PHYSICAL ACTIVITY COUNSELING DURING PREGNANCY: WHAT (NOT) TO SAY?
When Sara found out that she was pregnant for the second time, there were many aspects she felt prepared for, but struggling with her health was not one of them. On the advice of her doctor, Sara is seeking help from an exercise professional regarding her physical activity behavior. On the day of the consult, the exercise professional walks into the meeting room where Sara has been anxiously waiting. He quickly sits down in his chair and without much small talk asks what Sara is doing to stay physically active at this stage of her pregnancy. He types away speedily at his computer making notes, occasionally nodding in acknowledgment, or asking Sara a series of “predetermined” questions. He goes on to explain that Sara's current physical activity level is not ideal, and that it would be in her best interests to start an exercise routine. Although he shares many potential benefits of prenatal exercise, for both Sara and her baby, she seems resistant and has a long list of excuses for continuing her usual (inactive) habits. Despite the exercise professional's good intentions, Sara leaves feeling overwhelmed, discouraged, misunderstood, and frustrated. It is therefore unlikely that she will be heeding the exercise professional's advice by making the recommended changes to her current physical activity levels.
It may not be uncommon for pregnant individuals to feel like Sara — overwhelmed, discouraged, misunderstood, and/or frustrated — after discussing their feelings about starting a prenatal exercise program. Traditional approaches used by exercise professionals to discuss physical activity behavior(s) with pregnant clients often use a “Just the Facts” approach, which resembles this equation: (Present Facts + Answer Questions) = Physically Active Client. That said, if clients believe their feelings or concerns were misunderstood, unheard, or distorted in various ways by exercise professionals, they may be hesitant about (or resistant to) changing their physical activity behavior(s). Realistically, clients may already have the facts about changing physical activity for improved health. In other cases, clients may have a fear or belief that exercising during their pregnancy is unsafe (1). If changes ultimately feel unattainable or the client lacks interest, then it is unlikely that implementing a more physically active lifestyle will result from a consult with any exercise professional. This outcome is far from ideal because research has shown that between 75% and 85% of individuals do not meet current guidelines for physical activity during pregnancy (2,3). Furthermore, activity levels tend to decline throughout pregnancy, and especially toward the third trimester (4). This is despite clear evidence supporting the benefits of regular physical activity during pregnancy (3,5).
So, is there a way for exercise professionals to communicate with pregnant clients that empowers rather than discourages positive changes in their exercise routine?
In this article, we will discuss the concept of motivational interviewing (MI) as one approach to communicating with clients about prenatal exercise that may be useful for exercise professionals (5). In brief, MI is an evidence-based way of communicating that can foster positive changes in physical activity behavior. Exercise professionals using MI collaborate with their pregnant client(s), respecting and encouraging clients' autonomy to explore their own “internal” motives for initiating and sustaining physical activity. In other words, using an MI approach to exercise counseling treats pregnant clients as “experts” with knowledge about themselves and possibly knowledge of the physical activities they should be doing to improve (or maintain) their health. Read on to meet a case client (Sara), who will appear in several places throughout this article to help demonstrate some of the techniques used in MI to structure consults about making changes to physical activity behavior.
COMMUNICATION TOOLS FOR ENCOURAGING PHYSICAL ACTIVITY: WHAT TO USE?
The pioneers responsible for developing MI, Dr. William R. Miller and Dr. Stephen Rollnick (6), proposed the use of Open-Ended Questions, Affirmations, Reflections, and Summaries (O.A.R.S.) as fundamental skills in this communication framework. These skills can be used to communicate effectively with clients about changing health behavior(s). This section introduces these four skills. Table 1 provides illustrative tips for exercise professionals to guide their use of O.A.R.S. during physical activity consults with pregnant clients.
TABLE 1 -
Examples and Descriptions of O.A.R.S. Used in MI
||What Not to Do
||What to Do
||What's the Difference?
||“How will you incorporate aerobic activities into your routine to meet physical activity guidelines of 150 minutes/week?”
||“What exercises, if any, have you considered trying to implement into your day-to-day routine?”
||The first question, while likely to provoke a targeted response, makes the decision about type and frequency that should be done. The second question allows the client greater autonomy by including “if any”, thereby not obligating the client to respond in a certain way.
||“I think you've done a great job this week meeting your goals.”
||“This past week you've worked diligently to make progress toward the exercise goal you've set for yourself.”
||The first affirmation is a compliment using an evaluative tone. The second affirmation is client-centered, recognizing the client's effort and progress toward reaching a goal.
||“On the one hand, fitting exercise into your morning routine gives you energy for the rest of your day, but on the other hand, you struggle to find the time for it.”
||“On the one hand, you have a busy morning schedule, and on the other hand, when you do manage to fit in some exercise, it leaves you feeling energized for the rest of your day.”
||The first reflection ends with a negative comment, which may overshadow the positive element of the statement. The second reflection is framed in a more positive way, switches the dividing term “but” for the more inclusive “and,” then ends with the client's reason for change.
||“You mentioned needing help to create an exercise routine because you have three kids at home, work an office job with long hours, and can find little time for being active.”
||“Let's see if I've got it all. Along with your family and work duties, you'd like to establish an exercise routine to improve your physical and mental health. You'd like to start walking more and taking active breaks. What else?”
||These brief summaries have some key differences. The first summary centers on information that is less critical for making positive changes. The second summary gives a more comprehensive picture of the goals and possible changes the client would like to make then ends with a prompt for more discussion of any topic relevant to the consult.
Just like it sounds, this skill involves asking pregnant clients questions that can elicit responses that vary in depth (shallow to complex) beyond simply a yes or a no answer. These questions could begin with How, What, or Why. Beginning a sentence with Tell me…also may be helpful for evoking a more detailed answer from pregnant clients about their own physical activity regimen. Generally, open-ended questions can be an excellent skill to help pregnant clients explore their own reasons (or motives) for being physically active as well as any reservations or fears they may have about doing so. Exercise professionals could ask the following: “What support could help you change your physical activity routine?” or “How might you build physical activity into your day at work?” This approach to asking questions provides the opportunity for pregnant clients to generate different ways for changing their own physical activity behavior, rather than relying on the “expert” to do it for them.
Sidebar 1. Case Study: Meet Sara
Sara is 31 years old and is two months pregnant with her second child. Although she was active growing up, she hasn't exercised regularly in many years. Since her mid-20s, she has had difficulty maintaining a healthy weight, and this became more challenging after her first pregnancy. Her job and her 2-year-old son keep her very busy, and she usually finds herself exhausted at the end of each day. Sara's doctor is concerned that she is at risk for developing gestational diabetes as her pregnancy advances and therefore is recommending that she make some lifestyle changes. Sara was upset to hear this news from her doctor as she has no idea how to begin making these changes, especially when it comes to starting an exercise program. She has always felt uncomfortable in a gym and doesn't know how she could get motivated to exercise on her own. Following her doctor's advice just feels impossible to her.
Affirmations represent positive statements emphasizing a client's accomplishments or efforts. Affirmations involve highlighting specific action(s) or trait(s) displayed by pregnant clients, whereas compliments provide only general evaluations from the exercise professional. For instance, affirming a client's efforts by saying “you are working hard toward getting more physically fit,” differs from merely complimenting a pregnant client for the same action (e.g., “You're great”). It is often helpful to begin affirmations with “You,” not “I,” to ensure the emphasis is placed on the pregnant client rather than on the exercise professional.
Reflections can be simple or complex attempts by the exercise professional to reiterate, in a statement, an idea shared by pregnant clients. Simple reflections typically restate specific comments made by pregnant clients that the exercise professional heard during a consult and wishes to highlight. In contrast, complex reflections often involve rephrasing of a client's comments by the exercise professional to explore their meaning or significance relative to becoming more physically active. Exercise professionals may wish to avoid initiating reflections with “You said that…” to avoid the pitfalls of misinterpreting or misunderstanding comments made by clients during pregnancy.
Sidebar 2. Case Study: Reframing
Sara is feeling unsure about what to expect in her first consult. After the exercise professional introduces himself, he asks Sara what she would like to achieve with their discussion. She states that she knows that exercising regularly is what's best for herself and her baby, but that she is not sure if she can do it. Sara claims that she is already busy as a working mom, and that she sometimes feels she can barely manage her responsibilities as it is. While making sure not to disregard his client's concerns, the exercise professional highlights Sara's awareness of the importance of exercise, as well as her persistence, by saying the following: “It seems clear to me that you have overcome hurdles in the past to be there for your child, and that you want to learn how you can make positive changes for your own health and that of your baby.” This is an illustration of reframing in MI, which may reassure Sara during the consult with her exercise professional and encourage her to view the challenges of exercising differently.
Complex reflections: In some cases, exercise professionals may be faced with resistance from pregnant clients when discussing changes to physical activity. If pregnant clients seem uninterested (or unwilling) to discuss changes in their physical activity regimen, then exercise professionals may wish to shift topics or end the consult. It is unlikely that “forcing” a dialogue with pregnant clients will produce any positive changes to physical activity. With that said, there may be situations when a pregnant client expresses feelings of doubt, while also conveying some desire to change, either directly or indirectly. These are opportune moments to use complex reflections to help clients see a positive side to their actions or thoughts. An example of this type of complex reflection — known as “reframing” in MI — is shown in the case study in Sidebar 2.
Summaries represent “big picture” statements that pull together portions of the dialogue between pregnant clients and exercise professionals, either within (or across) consults. Summaries include a few key elements from the consult, such as feelings about physical activity, ideas for overcoming barriers to physical activity, and/or plans to change physical activity. The precise content of a summary varies depending on the outcome desired by the exercise professional. It may include helping pregnant clients see the big picture, collating key points for consideration at the end of a consult, or reinforcing key themes presented by clients that may be useful for motivating physical activity behavior.
HOW CAN I GET PREGNANT CLIENTS THINKING ABOUT PHYSICAL ACTIVITY?
Within MI, a client's words can be categorized as either change talk, which is speech favoring change, or sustain talk, which is speech favoring a desire to maintain the status quo (or not change behavior). Sometimes, clients may demonstrate ambivalence, by verbally expressing components that include both change talk and sustain talk relative to physical activity. The goal, ultimately, is for pregnant clients to express more change talk, which has been linked with positive changes to physical activity behavior. There are different skills that can be used by exercise professionals to help elicit change talk from clients, even when this may seem like a challenge for them during pregnancy.
Let's start by returning to the first MI skill introduced: Open-ended questions. The focus will be placed on a type of question that can help pregnant clients think about different reasons they may want to change their physical activity behavior. An example of this type of question is what MI proponents refer to as looking back/looking forward. Simply put, this strategy involves asking clients questions about some aspects of their past or future, as a prompt to reflect on (or imagine) what changing their physical activity habits could look like for them.
With a looking back question, clients are asked to think about a time when they successfully implemented a change of some kind. For instance, you might ask them to reflect on a stage of life when they were getting more physical activity, and how that compares to their life now. This may help pregnant clients recognize important differences in their situation and possibly get them thinking about which steps to take on the road to becoming more physically active.
In many circumstances, it may be beneficial to ask clients to envision a future with or without the behavior change in question. This is what looking forward questions allow you to do, and this is illustrated within the next case study.
HOW CAN I TELL WHETHER MY CLIENT IS READY TO MAKE A CHANGE?
Once you have begun discussing the idea of making changes to physical activity with a pregnant client, it may be difficult to tell where that person is relative to making the first step to changing their behavior. There is of course a difference between talking about change and making it happen! Scaling questions can be used by exercise professionals to assess the client's level of interest, readiness, or confidence in making desired changes to physical activity on a scale from 1 to 10. Perhaps the topic of a prenatal walking program has emerged during a consult, and you would like to understand how your pregnant client feels about it. You might ask your client to rate the level of interest in starting the program now, using a scale of 1 (not interested) to a 10 (very interested). If, later in the consult, you have worked with the pregnant client to develop a plan to begin this program, you might find it helpful to ask how confident your client feels about achieving this goal using a scale of 1 (not confident) to 10 (very confident).
Sidebar 3. Case Study: Looking Forward
The exercise professional quickly picks up on the ambivalence Sara is demonstrating about beginning an exercise program. Although Sara understands the importance of being physically active throughout her pregnancy, she is clearly hesitant to begin making changes. The exercise professional decides to ask this looking forward question to help Sara imagine what her life might look like if she decided to start exercising: “If you think about 4 or 5 years from now, imagining you've started an exercise routine, what does that look like for you?” Sara expresses her excitement about the prospect of being in a routine and notes that she would love to be able to chase her young kids around or tidy up the house without getting tired. The exercise professional, and hopefully Sara, can now clearly identify some of her motives for starting an exercise program. This is useful information to have for the consult going forward, to help propel Sara toward making positive changes to her physical activity regimen.
If a pregnant client provides a rather low number, it is likely too early to start discussing strategies for change. Instead, you might try to evoke further change talk, or help the pregnant client uncover a personal motive for change. Conversely, if a pregnant client shares a higher number, it may be time to talk about putting action steps in place to begin making the change.
After a scaling question, it can be useful to use specific follow-up questions (or probes) to get more information. This question can be asked in two ways, both of which prompt your pregnant clients to expand on the initial ranking they provided. The first method involves asking clients to explain why they did not choose a lower number, thus leading them to share what aspects of change they already feel good about. The second method of probing shifts to the higher end of the scale, in that you are looking for clients to think about what they need to do to increase their ranking. This type of probing also can open a dialogue about what barriers to change your pregnant clients are facing, which can then be discussed. Asking the questions in this order leaves pregnant clients thinking about how they might become more physically active. What does a scaling question (and probes) look like during physical activity consults? Table 2 illustrates the use of scaling questions with probes by exercise professionals.
TABLE 2 -
Scaling Questions and Follow-Up Probes During Exercise Consults
|“On a scale of 1 (low) to 10 (high), how motivated are you to increase your physical activity levels?”
||“I would say I'm about a 3.”
||“You're reluctant to begin making changes. What made you choose 3 rather than 1 or 2?”
||“I know physical activity is good for me; I just have a lot of other things going on that I need to prioritize.”
||“Your health is important to you…and you see physical activity as a key component of that. Knowing what your priorities are, what would it take for you to move from a 3 to a 4 or 5?”
|“On a scale of 1 (low) to 10 (high), how confident are you in your ability to start your new physical activity plan?”
||“I would probably put myself at a 7.”
||“You're fairly confident in your ability to put this plan into action. Tell me more about your answer…why not a 5 or 6?”
||“I feel ready to take the first step at this point.”
||“You're prepared to start moving forward in your plan. What might be keeping you from being at an 8 or 9?”
These tips were intended to serve as a useful starting point in learning about MI. This approach involves a myriad of techniques, processes, and complexities which, for the sake of succinctness, were not covered here. To learn more, check out the resource by Clifford and Curtis listed in the Recommended Reading section.
- • Clifford D, Curtis L. Motivational Interviewing in Nutrition and Fitness. New York (NY): Guilford Press; 2016. 276 p.
BRIDGING THE GAP
More than three quarters of pregnant individuals do not engage in the recommended amount of physical activity during pregnancy (1,2) and can feel overwhelmed and discouraged when exercise professionals make recommendations about changing their physical activity regimen. To minimize these risks, MI can be used to counsel pregnant individuals about physical activity. By integrating key tools from MI with an effective communication style, exercise professionals may be well positioned to help clients become more physically active during their pregnancy. Furthermore, obstetric care providers might consider speaking with exercise professionals regarding physical activity counseling to address gaps in this area.
1. Mudd LM, Nechuta S, Pivarnik JM, Paneth N; Michigan Alliance for the National Children's study. Factors associated with women's perceptions of physical activity safety during pregnancy
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2. Gaston A, Vamos CA. Leisure-time physical activity patterns and correlates among pregnant women in Ontario, Canada. Matern Child Health J
3. Mottola MF, Davenport MH, Ruchat SM, et al. 2019 Canadian guideline for physical activity throughout pregnancy
. Br J Sports Med
4. Borodulin KM, Evenson KR, Wen F, Herring AH, Benson AM. Physical activity patterns during pregnancy
. Med Sci Sports Exerc
5. Evenson KR, Mottola MF, Artal R. Review of recent physical activity guidelines during pregnancy
to facilitate advice by health care providers. Obstet Gynecol Surv
6. Miller WR, Rollnick S. Motivational Interviewing: Helping People Change
. 3rd ed. New York (NY): Guilford Press; 2013. p. 481.