Integrating Exercise Is Medicine^® into the Care of Pregnant Women

Abstract

A majority of women do not meet the recommended levels of physical activity before and during pregnancy. Physically active women experience fewer complications of pregnancy such as gestational diabetes, hypertensive disorders of pregnancy, and low back pain, to name only a few. Exercise is Medicine^® encourages adults to achieve a minimum of 150 min·wk⁻¹ of moderate-intensity physical activity, and the same is true for women having uncomplicated pregnancies. Prenatal care is an opportune time to counsel women on how to achieve an active lifestyle to support their own health and the health of their developing fetus.

Introduction

Pregnancy is often a time when women take steps to improve their lifestyle habits in an effort to optimize the fetal environment. For a long time, physicians have counseled women to reduce or eliminate tobacco use, avoid alcohol, and improve their dietary intake to ensure adequate fetal growth and development. However, despite recommendations encouraging physicians to counsel women to exercise regularly during pregnancy, a minority of women report receiving advice to do so (¹¹). There are numerous reasons for this: 1) physicians receive inadequate instruction on physical activity promotion during medical school and residency training (⁹); 2) the current prenatal care delivery system leaves little time to provide lifestyle counseling; 3) the majority of women begin pregnancy not meeting recommended levels of physical activity, making them less likely to engage in regular exercise during their pregnancy (²¹); and 4) women (and physicians) remain unconvinced that exercise is safe during pregnancy (⁷). To overcome these barriers, medical school and resident education, as well as continuing medical education, must change to include information on the benefits of physical activity during pregnancy, along with practical information on the integration of counseling into the care of women during pregnancy. To achieve the latter, physicians and clinical practices will need tools and processes that make it easier to effectively integrate physical activity counseling into prenatal care.

Physical Activity Counseling during Pregnancy

Decades of scientific evidence have demonstrated that moderate-intensity exercise for healthy pregnant women is not only safe but also beneficial for both women and their developing fetus. The 2008 Physical Activity Guidelines for Americans state: “Unless a woman has medical reasons to avoid physical activity during pregnancy, she can begin or continue moderate-intensity aerobic physical activity during her pregnancy and after the baby is born” (¹⁸). Likewise, the American College of Obstetricians and Gynecologists Committee Opinion on Exercise During Pregnancy and the Postpartum Period, updated in 2009, states: “In the absence of either medical or obstetric complications, 30 min or more of moderate exercise a day on most, if not all, days of the week is recommended for pregnant women, [and] pregnant women should be encouraged to engage in regular, moderate-intensity physical activity to continue to derive the same associated health benefits during their pregnancies as they did prior to pregnancy” (¹).

To achieve the goals of these recommendations, several enhancements will have to take place, including the following:

• a) additional public health efforts encouraging women to become and remain physical active during pregnancy;
• b) expanded educational opportunities to improve the knowledge and skills on physical activity counseling of clinicians delivering prenatal care (physicians, midwives, nurse practitioners, and physician assistants);
• c) integration of tools and processes to support clinicians in their efforts to promote physical activity during the course of prenatal care.

These efforts will help change public perception that exercise during pregnancy is unsafe for the mother and baby and improve the knowledge and effectiveness of clinicians.

Exercise is Medicine^® advocates that health care providers assess and review every patient’s physical activity program at every visit (⁸). Evidence demonstrates that brief clinical assessment tools, including the Physical Activity Vital Sign (PAVS), are valid measures of physical activity in adults and can be integrated effectively into clinical care without disruption (⁶). Integrating PAVS during the course of prenatal care would be a first step in systematizing physical activity promotion during pregnancy. The PAVS reports total minutes per week of physical activity by asking patients how many minutes per day and days per week they participate in physical activity, with the goal being 150 min·wk⁻¹ of moderate-intensity physical activity.

One of the unique aspects of health care delivery during pregnancy is repeated face-to-face clinical visits. In the United States, adults see their primary care physician on average 1.6 visits per year (¹⁷); however, women see their prenatal care provider up to 11 times over the course of an uncomplicated 40 wk of pregnancy (⁴). This provides multiple opportunities to counsel about physical activity over the course of pregnancy. Improving physical activity is achieved best using highly successful behavior change techniques (¹⁵). One such approach is the five A’s approach: assess, advise, agree, assist, and arrange (¹²). The PAVS serves as a tool to assess physical activity at each prenatal care visit. Following a brief assessment, advice can be tailored to a woman’s current physical activity level, readiness to change, past attempts at exercise, and current exercise goals. Subsequent visits can be used to follow up and reinforce the plan and assist the patient in meeting her exercise goals. Many believe the most important “A” of all is to arrange follow-up to monitor progress, provide feedback, and adjust goals (¹⁰), and the frequency of prenatal visits provides the perfect opportunity for achieving this.

Physical activity counseling during prenatal care has been found to be effective and feasible (^2,3). In two studies from Finland, exercise interventions were delivered by participants’ prenatal care providers during the course of routine prenatal care. This consisted of face-to-face education at four prenatal care visits in addition to written materials describing benefits of exercise during pregnancy, guidelines for exercise during pregnancy, and materials for goal setting and tracking physical activity between clinical visits. Providers were trained on behavioral approaches to physical activity promotion during pregnancy. The first study, involving 132 primiparous women, found that the weekly number of moderate-intensity leisure-time physical activity (LTPA) days was 43% higher, and the weekly duration of at least moderate-intensity LTPA was 154% higher in those who received exercise counseling from their prenatal care provider, compared to pregnant women who were not counseled. Prenatal care providers found the counseling to be feasible during the course of visits (²). A subsequent study by the same authors used a randomized control study design in a larger sample (n = 399) and found that women who received the exercise intervention (similar to that described previously) were more likely to continue exercise throughout their pregnancy compared to the control group. Likewise, providers viewed the intervention positively and found it feasible to integrate into routine prenatal care (³).

The benefits of exercise during pregnancy are numerous and beyond the scope of this article. From a public health perspective, women who enter pregnancy meeting the recommended levels of physical activity are much more likely to continue exercise throughout pregnancy (¹⁶). Similarly, women who exercise during pregnancy are more likely to resume exercise in the postpartum period (¹⁶). Regular physical activity throughout pregnancy is associated with a lower risk of gestational diabetes and a lower risk of hypertensive disorders of pregnancy (¹²), not to mention lower rates of obesity and excessive maternal weight gain during pregnancy (^13,18). All of which translate into improvements in the long-term health of women. Considering more than six million women are pregnant each year in the United States (⁵), medicine has an obligation to promote a healthy lifestyle to women during this phase of life. Anything short of that would be unethical (²⁰). Not only should providers counsel women during pregnancy, but also they should discuss exercise as a part of preconceptional care, and counseling should extend into the postpartum period.

Conclusion

The American College of Sports Medicine’s Exercise is Medicine^® program is committed to improving the role and influence of health care in promoting regular physical activity. Implementation of the PAVS tool to assess physical activity during pregnancy, along with integration of the five A’s behavioral approach, is a strategy that most prenatal care providers could integrate into the clinical care of pregnant women. Achieving this will require enhancements in the training of prenatal care providers, addition of the PAVS into the prenatal record, and tools and materials for patients. Ongoing research in this area will help further to elucidate best practice and optimal outcomes measures.

The authors declare no conflicts of interest and do not have any financial disclosures.