normotensive pregnancy in an armed conflict region.

What Accounts for Physical Activity during Pregnancy? A Study on the Sociodemographic Predictors of Self-Reported and Objectively Assessed Physical Activity during the 1st and 2nd Trimesters of Pregnancy

Physical activity (PA) during pregnancy has positive health implications for both mother and child. However, current literature indicates that not all pregnant women meet the international recommendations for PA (at least 150 min/week of moderate-to-vigorous PA). The main objective of this study was to assess PA levels among pregnant women in the city of Donostia-San Sebastian and identify their main sociodemographic predictors. We recruited 441 women in the 12th week of pregnancy from the local public obstetric health services. Women wore an accelerometer for one week during two separate time points (1st and 2nd trimesters of pregnancy) and completed a questionnaire assessing several sociodemographic variables as well as self-reported PA. With this information, we estimated women’s overall PA levels during both time points. The fulfillment of PA recommendations raised up to 77% and 85% during the first and second trimesters, respectively. We found that a higher number of children and a greater preference for exercise positively predicted light-to-moderate PA, being the most consistent predictors. The availability of a greater number of cars negatively predicted moderate-to-vigorous PA.

Protective Effect of Exercise in Pregnant Women Including Those Who Exceed Weight Gain Recommendations: A Randomized Controlled Trial

OBJECTIVE

To investigate the effect of supervised moderate to vigorous exercise on gestational weight gain, its related risks (gestational diabetes [GD]), macrosomia, and type of delivery), and the preventive effects on women who exceed the weight gain recommendations.

PATIENTS AND METHODS

We conducted a single-center, 2-armed, randomized controlled trial between October 1, 2009, and June 30, 2011, in which 678 women were assessed and 345 were randomized by a central computer system to an intervention group (N=115) or a standard care group (N=230). The intervention exercise program consisted of 70 to 78 sessions (24 weeks, 3 times per week, 60-65 minutes per session, moderate to vigorous intensity). The standard care group received usual care. Excessive gestational weight (EGW) gain was calculated on the basis of the 2009 Institute of Medicine (IOM) recommendations.

RESULTS

Of the 345 women randomized for treatment, 44 were lost to follow-up, leaving 301 women for analysis (intervention, 100; standard care, 201). Fewer women in the intervention group exceeded IOM recommendations (22 [22.0%] vs 69 [34.3%]; P=.03), including overweight and obese women (15 of 35 [42.9%] vs 40 of 50 [80.0%]; P=.001). Analysis of women exceeding weight recommendations revealed that the 3 main related risks were directly related to EGW gain in the standard care group (GD, P=.003; macrosomia, P<.001; type of delivery, P<.001) but not in the intervention group (GD, P>.99; macrosomia, 0%; type of delivery, P=.46).

CONCLUSION

Supervised moderate to vigorous exercise performed throughout gestation was effective in the prevention of EGW gain even for women with a pregestational body mass index greater than 25 kg/m². It also prevented its related risks (GD, macrosomia, and type of delivery) including for women exceeding the IOM recommendations, so we suggest that being active outweighs the effect of possible weight gain.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01477372.

Assessment of physical activity status among pregnant women in southwestern China

Objective

To assess the patterns and intensities of physical activity among pregnant women in southwestern China, which help us create a fitness regimen based on the 2002 American College of Obstetricians and Gynecologists (ACOG) guidelines for exercise during pregnancy.

Methods

A cross-sectional study was performed to recruit pregnant women at a prenatal checking visit clinic with the self-administered Chinese version of Pregnancy Physical Activity Questionnaire (PPAQ).

Results

A total of 1179 Chinese pregnant women were enrolled, of whom 92.60% were classified as not meeting the ACOG guidelines. By intensity, 47.36% of the score was attributed to light-intensity activities (1.5 to <3.0 metabolic equivalent [MET]) in the first trimester; the other 2 trimesters were similar. By patterns, about 45.15% of the score was attributed to inactivity. More than 82.35% of enrolled pregnant women regarded slowly walking as the most common type of exercise during pregnancy.

Conclusions

This study represents a group of Chinese women who maintained an inactive lifestyle, including low-intensity activities and unitary type of exercises during their pregnancy. Health-care providers are advised to provide appropriate physical activity guidelines to pregnant women. Development of MET-hours/week recommendations is warranted to promote greater physical activity during pregnancy.

Associations between maternal physical activity in early and late pregnancy and offspring birth size: remote federated individual level meta-analysis from eight cohort studies

OBJECTIVE

Evidence on the impact of leisure time physical activity (LTPA) in pregnancy on birth size is inconsistent. We aimed to examine the association between LTPA during early and late pregnancy and newborn anthropometric outcomes.

DESIGN

Individual level meta-analysis, which reduces heterogeneity across studies.

SETTING

A consortium of eight population-based studies (seven European and one US) comprising 72 694 participants.

METHODS

Generalised linear models with consistent inclusion of confounders (gestational age, sex, parity, maternal age, education, ethnicity, BMI, smoking, and alcohol intake) were used to test associations between self-reported LTPA at either early (8-18 weeks gestation) or late pregnancy (30+ weeks) and the outcomes. Results were pooled using random effects meta-analyses.

MAIN OUTCOME MEASURES

Birth weight, large-for-gestational age (LGA), macrosomia, small-for-gestational age (SGA), % body fat, and ponderal index at birth.

RESULTS

Late, but not early, gestation maternal moderate to vigorous physical activity (MVPA), vigorous activity, and LTPA energy expenditure were modestly inversely associated with BW, LGA, macrosomia, and ponderal index, without heterogeneity (all: I2  = 0%). For each extra hour/week of MVPA, RR for LGA and macrosomia were 0.97 (95% CI: 0.96, 0.98) and 0.96 (95% CI: 0.94, 0.98), respectively. Associations were only modestly reduced after additional adjustments for maternal BMI and gestational diabetes. No measure of LTPA was associated with risk for SGA.

CONCLUSIONS

Physical activity in late, but not early, pregnancy is consistently associated with modestly lower risk of LGA and macrosomia, but not SGA.

TWEETABLE ABSTRACT

In an individual participant meta-analysis, late pregnancy moderate to vigorous physical activity modestly reduced birth size outcomes.

The Influence of Objectively Measured Physical Activity During Pregnancy on Maternal and Birth Outcomes in Urban Black South African Women

Objectives Research indicates the beneficial effects of physical activity during pregnancy on maternal health, although controversy still exists regarding its influence on birth outcomes. Little research has been done to objectively measure physical activity during pregnancy in black African women from low-to-middle income countries. The purpose of this study was to examine the association between physical activity and maternal and birth outcomes in this unique population. Methods This observational, longitudinal study assessed total physical activity using a hip-mounted triaxial accelerometer at 14–18 weeks (second trimester, n = 120) and 29–33 weeks (third trimester, n = 90) gestation. Physical activity is expressed as gravity-based acceleration units (mg). Maternal outcomes included both weight and weight gain at 29–33 weeks gestation. Birth outcomes included gestational age, birth weight, ponderal index and Apgar score, measured within 48 h of delivery. Results There was a significant decline in physical activity from the second to the third trimester (12.8 ± 4.1 mg vs. 9.7 ± 3.6 mg, p ≤ 0.01). Physical activity at 29–33 weeks as well as a change in PA was inversely associated with weight change at 29–33 weeks (β = − 0.24; 95% CI − 0.49; − 0.00; p = 0.05 and β = − 0.36; 95% CI − 0.62; − 0.10; p = 0.01, respectively). No significant associations were found between physical activity and birth outcomes. Conclusions for Practice Physical activity during pregnancy may be an effective method to control gestational weight gain, whilst presenting no adverse risk for fetal development, in women from a low-income urban setting.

Prevalence of behavioral risk factors of cardiovascular diseases and associated socio-economic factors among pregnant women in a rural area in Southern Nepal

BACKGROUND

Cardiovascular diseases (CVDs) have dramatically infiltrated populations living in abject poverty in Low- and Middle-income Countries (LMICs), and poor maternal and child health outcomes have been frequently reported for those with CVD risk factors. However, few studies have explored the behavioral risk factors of CVDs among pregnant women in rural settings. This study aimed at determining the prevalence and identifying the socio-economic predictors of behavioral risk factors of CVDs among pregnant women in rural area in Southern Nepal.

METHODS

A Community-based cross-sectional study was conducted in 52 clusters of Dhanusha District of Nepal in a total of 426 pregnant women in their second trimester using multistage cluster sampling method. Multivariable logistic regression model was used to assess independent associations between behavioral risk factors during pregnancy and maternal socio-economic characteristics.

RESULTS

Of the 426 study participants, 86.9, 53.9, 21.3 and 13.3%, respectively, reported insufficient fruits and vegetables consumption, insufficient physical activity, tobacco use, and harmful alcohol drinking. Socio-economic factors significantly associated with more than one behavioral risk factors in expectant mothers with a primary level education (adjusted odds ratio (AOR) 2.78; 95% Confidence Interval (CI) (1.35-5.72)), 20-34 years age group (Adjusted Odds Ratio (AOR) 0.27; 95% CI (0.13-0.56)), and those with the highest wealth index (AOR 0.36; 95% CI (0.16-0.84)).

CONCLUSION

Higher prevalence of behavioral risk factors for CVDs and their socio-economic factors prevailing among pregnant women living in rural Nepal call for immediate health promotion interventions such as community awareness and appropriate antenatal counseling.

Constructing and applying an exercise counseling model for pregnant women: A preliminary study

Pregnant women tend to exercise less than women who have not yet been pregnant. In the present study, which involves two studies, we aimed to construct an effective, individualized exercise counseling model for pregnant women. In study 1, a three-round session that involved 10 multidisciplinary health care experts reached a consensus via the Delphi method. In the preliminary study, two healthy pregnant women were recruited from the prenatal outpatient departments of hospitals in Taipei, Taiwan. Both of them were 32 years old and primipara. The results of study 1, the established five stages of the individualized exercise counseling model for pregnant women were as follows: assessment, defining barriers that interfere with achieving the target, planning, implementation and monitoring, and evaluation. In the preliminary study, we applied this counseling model of study 1 to 2 healthy pregnant women. The 5-stage counseling model can encourage pregnant women to begin to exercise or to continue exercising. We believe that this exercise counseling model can potentially be used by nurses. It can help them to encourage pregnant women to regularly exercise, and to promote exercise as part of a healthy lifestyle.

Examination of the association of physical activity during pregnancy after cesarean delivery and vaginal birth among Chinese women

Background

The goal was to study whether higher physical activity can increase the success rate of Vaginal Birth after Cesarean Delivery (VBAC).

Methods

We enrolled 823 patients with previous cesarean section delivery history (between January 2015 and December 2017) and measured their physical activity during pregnancy. A final number of 519 patients were included for the trial of labor after cesarean delivery (TOLAC). All patients signed informed consent forms.

Results

We conducted bivariate analyses and identified that several variables were associated with successful VBAC: Prior history of vaginal birth (odds ratio [OR] 2.4, 95% CI 1.8–3.9); previous indication for primary cesarean delivery (OR 2.2, 95% CI 1.5–3.0); age younger than 40 years (OR 2.1, 95% CI 1.3–3.4); Weight gain less than 20 kg (OR 1.5, 95% CI 1.3–2.4); high pelvic/birth weight score (OR 1.4, 95% CI 1.1–2.0); no induction of labor (OR 1.9, 95% CI 1.4–2.8); and estimated prenatal fetal weight (OR 1.4, 95% CI 1.2–1.5). We also found that the bivariate association between physical activity and VBAC was significant (p = 0.002). In addition, there was higher odds of VBAC in women who had active physical activity of more than 150 min/week (adjusted OR 1.86, 95% CI 1.69–2.07). Lower odds of VBAC was associated with older age, weight gain during pregnancy, induction of labor, and having estimated prenatal fetal weight more than 3500 g.

Conclusion

Physical activity during pregnancy may influence the success rate of VBAC in Chinese women. Future studies will be needed to prove the robustness of this association using more detailed exposure and outcome definitions.

ESHRE guideline: recurrent pregnancy loss

STUDY QUESTION

What is the recommended management of women with recurrent pregnancy loss (RPL) based on the best available evidence in the literature?

SUMMARY ANSWER

The guideline development group formulated 77 recommendations answering 18 key questions on investigations and treatments for RPL, and on how care should be organized.

WHAT IS KNOWN ALREADY

A previous guideline for the investigation and medical treatment of recurrent miscarriage was published in 2006 and is in need of an update.

STUDY DESIGN, SIZE, DURATION

The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 31 March 2017 and written in English were included. Cumulative live birth rate, live birth rate and pregnancy loss rate (or miscarriage rate) were considered the critical outcomes.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. A stakeholder review was organized after finalization of the draft. The final version was approved by the guideline group and the ESHRE Executive Committee.

MAIN RESULTS AND THE ROLE OF CHANCE

The guideline provides 38 recommendations on risk factors, prevention and investigations in couples with RPL, and 39 recommendations on treatments. These include 60 evidence-based recommendations – of which 31 were formulated as strong recommendations and 29 as conditional – and 17 good practice points. The evidence supporting investigations and treatment of couples with RPL is limited and of moderate quality. Of the evidence-based recommendations, only 10 (16.3%) were supported by moderate quality evidence. The remaining recommendations were supported by low (35 recommendations: 57.4%), or very low quality evidence (16 recommendations: 26.2%). There were no recommendations based on high quality evidence. Owing to the lack of evidence-based investigations and treatments in RPL care, the guideline also clearly mentions investigations and treatments that should not be used for couples with RPL.

LIMITATIONS, REASONS FOR CAUTION

Several investigations and treatments are offered to couples with RPL, but most of them are not well studied. For most of these investigations and treatments, a recommendation against the intervention or treatment was formulated based on insufficient evidence. Future studies may require these recommendations to be revised.

WIDER IMPLICATIONS OF THE FINDINGS

The guideline provides clinicians with clear advice on best practice in RPL, based on the best evidence available. In addition, a list of research recommendations is provided to stimulate further studies in RPL. One of the most important consequences of the limited evidence is the absence of evidence for a definition of RPL.

STUDY FUNDING/COMPETING INTEREST(S)

The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payment. J.E. reports position funding from CARE Fertility. S.L. reports position funding from SpermComet Ltd. S.M. reports research grants, consulting and speaker’s fees from GSK, BMS/Pfizer, Sanquin, Aspen, Bayer and Daiichi Sankyo. S.Q. reports speaker’s fees from Ferring. The other authors report no conflicts of interest.

ESHRE Pages are not externally peer reviewed. This article has been approved by the Executive Committee of ESHRE.

Combined diet and exercise interventions for preventing gestational diabetes mellitus

BACKGROUND

Gestational diabetes mellitus (GDM) is associated with a wide range of adverse health consequences for women and their infants in the short and long term. With an increasing prevalence of GDM worldwide, there is an urgent need to assess strategies for GDM prevention, such as combined diet and exercise interventions. This is an update of a Cochrane review that was first published in 2015.

OBJECTIVES

To assess the effects of diet interventions in combination with exercise interventions for pregnant women for preventing GDM, and associated adverse health consequences for the mother and her infant/child.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (27 November 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs, comparing combined diet and exercise interventions with no intervention (i.e. standard care), that reported on GDM diagnosis as an outcome. Quasi-RCTs were excluded. Cross-over trials were not eligible for inclusion. We planned to include RCTs comparing two or more different diet/exercise interventions, however none were identified.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data, assessed the risk of bias of the included trials and assessed quality of evidence for selected maternal and infant/child outcomes using the GRADE approach. We checked data for accuracy.

MAIN RESULTS

In this update, we included 23 RCTs (involving 8918 women and 8709 infants) that compared combined diet and exercise interventions with no intervention (standard care). The studies varied in the diet and exercise programs evaluated and health outcomes reported. None reported receiving funding from a drug manufacturer or agency with interests in the results. Overall risk of bias was judged to be unclear due to the lack of methodological detail reported. Most studies were undertaken in high-income countries.For our primary review outcomes, there was a possible reduced risk of GDM in the diet and exercise intervention group compared with the standard care group (average risk ratio (RR) 0.85, 95% confidence interval (CI) 0.71 to 1.01; 6633 women; 19 RCTs; Tau² = 0.05; I² = 42%; P = 0.07; moderate-quality evidence). There was also a possible reduced risk of caesarean section (RR 0.95, 95% CI 0.88 to 1.02; 6089 women; 14 RCTs; moderate-quality evidence). No clear differences were seen between groups for pre-eclampsia (RR 0.98, 95% CI 0.79 to 1.22; 5366 participants; 8 RCTs; low-quality evidence), pregnancy-induced hypertension and/or hypertension (average RR 0.78, 95% CI 0.47 to 1.27; 3073 participants; 6 RCTs; Tau² = 0.19; I² = 62%; very low-quality evidence), perinatal mortality (RR 0.82, 95% CI 0.42 to 1.63; 3757 participants; 2 RCTs; low-quality evidence) or large-for-gestational age (RR 0.93, 95% CI 0.81 to 1.07; 5353 participants; 11 RCTs; low-quality evidence). No data were reported for infant mortality or morbidity composite.Subgroup analyses (based on trial design, maternal body mass index (BMI) and ethnicity) revealed no clear differential treatment effects. We were unable to assess the impact of maternal age, parity and specific features of the diet and exercise interventions. Findings from sensitivity analyses (based on RCT quality) generally supported those observed in the main analyses. We were not able to perform subgroup analyses based on maternal age, parity or nature of the exercise/dietary interventions due to the paucity of information/data on these characteristics and the inability to meaningfully group intervention characteristics.For most of the secondary review outcomes assessed using GRADE, there were no clear differences between groups, including for perineal trauma (RR 1.27, 95% CI 0.78 to 2.05; 2733 participants; 2 RCTs; moderate-quality evidence), neonatal hypoglycaemia (average RR 1.42, 95% CI 0.67 to 2.98; 3653 participants; 2 RCTs; Tau² = 0.23; I² = 77%; low quality evidence); and childhood adiposity (BMI z score) (MD 0.05, 95% CI -0.29 to 0.40; 794 participants; 2 RCTs; Tau² = 0.04; I² = 59%; low-quality evidence). However, there was evidence of less gestational weight gain in the diet and exercise intervention group compared with the control group (mean difference (MD) -0.89 kg, 95% CI -1.39 to -0.40; 5052 women; 16 RCTs; Tau² = 0.37; I² = 43%;moderate-quality evidence). No data were reported for maternal postnatal depression or type 2 diabetes; childhood/adulthood type 2 diabetes, or neurosensory disability.

AUTHORS' CONCLUSIONS

Moderate-quality evidence suggests reduced risks of GDM and caesarean section with combined diet and exercise interventions during pregnancy as well as reductions in gestational weight gain, compared with standard care. There were no clear differences in hypertensive disorders of pregnancy, perinatal mortality, large-for-gestational age, perineal trauma, neonatal hypoglycaemia, and childhood adiposity (moderate- tovery low-quality evidence).Using GRADE methodology, the evidence was assessed as moderate to very low quality. Downgrading decisions were predominantly due to design limitations (risk of bias), and imprecision (uncertain effect estimates, and at times, small sample sizes and low event rates), however two outcomes (pregnancy-induced hypertension/hypertension and neonatal hypoglycaemia), were also downgraded for unexplained inconsistency (statistical heterogeneity).Due to the variability of the diet and exercise components tested in the included studies, the evidence in this review has limited ability to inform practice. Future studies could describe the interventions used in more detail, if and how these influenced behaviour change and ideally be standardised between studies. Studies could also consider using existing core outcome sets to facilitate more standardised reporting.

Improving pregnancy outcome in obese women: the UK Pregnancies Better Eating and Activity randomised controlled Trial

Background

Obesity in pregnancy is associated with insulin resistance, which underpins many common complications including gestational diabetes mellitus (GDM) and fetal macrosomia.

Objectives

To assess the effect of a complex behavioural intervention based on diet and physical activity (PA) on the risk of GDM and delivery of a large-for-gestational age (LGA) infant.

Design

Three phases: (1) the development phase, (2) the pilot study and (3) a multicentre randomised controlled trial (RCT) comparing a behavioural intervention to improve glycaemic control with standard antenatal care in obese pregnant women. A cost–utility analysis was undertaken to estimate the cost-effectiveness of the health training (intervention) over and above standard care (control).

Setting

Pilot study: antenatal clinics in four inner-city UK hospitals. RCT: eight antenatal clinics in eight UK inner-city hospitals.

Participants

Women were eligible for inclusion if they had a body mass index of ≥ 30 kg/m2, were pregnant with a single fetus and at 15+0to 18+6weeks’ gestation, were able to give written informed consent and were without predefined disorders.

Intervention

The intervention comprised an initial session with a health trainer, followed by eight weekly sessions. Dietary advice recommended foods with a low dietary glycaemic index, avoidance of sugar-sweetened beverages and reduced saturated fats. Women were encouraged to increase daily PA.

Main outcome measures

Development phase: intervention development, acceptability and optimal approach for delivery. Pilot study: change in dietary and PA behaviours at 28 weeks’ gestation. RCT: the primary outcome of the RCT was, for the mother, GDM [as measured by the International Association of the Diabetes and Pregnancy Study Groups (IADPSG)’s diagnostic criteria] and, for the infant, LGA delivery (i.e. customised birthweight ≥ 90th centile for gestational age).

Results

Development phase: following a literature meta-analysis, a study of dietary intention questionnaires and semistructured interviews, an intervention based on behavioural science was developed that incorporated optimal and acceptable methods for delivery. Pilot study: the pilot study demonstrated improvement in dietary behaviours in the intervention compared with the standard care arm but no increase in objectively measured PA. Process evaluation demonstrated feasibility and general acceptability. RCT: the RCT showed no effect of the intervention on GDM in obese pregnant women or the number of deliveries of LGA infants. There was a reduction in dietary glycaemic load (GL) and reduced saturated fat intake, an increase in PA and a modest reduction in gestational weight gain, all secondary outcomes. Lower than expected was the number of LGA infant deliveries in all women, which suggested that universal screening for GDM with IADPSG’s diagnostic criteria, and subsequent treatment, may reduce the number of deliveries of LGA infants. According to the cost–utility analysis, the estimated probability that the UK Pregnancies Better Eating and Activity Trial (UPBEAT) behavioural intervention is cost-effective at the £30,000/quality-adjusted life-year willingness-to-pay threshold was 1%.

Limitations

Included the high refusal rate for participation and self-reported assessment of diet and PA.

Conclusions

The UPBEAT intervention, an intense theoretically based intervention in obese pregnant women, did not reduce the risk of GDM in women or the number of LGA infant deliveries, despite successfully reducing the dietary GL. Based on total cost to the NHS provider and health gains, the UPBEAT intervention provided no supporting evidence to suggest that the intervention represents value for money based on the National Institute for Health and Care Excellence benchmarks for cost-effectiveness.

Future work

Alternative strategies for reducing the risk of GDM in obese pregnant women and the number of LGA infant deliveries should be considered, including development of clinically effective interventions to prevent obesity in women of reproductive age, of clinically effective interventions to reduce weight retention following pregnancy and of risk stratification tools in early pregnancy.

Trial registration

Current Controlled Trials ISRCTN89971375 and UK Clinical Research Network Portfolio 5035.

Funding

This project was funded by the NIHR Programme Grant for Applied Research programme and will be published in full inProgramme Grants for Applied Research, Vol. 5, No. 10. See the NIHR journals library website for further project information. Contributions to funding were also provided by the Chief Scientist Office CZB/4/680, Scottish Government Health Directorates, Edinburgh; Guys and St Thomas’ Charity, Tommy’s Charity (Lucilla Poston, Annette L Briley, Paul T Seed) and the NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, UK and the Academy of Finland, Finland. Keith M Godfrey was supported by the National Institute for Health Research through the NIHR Southampton Biomedical Research Centre. Lucilla Poston and Keith M Godfrey were supported by the European Union’s Seventh Framework Programme (FP7/2007-2013), project EarlyNutrition under grant agreement number 289346.

Non-occupational physical activity during pregnancy and the risk of preterm birth: a meta-analysis of observational and interventional studies

A meta-analysis was conducted to evaluate the association between non-occupational physical activity (PA) during pregnancy and the risk of preterm birth (PTB). By searching PubMed and EMBASE from inception to August 20, 2016, 25 observational studies (18 cohorts and 7 case-controls) and 12 interventional studies were identified. Comparing the highest to the lowest category of leisure-time PA during pregnancy, the pooled relative risk (RR) of PTB was 0.83 [95% confidence interval (CI) = 0.74-0.93] for cohort studies and 0.60 (95% CI = 0.43-0.84) for case-control studies. No overall significant association was found between domestic or commuting PA and the risk of PTB. In addition, PA intervention did not indicate significant beneficial effect on the risk of PTB. Evidence from the observational studies suggested that leisure-time, but not domestic or commuting, PA during pregnancy was inversely associated with the risk of PTB. The findings were not supported by small-scale and short-term interventional studies. Further research with objective measurement on leisure-time PA is warranted.

Physical activity in pregnancy and adverse birth outcomes

This study focused on the association between physical activity in the second trimester of pregnancy and adverse perinatal outcomes: low birth weight (LBW), preterm birth (PTB), and intrauterine growth restriction (IUGR). The study used a sample from the BRISA cohort, São Luís, Maranhão State, Brazil, which included women with singleton pregnancy, gestational age from 22 to 25 weeks confirmed by obstetric ultrasound performed at < 20 weeks, and re-interviewed in the first 24 hours postpartum (n = 1,380). Level of physical activity was measured by the International Physical Activity Questionnaire (IPAQ), short version, categorized as high, moderate, and low. A directed acyclic graph (DAG) was used to identify minimum adjustment to control confounding. High physical activity was not associated with LBW (RR = 0.94; 95%CI: 0.54-1.63), PTB (RR = 0.86; 95%CI: 0.48-1.54), or IUGR (RR = 0.80; 95%CI: 0.55-1.15). The results support the hypothesis that physical activity during pregnancy does not result in adverse perinatal outcomes.

Influences of prior miscarriage and weight status on perinatal psychological well-being, exercise motivation and behavior

OBJECTIVES

women who have experienced miscarriage may be at increased risk for elevated depressive and anxiety symptoms in subsequent pregnancies. Exercise may be a useful strategy for coping with these symptoms. Little is known about how miscarriage influences prenatal exercise behavior. The study purpose was to examine the influences of miscarriage history and prepregnancy weight status on pregnant women's psychological health, exercise motivation, and behavior using the Theory of Planned Behavior.

PARTICIPANTS/SETTING

Pregnant women (N=203; 41 with prior miscarriage; 72 overweight/obese; BMI > 25.0) in the northeast United States.

DESIGN

Women prospectively reported their depressive/anxiety symptoms and exercise motivation/behavior in the 1st, 2nd, and 3rd trimesters via mailed surveys. Group differences in depressive/anxiety symptoms, exercise behavior, and its motivational determinants were examined using Chi Square analyses and Univariate and Multivariate Analyses of Covariance.

MEASUREMENTS AND FINDINGS

Women with a history of miscarriage had higher 1st and 2nd trimester depressive/anxiety symptoms and lower 1st trimester attitudes about exercise and 1st and 2nd trimester perceived behavior control than women without a history of miscarriage. Overweight/obese women had higher 1st and 2nd trimester pregnancy depressive/anxiety symptoms, engaged in less prepregnancy exercise, and had lower levels of exercise intention, attitude, and perceived behavior control throughout pregnancy than normal weight women.

KEY CONCLUSIONS

Women with a history of miscarriage and overweight/obese women have poorer psychological health and lower motivation to exercise during pregnancy than women without a history of miscarriage and normal weight women.

IMPLICATIONS FOR PRACTITIONERS

Interventions and healthcare provider communications aimed at promoting perinatal exercise behavior and psychological health should take into account pre-pregnancy weight status and pregnancy history to identify strategies to help women, particularly overweight/obese women with a history of miscarriage, to overcome exercise barriers.

Exercise and pregnancy in recreational and elite athletes: 2016 evidence summary from the IOC expert group meeting, Lausanne. Part 2-the effect of exercise on the fetus, labour and birth

This is Part 2 of 5 in the series of evidence statements from the IOC expert committee on exercise and pregnancy in recreational and elite athletes. Part 1 focused on the effects of training during pregnancy and on the management of common pregnancy-related symptoms experienced by athletes. In Part 2, we focus on maternal and fetal perinatal outcomes.

Social and Cultural Factors Affecting Maternal Health in Rural Gambia: An Exploratory Qualitative Study

BACKGROUND

The high rate of maternal mortality reported in The Gambia is influenced by many factors, such as difficulties in accessing quality healthcare and facilities. In addition, socio-cultural practices in rural areas may limit the resources available to pregnant women, resulting in adverse health consequences. The aim of this study is to depict the gender dynamics in a rural Gambian context by exploring the social and cultural factors affecting maternal health.

METHODS AND FINDINGS

Five focus group discussions that included 50 participants (aged 15-30 years, with at least one child) and six in-depth interviews with traditional birth attendants were conducted to explore perceptions of maternal health issues among rural women. The discussion was facilitated by guides focusing on issues such as how the women perceived their own physical health during pregnancy, difficulties in keeping themselves healthy, and health-related problems during pregnancy and delivery. The data resulting from the discussion was transcribed verbatim and investigated using a qualitative thematic analysis. In general, rural Gambian women did not enjoy privileges in their households when they were pregnant. The duties expected of them required pregnant women to endure heavy workloads, with limited opportunities for sick leave and almost nonexistent resources to access prenatal care. The division of labor between men and women in the household was such that women often engaged in non-remunerable field work with few economic resources, and their household duties during pregnancy were not alleviated by either their husbands or the other members of polygamous households. At the time of delivery, the decision to receive care by trained personnel was often beyond the women's control, resulting in birth-related complications.

CONCLUSIONS

Our findings suggest that despite women's multiple roles in the household, their positions are quite unfavorable. The high maternal morbidity and mortality rate in The Gambia is related to practices associated with gender inequality.

Do Physical Activity Patterns Across the Lifecourse Impact Birth Outcomes?

The significant impact of physical activity during, or immediately prior to pregnancy on a range of pregnancy and birth outcomes has been established. However, lifecourse theory posits that the antecedents of poor outcomes occur across a larger trajectory of time. The objective of this study was to examine whether physical activity patterns over the lifecourse impact birth outcomes. The sample (n = 1,713) was derived from Waves I, III, and IV of the National Longitudinal Study of Adolescent Health and limited to women who had their first, singleton live birth between Waves III and IV; respondents who had missing data were excluded. Outcome variables included preterm birth (<37 weeks) and low birth weight (<5.5 pounds). Physical activity was categorized as follows: long-term physically active (active at Waves I and III); short-term physically active (active at only Wave I or III); and not physically active (not active at Waves I and III). Survey-weighted logistic regression controlled for socio-demographic and established predictors of poor birth outcomes. Women categorized as long-term physically active had lower rates of preterm births (12.2 vs. 18.7 %) and low birth weight (9.1 vs. 11.1 %) compared to women categorized as not physically active. However, when controlling for covariates, adjusted analysis revealed that physical activity consistency only predicted preterm birth (aOR = 0.55, 95 % CI = 0.33-0.91). Findings suggest that physical activity patterns across the lifecourse may decrease risk of preterm birth. Implications include efforts supporting patterns of physical activity over longer periods of time prior to pregnancy.

Maternal dietary intake and physical activity habits during the postpartum period: associations with clinician advice in a sample of Australian first time mothers

BACKGROUND

Numerous health benefits are associated with achieving optimal diet and physical activity behaviours during and after pregnancy. Understanding predictors of these behaviours is an important public health consideration, yet little is known regarding associations between clinician advice and diet and physical activity behaviours in postpartum women. The aims of this study were to compare the frequency of dietary and physical activity advice provided by clinicians during and after pregnancy and assess if this advice is associated with postpartum diet and physical activity behaviours.

METHODS

First time mothers (n = 448) enrolled in the Melbourne InFANT Extend trial completed the Cancer Council of Australia's Food Frequency Questionnaire when they were three to four months postpartum, which assessed usual fruit and vegetable intake (serves/day). Total physical activity time, time spent walking and time in both moderate and vigorous activity for the previous week (min/week) were assessed using the Active Australia Survey. Advice received during and following pregnancy were assessed by separate survey items, which asked whether a healthcare practitioner had discussed eating a healthy diet and being physically active. Linear and logistic regression assessed associations of advice with dietary intake and physical activity.

RESULTS

In total, 8.6% of women met guidelines for combined fruit and vegetable intake. Overall, mean total physical activity time was 350.9 ± 281.1 min/week. Time spent walking (251.97 ± 196.78 min/week), was greater than time spent in moderate (36.68 ± 88.58 min/week) or vigorous activity (61.74 ± 109.96 min/week) and 63.2% of women were meeting physical activity recommendations. The majority of women reported they received advice regarding healthy eating (87.1%) and physical activity (82.8%) during pregnancy. Fewer women reported receiving healthy eating (47.5%) and physical activity (51.9%) advice by three months postpartum. There was no significant association found between provision of dietary and/or physical activity advice, and mother's dietary intakes or physical activity levels.

CONCLUSIONS

Healthy diet and physical activity advice was received less after pregnancy than during pregnancy yet no association between receipt of advice and behaviour was observed. More intensive approaches than provision of advice may be required to promote healthy diet and physical activity behaviours in new mothers.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ( ACTRN12611000386932 13/04/2011).

Maternal obesity and offspring body composition by indirect methods: a systematic review and meta-analysis

Abstract This study reviewed the evidence that assessed the association between maternal pre-pregnancy body mass index (BMI) and/or gestational weight gain and offspring body composition in childhood. A systematic review was conducted. Cohort studies, case-control studies and randomized controlled trials measuring offspring body composition by indirect methods were included. Meta-analyses of the effect of pre-pregnancy BMI on offspring fat-free mass, body fat percent, and fat mass were conducted through random-effects models. 20 studies were included, most of which reported a positive association of pre-pregnancy BMI with offspring body fat. Standardized mean differences in body fat percent, fat mass and fat-free mass between infants of women with normal pre-pregnancy BMI and those of overweight/obese women were 0.31 percent points (95%CI: 0.19; 0.42), 0.38kg (95%CI: 0.26; 0.50), and 0.18kg (95%CI: -0.07; 0.42), respectively. Evidence so far suggests that pre-pregnancy maternal overweight is associated with higher offspring adiposity.

Prediction of gestational weight gain - a biopsychosocial model

OBJECTIVE

To examine the influence of health behaviours and psychological well-being on gestational weight gain using a biopsychosocial model.

DESIGN

A prospective cohort study of pregnant women consecutively recruited at their first antenatal care visit. A self-administered questionnaire was used to collect data on health behaviours and psychological well-being in early pregnancy. Linear regression and logistic regression were used to identify predictors of total weight gain in kilograms and weight gain outside the current Institute of Medicine recommendations, respectively.

SETTING

A maternity hospital in the Republic of Ireland.

SUBJECTS

Data on 799 women were analysed.

RESULTS

Pre-pregnant BMI ≥30·0 kg/m2, short stature, parity >0, decreased food intake and absence of health insurance predicted lower absolute gestational weight gain, while foreign nationality, consumption of takeaway meals more than once weekly and increased food intake predicted higher absolute gestational weight gain. Overweight and obesity, foreign nationality, increased food intake and height >170 cm were risk factors for excessive weight gain, while antenatal depression was protective against excessive weight gain. Notably, physical activity measures were not related to the gestational weight gain outcomes. Pre-pregnancy overweight and increased food intake were the strongest predictors of excessive gestational weight gain.

CONCLUSIONS

None of the psychological well-being measures examined, with the exception of antenatal depression, was associated with any of the weight gain outcomes. The behavioural predictors of gestational weight gain were increased food intake and takeaway consumption. Public health promotions should target pre-pregnancy BMI and pregnancy-associated change in food intake.

Diet and exercise interventions for preventing gestational diabetes mellitus

BACKGROUND

Gestational diabetes mellitus (GDM) is associated with a wide range of adverse health consequences for women and their babies in the short and long term. With an increasing prevalence of GDM worldwide, there is an urgent need to assess strategies for GDM prevention, such as combined diet and exercise interventions.

OBJECTIVES

To assess the effects of combined diet and exercise interventions for preventing GDM and associated adverse health consequences for women and their babies.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (11 February 2014) and reference lists of retrieved studies. We updated the search in February 2015 but these results have not yet been incorporated and are awaiting classification.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and cluster-RCTs assessing the effects of interventions that included diet and exercise components. We included studies where combined diet and exercise interventions were compared with no intervention (i.e. standard care).We planned to also compare diet and exercise interventions with alternative diet and/or exercise interventions but no trials were identified for this comparison.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of the included studies. Data were checked for accuracy.

MAIN RESULTS

We included 13 randomised controlled trials (involving 4983 women and their babies). We assessed the included trials as being of moderate risk of bias overall.When comparing women receiving a diet and exercise intervention with those receiving no intervention, there was no clear difference in the risk of developing GDM (average risk ratio (RR) 0.92, 95% confidence interval (CI) 0.68 to 1.23; 11 trials, 3744 women), caesarean section (RR 0.92, 95% CI 0.83 to 1.01; seven trials, 3246 women), or large-for-gestational age (RR 0.90, 95% CI 0.77 to 1.05; 2950 infants). Only one trial reported on perinatal mortality, and found no clear difference in the risk of stillbirth (RR 0.99, 95% CI 0.29 to 3.42; 2202 fetuses) or neonatal death (RR 0.99, 95% CI 0.06 to 15.85; 2202 neonates).Very few differences were shown between groups for the review's secondary outcomes, including for induction of labour, perineal trauma, pre-eclampsia, postpartum haemorrhage and infection, macrosomia, birthweight, small-for-gestational age, ponderal index, neonatal hypoglycaemia requiring treatment, hyperbilirubinaemia requiring treatment, shoulder dystocia, bone fracture or nerve palsy. Women receiving a combined diet and exercise intervention were, however, found to have a reduced risk of preterm birth compared with women receiving no intervention (RR 0.71, 95% CI 0.55 to 0.93; five trials, 2713 women).A trend towards reduced weight gain during pregnancy was shown for women receiving the combined diet and exercise intervention (mean difference (MD) -0.76 kg, 95% CI -1.55 to 0.03; eight trials, 2707 women; P = 0.06, random-effects); but no clear difference in postnatal weight retention was observed overall.In relation to adherence to the interventions, a number of trials that reported on behaviour modifications showed benefits in diet- (5/8 trials) and physical activity- (4/8 trials) related behaviours for women receiving the combined diet and exercise intervention, compared with women receiving no intervention; however there was notable variation across trials in outcomes measured and results observed. Only two trials reported on well-being and quality of life of women, and did not observe differences between groups for these outcomes.Very few trials reported on outcomes relating to the use of health services, although one trial suggested a reduced length of antenatal hospital stay for women receiving a combined diet and exercise intervention (MD -0.27 days, 95% CI -0.49 to -0.05; 2153 women).No information was available on outcomes for the infant as a child or adult, or for most longer-term outcomes for the mother.

AUTHORS' CONCLUSIONS

There are limitations associated with the available RCT evidence on the effects of combined diet and exercise interventions during pregnancy for preventing GDM. Results from 13 RCTs (of moderate quality) suggest no clear difference in the risk of developing GDM for women receiving a combined diet and exercise intervention compared with women receiving no intervention. However, the ability to draw firm conclusions was limited by variations in the quality of trials, characteristics of the interventions and populations assessed, and outcome definitions between trials.Based on the data currently available, conclusive evidence is not available to guide practice. Further large, well-designed RCTs, addressing the limitations of previous studies, are needed to assess the effects of combined interventions on preventing GDM and other relevant pregnancy outcomes including caesarean birth, large-for-gestational age and perinatal mortality. Health service utilisation and costs, and longer-term outcomes for mothers and their babies should be included. We identified another 16 trials which are ongoing and we will consider these for inclusion in the next update of this review.

Physical activities during pregnancy and type of delivery in nulliparae

The aim of this study was to investigate changes in physical activity across pregnancy and the relationship between trimester-specific physical activity and unplanned caesarean sections (CSs). A cohort study design was carried out. A cohort of 150 pregnant women was established when they received prenatal care at 29-40 weeks of gestation at a medical centre in northern Taiwan. Participants were asked to recall the amounts of physical activity in which they had engaged in the three trimesters as assessed by the Pregnancy Physical Activity Questionnaire (PPAQ). Overall self-reported physical activity for the cohort decreased by 31% in the first trimester compared to the pre-gravid period, then increased in the second trimester and remained stable until delivery. A repeated measures analysis of variance was used to evaluate the data and revealed significantly more physical activity during the second trimester than in the first and third trimesters (F = 36.471, P = 0.000). In addition, there was a significant difference between normal spontaneous delivery and unplanned CS groups (F = 4.770, P = 0.031). Logistic regression determined that the odds ratio of undergoing a CS increased by 0.644 (95% confidence interval: 0.429-0.968) for women in the third trimester who performed low levels of physical activity. Results support the benefits of physical activity, and professionals are encouraged to provide pregnant women with information on recommendations for physical activity, particularly in terms of reducing unplanned CSs.

[International recommandations on physical exercise for pregnant women]

Benefits of physical exercise on the physical and psychological health lead to specifics guidelines during pregnancy. For pregnant women, to take part in aerobics exercise (walking, biking) (i.e. 30 minutes, three times per week at 60-90% of the maximal heart rate) and strength training (i.e. one to two times per week) is recommended. Physical exercise programs during pregnancy have shown benefits for preventing and treating complications pregnancy (e.g. gestational diabetes mellitus, overweight). Benefits of exercise and risks associated with sedentary should be widely diffused among pregnant women and prenatal caregivers.

The effect of maternal exercise during pregnancy on abnormal fetal growth

Aim

To assess the effect of maternal physical activity during pregnancy on abnormal fetal growth.

Methods

The study group of 166 women in gestational week 6-8 exercised regularly three days per week at submaximal intensity during their entire pregnancy and the control group of 168 women received standard antenatal care. The main outcomes were macrosomia and intrauterine growth restriction.

Results

The study group had a lower frequency of macrosomia in newborns (6.0% vs 12.5%, P = 0.048) and gestational diabetes (1.8% vs 8.3%, P = 0.008) than the control-group, but there was no significant difference in intrauterine growth restriction (7.2% vs 6.5%). There was also no significant differences in other perinatal outcomes.

Conclusions

The beneficial effect of maternal physical activity on fetal growth may be caused the impact of aerobic exercise on glucose tolerance. Fitness trainers and kinesiologists, as well as health care providers, should be educated on the benefits of regular exercise during pregnancy and safe physical exercise for pregnant women.

Measuring physical activity in pregnancy: a comparison of accelerometry and self-completion questionnaires in overweight and obese women

OBJECTIVES

Increased physical activity in pregnancy may reduce the risk of gestational diabetes and pre-eclampsia, which occur more commonly in overweight and obese women. There is limited assessment of physical activity questionnaires in pregnancy. This study compares self-reported physical activity using two questionnaire methods with objectively recorded physical activity using accelerometry in overweight and obese pregnant women.

STUDY DESIGN

59 women with booking BMI≥25 kg/m(2) completed the Recent Physical Activity Questionnaire (RPAQ) and Australian Women's Activity Survey (AWAS) or recorded at least 3 days of accelerometry at median 12 weeks' gestation. Accelerometer thresholds of 100 counts/min and 1952 counts/min were used to define light and moderate or vigorous physical activity (MVPA) respectively.

RESULTS

48% of women were in their first pregnancy and 41% were obese. Median daily self-reported MVPA was significantly higher for both AWAS (127 min, p<0.001) and RPAQ (81 min, p<0.001) than that recorded by accelerometer (35 min). There was low or moderate correlation between questionnaire and accelerometer estimates of total active time (AWAS ρ=0.36, p=0.008; RPAQ ρ=0.53, p<0.001) but no significant correlation between estimates of time spent in MVPA.

CONCLUSIONS

These self-report questionnaires over-estimated MVPA and showed poor ability to discriminate women on the basis of MVPA. Accelerometry measurement was feasible and acceptable. Objective methods should be used where possible in studies measuring physical activity in pregnancy. Questionnaires remain valuable to define types of activity.

Physical Activity Pattern and Personal-Social Factors of Mothers During Pregnancy And Infant Birth Weight Based On MET Scale: A Case-Control Study

Background

Low birth weight is one of the most important public health issues in developing and developed countries and identifying its etiology is important for prevention.

Objectives

Considering the unknown impact of physical activity on low birth weight, this research was conducted to investigate the relationship between physical activity and low birth weight.

Patients and Methods

This research was conducted using a case-control design. The control group was made of 500 women with normal birth weight infants and the case group included 250 women with low birth weight infants from the selected hospitals in city of Tehran. The information was gathered using a researcher-made questionnaire which was prepared for determining the relationship between mothers’ lifestyle during pregnancy and infants' low birth weight using social determinants of health approach. In this questionnaire, scope of physical activity was investigated in three groups of athletic activities, activities at home and leisure activities. Activity intensity was determined using MET scale and the data were analyzed in SPSS software using independent t-test, Chi-square and logistic regression.

Results

In the present research, based on the results of multiple logistic regression test, an increase in the time spent on sport activities (OR = 2.20) and home activities (OR =1.44) (P = 0.003) was accompanied by increased chance of giving birth to low birth weight infants; in contrast, one hour increase of leisure activities decreased the probability of low birth weight infants by 0.32 (P = 0.008).

Conclusions

An increase in the time spent on sport and home activities, even after considering other influential factors, was related to low birth weight.

Potential mechanisms of exercise in gestational diabetes

Gestational diabetes mellitus (GDM) is defined as glucose intolerance first diagnosed during pregnancy. This condition shares same array of underlying abnormalities as occurs in diabetes outside of pregnancy, for example, genetic and environmental causes. However, the role of a sedentary lifestyle and/or excess energy intake is more prominent in GDM. Physically active women are less likely to develop GDM and other pregnancy-related diseases. Weight gain in pregnancy causes increased release of adipokines from adipose tissue; many adipokines increase oxidative stress and insulin resistance. Increased intramyocellular lipids also increase cellular oxidative stress with subsequent generation of reactive oxygen species. A well-planned program of exercise is an important component of a healthy lifestyle and, in spite of old myths, is also recommended during pregnancy. This paper briefly reviews the role of adipokines in gestational diabetes and attempts to shed some light on the mechanisms by which exercise can be beneficial as an adjuvant therapy in GDM. In this regard, we discuss the mechanisms by which exercise increases insulin sensitivity, changes adipokine profile levels, and boosts antioxidant mechanisms.

Work activities and risk of prematurity, low birth weight and pre-eclampsia: an updated review with meta-analysis

OBJECTIVES

We assessed the evidence relating preterm delivery (PTD), low birth weight, small for gestational age (SGA), pre-eclampsia and gestational hypertension to five occupational exposures (working hours, shift work, lifting, standing and physical workload). We conducted a systematic search in Medline and Embase (1966 to 2011), updating a previous search with a further 6 years of observations.

METHODS

As before, combinations of keywords and medical subject headings were used. Each relevant paper was assessed for completeness of reporting and potential for important bias or confounding, and its effect estimates abstracted. Where similar definitions of exposure and outcome existed we calculated pooled estimates of relative risk (RR) in meta-analysis.

RESULTS

Analysis was based on 86 reports (32 cohort investigations, 57 with usable data on PTD, 54 on birth weight and 11 on pre-eclampsia/gestational hypertension); 33 reports were new to this review. For PTD, findings across a substantial evidence base were generally consistent, effectively ruling out large effects (eg, RR>1.2). Larger and higher quality studies were less positive, while meta-estimates of risk were smaller than in previous analyses and best estimates pointed to modest or null effects (RR 1.04 to 1.18). For SGA, the position was similar but meta-estimates were even closer to the null (eight of nine RRs ≤ 1.07). For pre-eclampsia/gestational hypertension the evidence base remains insufficient.

CONCLUSIONS

The balance of evidence is against large effects for the associations investigated. As the evidence base has grown, estimates of risk in relation to these outcomes have become smaller.

[Evidence-based practices published in Brazil: identification and analysis studies about human health prevention]

Integrative review of Brazilian studies about evidence-based practices (EBP) about prevention in human health, published in Web of Science/JCR journals, between October 2010 and April 2011. The aim was to identify the specialties that most accomplished these studies, their foci and methodological approaches. Based on inclusion criteria, 84 studies were selected, mainly published in public health journals, focusing on primary care and also addressing clinical issues and different specialties. Prevention foci and methodological approaches also varied, with a predominance of systematic reviews without meta-analysis. The results indicate that there is no single way to conceptualize and practice EBP in the field of prevention, and that its application may not only serve to obtain indisputable evidence to equip intervention actions. This endless knowledge area is under construction, with a view to the analysis and further understanding of health phenomena.

Pregnancy: occupational aspects of management: concise guidance

Most pregnant women are exposed to some physical activity at work. This Concise Guidance is aimed at doctors advising healthy women with uncomplicated singleton pregnancies about the risks arising from five common workplace exposures (prolonged working hours, shift work, lifting, standing and heavy physical workload). The adverse outcomes considered are: miscarriage, preterm delivery, small for gestational age, low birth weight, pre-eclampsia and gestational hypertension. Systematic review of the literature indicates that these exposures are unlikely to carry much of an increased risk for any of the outcomes, since small apparent effects might be explicable in terms of chance, bias, or confounding, while larger and better studies yield lower estimated risks compared with smaller and weaker studies. In general, patients can be reassured that such work is associated with little, if any, adverse effect on pregnancy. Moreover, moderate physical exercise is thought to be healthy in pregnancy and most pregnant women undertake some physical work at home. The guidelines provide risk estimates and advice on counselling.

Exercise for pregnant women for preventing gestational diabetes mellitus

BACKGROUND

Gestational diabetes mellitus (GDM) affects a significant number of women each year. GDM is associated with a wide range of adverse outcomes for women and their babies. Recent observational studies have found physical activity during normal pregnancy decreases insulin resistance and therefore might help to decrease the risk of developing GDM.

OBJECTIVES

To assess the effects of physical exercise for pregnant women for preventing glucose intolerance or GDM.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (2 April 2012), ClinicalTrials.gov (2 April 2012) and the WOMBAT Perinatal Trials Registry (2 April 2012).

SELECTION CRITERIA

Randomised and cluster-randomised trials assessing the effects of exercise for preventing pregnancy glucose intolerance or GDM.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of included studies.

MAIN RESULTS

We included five trials with a total of 1115 women and their babies (922 women and their babies contributed outcome data). Four of the five included trials had small sample sizes with one large trial that recruited 855 women and babies. All five included trials had a moderate risk of bias. When comparing women receiving additional exercise interventions with those having routine antenatal care, there was no significant difference in GDM incidence (three trials, 826 women, risk ratio (RR) 1.10, 95% confidence interval (CI) 0.66 to 1.84), caesarean section (two trials, 934 women, RR 1.33, 95% CI 0.97 to 1.84) or operative vaginal birth (two trials, 934 women, RR 0.83, 95% CI 0.58 to 1.17). No trial reported the infant primary outcomes prespecified in the review.None of the five included trials found significant differences in insulin sensitivity. Evidence from one single large trial suggested no significant difference in the incidence of developing pregnancy hyperglycaemia not meeting GDM diagnostic criteria, pre-eclampsia or admission to neonatal ward between the two study groups. Babies born to women receiving exercise interventions had a non-significant trend to a lower ponderal index (mean difference (MD) -0.08 gram x 100 m(3), 95% CI -0.18 to 0.02, one trial, 84 infants). No significant differences were seen between the two study groups for the outcomes of birthweight (two trials, 167 infants, MD -102.87 grams, 95% CI -235.34 to 29.60), macrosomia (two trials, 934 infants, RR 0.91, 95% CI 0.68 to 1.22), or small-for-gestational age (one trial, 84 infants, RR 1.05, 95% CI 0.25 to 4.40) or gestational age at birth (two trials, 167 infants, MD -0.04 weeks, 95% CI -0.37 to 0.29) or Apgar score less than seven at five minutes (two trials, 919 infants, RR 1.00, 95% CI 0.27 to 3.65). None of the trials reported long-term outcomes for women and their babies. No information was available on health services costs.

AUTHORS' CONCLUSIONS

There is limited randomised controlled trial evidence available on the effect of exercise during pregnancy for preventing pregnancy glucose intolerance or GDM. Results from three randomised trials with moderate risk of bias suggested no significant difference in GDM incidence between women receiving an additional exercise intervention and routine care.Based on the limited data currently available, conclusive evidence is not available to guide practice. Larger, well-designed randomised trials, with standardised behavioural interventions are needed to assess the effects of exercise on preventing GDM and other adverse pregnancy outcomes including large-for-gestational age and perinatal mortality. Longer-term health outcomes for both women and their babies and health service costs should be included. Several such trials are in progress. We identified another seven trials which are ongoing and we will consider these for inclusion in the next update of this review.

The potential impact of physical activity during pregnancy on maternal and neonatal outcomes

INTRODUCTION

Pregnancy is a critical period of body weight regulation. Maternal obesity and excessive gestational weight gain have become increasingly common and contribute to poor obstetrical outcomes for mother and baby. Regular participation in physical activity may improve risk profiles in pregnant women.

PURPOSE AND METHODS

Our objectives were to provide an overview of maternal-fetal exercise physiology, summarize current evidence on the effects of physical activity during pregnancy on maternal-fetal outcomes, and review the most recent clinical practice guidelines. In addition, we summarize the findings in the context of the current obesity epidemic and discuss implications for clinical practice. A literature review was completed in which we queried OVID (Medline), EMBASE, and PSYCHINFO databases with title words "exercise or physical activity" and "pregnancy or gestation" from 1950 to March 1, 2010. A total of 212 articles were selected for review.

RECOMMENDATIONS

Care providers should recommend physical activity to most pregnant women (i.e., those without contraindications) and view participation as a safe and beneficial component of a healthy pregnancy.

TARGET AUDIENCE

Obstetricians & Gynecologists and Family Physicians.

LEARNING OBJECTIVES

After participating in this CME activity, physicians should be better able to classify the potential impact of physical activity on maternal glycemic control and fetal growth outcomes. Assess maternal lifestyle and provide recommendations on appropriate gestational weight gain, evaluate pregnant women for contraindications to physical activity participation, make individualized recommendations for exercise participation, and educate patients on the merits of physical activity for health benefit.

Prenatal exercise research

In this review of recent research on prenatal exercise, studies from several different countries suggest that only approximately 40% of pregnant women exercise, even though about 92% are encouraged by their physicians to exercise, albeit with some 69% of the women being advised to limit their exercise. A moderate exercise regime reputedly increases infant birthweight to within the normal range, but only if exercise is decreased in late pregnancy. Lower intensity exercise such as water aerobics has decreased low back pain more than land-based physical exercise. Heart rate and blood pressure have been lower following yoga than walking, and complications like pregnancy-induced hypertension with associated intrauterine growth retardation and prematurity have been less frequent following yoga. No studies could be found on tai chi with pregnant women even though balance and the risk of falling are great concerns during pregnancy, and tai chi is one of the most effective forms of exercise for balance. Potential underlying mechanisms for exercise effects are that stimulating pressure receptors during exercise increases vagal activity which, in turn, decreases cortisol, increases serotonin and decreases substance P, leading to decreased pain. Decreased cortisol is particularly important inasmuch as cortisol negatively affects immune function and is a significant predictor of prematurity. Larger, more controlled trials are needed before recommendations can be made about the type and amount of pregnancy exercise.