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Systematic Review

Barriers to Exercise in Postpartum Women: A Mixed-Methods Systematic Review

Edie, Rebekah SPT1; Lacewell, Alexis SPT1; Streisel, Christine SPT1; Wheeler, Lauren SPT1; George, Ellie SPT1; Wrigley, Jordan MA, MSLS2; Pietrosimone, Laura PT, DPT, PhD1; Figuers, Carol PT, EdD1

Author Information
Journal of Women's Health Physical Therapy: April/June 2021 - Volume 45 - Issue 2 - p 83-92
doi: 10.1097/JWH.0000000000000201

Abstract

INTRODUCTION

Exercise is a safe way to improve physical fitness and psychological well-being in postpartum women.1 It can also reduce the risk of obesity, postpartum depression, and metabolic conditions.1–4 The American College of Obstetricians and Gynecologists (ACOG) recommends 150 minutes of moderate-intensity exercise dispersed throughout the week and indicate that women may begin exercising after pregnancy in the absence of medical complications and any surgical restrictions, depending on the mode of delivery.1 While the ACOG recommends 150 minutes of moderate-intensity exercise, new mothers in the postpartum period are less likely to meet the national guidelines for moderate physical activity.1,5,6 Physical therapists (PTs) have the skill set to advise and prescribe exercise to postpartum people. As movement specialists, PTs can play an essential role in the implementation of counseling exercise for postpartum people, as well as disseminating this information to the interdisciplinary team. Before prescribing exercise, however, PTs should better understand the barriers that are inhibiting postpartum people from exercise to improve not only physical activity adherence but also overall quality of life.

Childbirth initiates a significant change in a woman's life, and many postpartum women experience a myriad of physiological, psychological, and social changes while becoming mothers.7 Women must recover from childbirth and/or adjust to the changes their body experienced through pregnancy into postpartum, all while tending to the needs of their newborn.7 This transition is a time when women may be susceptible to prioritizing the needs of others over themselves.7 Identifying the barriers to exercise that may coincide with the changes new parents experience is important in understanding why exercise compliance may be challenging during the postpartum period. Acknowledging the barriers may also help PTs better promote health and wellness to the postpartum population.

The purpose of this systematic review is to identify the barriers to exercise among postpartum people. To our knowledge, no systematic review has been conducted on this topic. Exercise can provide a safe way for parents to manage the confluence of change in their lives, and recognizing barriers that make it challenging may have important implications in improving overall adherence to exercise and influence the counseling approach that a PT may utilize.

METHODS

Search Strategy

This study used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement throughout the search and reporting. PRISMA is an evidence-based list of items used to improve reporting in systematic reviews and meta-analyses.8 This systematic review was also registered with PROSPERO International prospective register of systematic reviews.9 Relevant articles were searched using the databases MEDLINE/PubMed, EMBASE (via Elsevier), Scopus (via Elsevier), and CINAHL (via EBSCO). The key MeSH terms used were postpartum period, peripartum period, obstetrics, exercise, and patient compliance. A complete overview of the search criteria is listed in the Appendix.

Inclusion/Exclusion Criteria

To be included, studies had to meet the following criteria: (1) to address or list barriers to exercise or physical activity; (2) postpartum population; and (3) the postpartum people in the study were 12 months or less postpartum. Any form of birth (ie, stillbirth, miscarriage) and delivery was also included. Both qualitative and quantitative studies were included. Exclusion criteria included any articles discussing postpartum people with gestational diabetes or other significant metabolic diseases, studies conducted solely during the pregnancy, animal studies, and articles not in English (Figure 1).

Figure 1.
Figure 1.:
Study selection.

Study Selection

The initial search yielded 1398 articles after duplicates were removed. Publications were initially accepted or rejected on the basis of titles and abstracts; abstracts that mentioned barriers to exercise and health care provider (HCP) education were considered for full-text review by the 2 of the authors (R.E. and C.S.). Disagreements on whether to include an article for full-text review were decided by a third author (E.G.). Sixty-one full-text articles were reviewed for final consideration.

The 61 full-text articles were divided and reviewed among 5 authors (R.E., A.L., C.S., L.W., E.G.) so that each article was read by at least 2 different authors. Each author independently decided whether to include or exclude the full-text article based on the predetermined inclusion/exclusion criteria and whether the article discussed the role of HCP education/counseling in postpartum exercise. All disagreements were settled by consensus of a third, blinded author, leaving 15 full-text articles approved for data extraction (R.E., A.L., C.S., L.W., E.G.). Five articles were later excluded during the data extraction because they either did not provide sufficient reporting of their samples or did not meet criteria upon further review, yielding a total of 10 articles included in this systematic review (7 qualitative and 3 quantitative).

Data Extraction

The barriers listed from all articles were tallied and placed into one of 5 categories: intrapersonal, interpersonal, sociocultural/demographic, physical environment, and health care environment. These themes were adopted and modified from Jenkins et al.10 The intrapersonal category included tiredness and/or lack of sleep, low energy and/or fatigue, low motivation, physical or health limitations (soreness, sickness, illness, etc), high and/or low exercise tolerance, appearance, ability and/or confidence concerns (including being overweight and/or obese), lack of enjoyment, attitudes/beliefs toward exercise, depression, and already active enough.10 When a study reported “lack of sleep,” it was categorized with “tired.” “No energy and/or fatigue” were categorized separately because they are defined as exhaustion that is not relieved by rest.11 “Low exercise tolerance” and “exercise not important” were later eliminated because no studies mentioned these barriers.

The interpersonal category included time and/or unpredictable routine/schedule, ethic of care/sense of entitlement, busy with domestic chores/care/responsibilities, organizational demands/work/employment, health and mood of baby, and lack of partner support.10 The sociocultural/demographic category included lack of support from family, friends, and other mothers, education level, marital status and/or single parent, and available finances, low income, and/or lower poverty index.10 Available finances, low income, and/or lower poverty index were combined because they are all indicators of financial status. In addition to note, the authors of this systematic review classified lack of support from family, friends, and other mothers as a sociocultural influence because postpartum support can vary greatly depending on an individual's cultural identity. The physical environment category included lack of access to preferred exercise environment, weather, access to childcare, and transportation.10 The health care environment category included lack of information, advice, or encouragement, breastfeeding, and pregnancy complications (eg, preeclampsia).10

For the reporting of barriers, one author (A.L.) identified and coded barriers using similar key phrases and themes that were consistent throughout the included studies. For example, if an article mentioned “lack of motivation,” it was coded and included with “low motivation.”5,12–17 Similarly, “too tired,” “mom too tired,” “being too tired,” and “being tired” were identified and coded together as “tiredness.”5,12,14,16–18 One article listed psychosocial measures in relation to the participants' ability to exercise postpartum, which the authors included as barriers.19 For example, the psychosocial measurement of “self-efficacy” was coded with “attitudes and beliefs toward exercise.”19 If an article mentioned a barrier, it was recorded and then tallied. See Figure 2 for reference of the barriers reported. (See Supplemental Digital Content Material, available at: https://links.lww.com/JWHPT/A45, to reference which article reported each identified barrier.) Barriers were coded and counted the same regardless of the type of study and whether or not they were reported as statistically significant.

Figure 2.
Figure 2.:
Record of barriers reported.

One author (A.L.) extracted the salient characteristics of each study. The data included the number of postpartum women in the study, mean age of the mother when the study occurred, the number of children the mother had, the number of months postpartum, education, marital status, race/ethnicity, employment, and barriers. Refer to Table 1 for the characteristics of included study.

Table 1. - Characteristics of Included Studies
Author (Year) Sample, n Age, y Time Postpartum First-Time Mothers, n Mothers With More Than One Child, n Education, n
Albright et al (2005)14 79 31.8 NR 43.5 35.6 FE = 15.6 y
Albright et al (2009)13 20 32.9 NR 10 10 FE = 16.8 y
Albright et al (2015)5 115 32.3 NR 45 70 CG = 68
SC = 26
HS = 21
Cramp and Bray (2011)17 230 30.9 12-30 wk 141.9 88.1 192.7
Evenson et al (2009)16 530 <20, n = 6
20-29, n = 162
≥30, n = 362
12 mo 254 276 CG = 362
SC = 87
HS = 81
Groth and David (2008)15 49 Range = 18-42 4 d to 11.5 mo 21.6 27.4 NS
Mailey and Hsu (2019)12 49 32.3, range = 25-40 6 wk to 12 mo 33 16 CG = 48
Saligheh et al (2016)18 14 Range = 18-38 6 wk to 12 mo 0 14 CG = 8.4
SC = 5.6
Thomson et al (2018)19 54 23.55 12 mo NS NS SC = 30
HS = 24
Vladutiu et al (2015)22 667 <20, n = 19
20-<35, n = 477
≥35, n = 171
3 mo 334 333 435
Author (Year) Marital Status Race and Ethnicity Employment
Albright et al (2005)14 M = 74.3
NM/NP = 4.7
S/D = NS
White = 29
Asian/Asian American = 30
Native Hawaiian/Pacific Islander = 11
Mixed/other/unknown = 9
NS
Albright et al (2009)13 M = 19
NM/NP = 1
S/D = NS
White = 10
Asian/Asian American = 7
Native Hawaiian/Pacific Islander = 3
E = 9
NE = 11
Albright et al (2015)5 M = 25
NM/NP = 88
S/D = 1
White = 18
Hispanic = 15
Asian/Asian American = 44
Native Hawaiian/Pacific Islander = 30
Mixed/other/unknown = 23
E = 72
NE = 43
Cramp and Bray (2011)17 M = 226.8
NM/NP = 3.2
S/D = NS
White = 209.3
Mixed/other/unknown = 20.7
E = 155.3
O = 74.75
Evenson et al (2009)16 M = 449
NM/NP = 81
S/D = NS
White = 408
Black = 62
Hispanic = 24
Mixed/other/unknown = 32
E = 334
NE = 196
Groth and David (2008)15 NS White = 12
Black = 24
Hispanic = 13
NS
Mailey and Hsu (2019)12 M = 3
NM/NP = 46
S/D = NS
White = 43.022 E = 37
O = 12
Saligheh et al (2016)18 M = 14
NM/NP = 0
S/D = 0
Mixed/other/unknown = 1.4
Australian = 8.4
British = 4.2
E = 14
Thomson et al (2018)19 M = 6
NM/NP = 48
S/D = NS
White = 2
Black = 52
E = 21
NE = 19
O = 14
Vladutiu et al (2015)22 M = 605
NM/NP = 62
S/D = 0
White = 499
Black = 99
Mixed/other/unknown = 67
E = 348
NE = 319

Quality of Studies

Results of the quality of studies using the Downs and Black Checklist of Methodological Quality are reported in Table 2.20 The checklist can assess methodological quality of both randomized and nonrandomized controlled trials, providing an overall score of study quality for quality of reporting, internal validity, power, and external validity.20 Twenty-six items were scored as 1 (yes) or 0 (no/unable to determine), with scores ranging from 0 to 26. This review modified the checklist to exclude the final question about power because the question's scoring was contingent upon using power, and no studies in this review calculated power. Therefore, the highest score a study could receive in this review was 26. Higher scores indicate higher methodological study quality, and the following scores have been previously categorized by quality as excellent (26-28), good (20-25), fair (15-19), and poor (≤14).21 In this systematic review, 5 studies were good quality, and 5 studies were fair quality. Two authors (E.G., L.W.) scored the 10 articles, and disagreements in scoring were resolved by a third blinded author (C.S.). See Supplemental Digital Content Material (available at: https://links.lww.com/JWHPT/A46) for the comprehensive checklist.

Table 2. - Quality of Studies Using the “Downs and Black Checklist of Methodological Quality”
Author (Year) Reporting External Validity Bias Confounding Overall Score
Albright et al (2005)14 7/10 1/3 4/7 3/6 15/26
Albright et al (2009)13 9/10 2/3 5/7 4/6 20/26
Albright et al (2015)5 8/10 2/3 5/7 5/6 20/26
Cramp and Bray (2011)17 7/10 3/3 5/7 5/6 20/26
Evenson et al (2009)16 9/10 2/3 5/7 4/6 20/26
Groth and David (2008)15 8/10 2/3 4/7 2/6 16/26
Mailey and Hsu (2019)12 7/10 2/3 5/7 4/6 18/26
Saligheh et al (2016)18 7/10 2/3 4/7 2/6 15/26
Thomson et al (2018)19 9/10 3/3 6/7 4/6 22/26
Vladutiu et al (2015)22 7/10 2/3 5/7 4/6 18/26

RESULTS

Study Characteristics

Of the 10 final studies, 7 were qualitative and 3 were quantitative. The articles were published between 2005 and 2019. Eight of the studies were conducted in the United States, one in Canada, and one in Australia (see Supplemental Digital Content Material, available at: https://links.lww.com/JWHPT/A47, for further detail and type of each study). A total of 1807 postpartum women were captured in the review. Of the demographic information available, the average age reported was 28.91 years, with a range of 18 to 45 years. The women ranged from 4 days to 12 months postpartum; 48% were first-time mothers, 61% were college graduates or held postgraduate degrees, 81% were married or living as partners, 68% were White, and 54% were employed (Table 1). Four of the 10 articles implemented a postpartum health/exercise literacy or education component as part of their intervention; all of the articles discussed postpartum health/exercise literacy or education in some regard, indicating that it was lacking in capacity and/or needed to be explored further with additional research.

Reported Barriers

The top reported barriers within each domain were tiredness and/or lack of sleep (7 out of 10 articles mentioned), time and/or unpredictable routines/schedule and busy with domestic chores/care/responsibilities (8 out of 10 articles mentioned), lack of support from family, friends, and other mothers (9 out of 10 articles mentioned), weather (7 out of 10 articles mentioned), and breastfeeding (3 out of 10 articles mentioned), respectively (Figure 2).

DISCUSSION

The goal of this systematic review is to identify and synthesize the barriers to exercise in postpartum people, which are categorized into intrapersonal, interpersonal, sociocultural/demographic, physical environment, and health care environment. It is also important to address the clinical relevance these barriers may have in relation to the role of the PT. The role of the PT is to provide therapeutic exercise, and having an understanding of these barriers may help PTs better prescribe and provide optimal care. This review identifies postpartum barriers and also offers suggestions on how PTs may educate and facilitate meaningful exercise to improve physical activity among postpartum people.

Intrapersonal

The most frequently reported interpersonal barriers to exercise were tiredness and/or lack of sleep, low motivation, and physical or health limitations (soreness, sickness, illness, etc). PTs can educate postpartum people on the importance of sleep and sleep health strategies during this time not only because tiredness is a major barrier to exercise but also because adequate sleep may reduce risk of further health complications.11 While postpartum parents may believe in the benefits exercise has on energy levels, they may not always prioritize it. PTs may also help postpartum parents not only strategize ways to exercise to improve energy but also provide energy conservation techniques to better allocate their energy in ways that will prioritize their health.

Six articles reported low motivation as a barrier to exercise postpartum.5,12,14,16–18 Saligheh et al18 speculated that the social isolation of being a new mother might contribute to low motivation. A possible solution to this may be informing parents of local fitness classes and walking groups, as having the social support of other parents may help mitigate feelings of social isolation and low motivation.

Six articles reported appearance, ability, and/or confidence concerns as barriers.13,15,16,18,19,22 PTs should be cognizant of this as a barrier and ask postpartum people questions that may help identify those feeling dissatisfied with their postpartum body. PTs can offer ways to help them address their appearance, ability, and/or confidence and provide support to those vulnerable to struggling with body image. Group postpartum fitness classes and walking groups also may offer a source of community that helps these parents feel less alone in their postpartum experience, particularly relating to the changes that their body endured as a result of their pregnancy.

Another frequently cited intrapersonal barrier was physical or health limitations (soreness, sickness, illness, etc), which may best be addressed by HCPs during follow-up clinical visits. PTs specifically can assist new parents with musculoskeletal changes and skillfully discuss and recommend appropriate modifications that might make exercise more tolerable, enjoyable, and safe. PTs and HCPs who see postpartum people for their 6-week visit should develop partnerships to enhance interprofessional communication to provide better comprehensive care.

Interpersonal

The most reported interpersonal barriers were time and/or unpredictable routine/schedule, demands/work/employment, and being too busy with domestic chores/care/responsibilities. Caring for a newborn is time consuming, and this should be considered when strategizing ways to incorporate physical activity in their day. PTs can provide meaningful education and strategies for parents who might feel like they cannot prioritize exercise due to alterations in the way time is spent during a day. For example, some parents may not know that exercising 10 minutes at a time for a total of 20 to 60 minutes a day is also acceptable for achieving the health benefits of exercise and may make exercise seem more manageable for parents who feel like they do not have enough time or are too busy.23

Five studies reported demands/work/employment as a barrier to exercise.5,14,16,17,22 Maternity leave length varies in the United States depending on employer policy, and many postpartum parents may feel pressured to return to work for financial reasons or job security. This barrier represents a more macroeconomic and societal issue that may be addressed from a more systemic policy approach, and further research should examine the effects paid maternity and paternity leave have on postpartum exercise.

Four studies mentioned partner support as a barrier to exercise.14,16,18,22 Partner support can mean having someone to share the workload of parenting or caring for a newborn, as well as someone to provide emotional support for the postpartum parents. One study found that unmarried women had decreased odds of participating in recreational moderate to vigorous physical activity, which could be due to mothers not having someone to provide childcare while they exercise.22 PTs can stay informed of local exercise classes, gyms, or meetup groups that allow parents to bring their child to the session or offer childcare services. Many yoga and Pilates mat classes incorporate babies into the workout themselves, resolving the need for childcare, and providing a means for mothers to exercise. Postpartum parents may also rely on the emotional support of a partner who encourages them to exercise and take time for themselves. PTs, counselors, and other HCPs in their network may also serve as a source of support for postpartum parents who feel they are lacking partner support.

Sociocultural and Demographic Influence

The most reported barrier within the sociocultural/demographic influence was a lack of support from family, friends, and other mothers. It was also the most frequently reported barrier in this entire systematic review, signifying how important social support is in the postpartum population. It is possible that if postpartum parents gained more social support (ie, emotionally, help with chores, childcare, etc), other barriers such as low motivation, time, and being too busy could also be mitigated.

Physical Environment

Weather and access to childcare were the most reported physical environmental barriers found in this systematic review. Weather plays a large contributing factor in a postpartum parent's ability to exercise outdoors and will vary greatly depending on the geographic location of where a parent lives. It is free to walk or run outside, but inclement conditions can be a limiting factor for many parents in being able to engage in these activities. PTs can help parents create exercise plans that they can do indoors. It is surprising to the authors that “feeling safe” was not a listed barrier in any of the studies, and the reviewers speculate that this could be because the majority of the women in the studies included in this systematic review (White, married/in a partnership, educated) have the resources to afford living in areas where safety is not a major concern.

Health Care Environment

The most reported health care environment barriers listed were breastfeeding and lack of information/advice/encouragement. It is important for HCPs to educate postpartum parents about exercise and breastfeeding, especially during the 6-week postpartum checkup. It is safe to exercise while breastfeeding and will not harm the health of the mother or hinder the baby's acceptance of breast milk.24,25 Postpartum parents who may be struggling with low motivation, lack of support, resources, and location may need more counseling for developing exercise plans, and HCPs should be cognizant of following up with parents who may need more guidance. When educating postpartum parents on exercise, it is important to find activities the person enjoys doing, as this will lead to greater short- and long-term compliance. Exercise programs should be individualized and tailored to the needs of the parent, and it is important to offer solutions to potential barriers to help parents meet their goals. PTs can empower new parents who may struggle with exercise and self-efficacy by devising small goals and encouraging self-reflection and self-monitoring of their progress.

Strengths and Limitations

The authors believe the primary strength of this mixed-methods systematic review is that it is the first review to synthesize the literature of barriers to exercise in postpartum parents, providing a framework for the direction of future research among this population.

This review was limited to articles written in English. The women in the included studies were primarily White, employed, married/in a partnership, and college graduates, which may have also biased the barriers reported. The 12-month postpartum period inclusion criteria may also have limited our findings, as the barriers to exercise for a 2-month postpartum parent may look vastly different from a 2-year postpartum parent.

Suggestions for Future Research

The most reported barriers (tiredness, lack of support, etc) in this review are not surprising, but they do offer insight into where future physical therapy and rehabilitation research is indicated. Lack of support from family/friends/other mothers was the most reported barrier in this review, and investigation is especially needed that considers the social support and structures surrounding parents postpartum. Further research should identify the gaps and discrepancies within policies, maternity/paternity laws, access to childcare, and community infrastructures that may be hindering postpartum parents from exercise. In addition, postpartum parents have one 6-week postpartum follow-up visit with their primary care provider, and more research also is needed to explore how expanded postpartum care may affect exercise adherence.26 Future research should also reflect the emergence of smartphones and telehealth, as advanced technology will continue to change how counseling and health care are administered.

The authors believe the one of the most important findings of this review is the lack of diverse representation in the literature. The majority of postpartum women in this systematic review were White, employed, married/in a partnership, and college graduates; all of these factors likely influenced the barriers the women in the studies reported. There is a paucity of studies including postpartum parents of diverse demographic and socioeconomic backgrounds. Age, race, gender identity, employment status, single parent versus co-parent, and the effect the number of children has on exercise postpartum may all provide a framework for future research. In addition, no studies provided any information on nontraditional family units and including LGBTQ+ parents, adoption families, and stepparents when discussing partner support, and more research is needed to reflect the diverse relationships of current society.

CONCLUSION

This systematic review provides clear clinical relevance, as PTs play a vital role in offering guidance and motivation to postpartum parents. The most commonly reported barriers to exercise for postpartum women include tiredness and/or lack of sleep, busy with domestic chores/care/responsibilities, time and/or unpredictable routines/schedule, lack of support from family/friends/other mothers, weather, and breastfeeding. PTs are trained to provide skillful exercise recommendations and should consider these barriers when counseling postpartum parents in strategizing ways to increase their physical activity. Many of the reported barriers overlap with one another and being able to address one barrier may also help absolve another. For example, a parent struggling with low motivation or decreased body confidence may benefit tremendously from a group exercise class for new parents. This may improve motivation, social support, and surround them with other women who may be experiencing similar struggles. PTs should query postpartum patients on barriers as a part of routine patient care encounters. This will facilitate robust provider-patient interactions to create an individual exercise program to meet the patient's goals. A customized exercise plan may improve not only long-term exercise compliance but also quality of life of this unique population.

Note from the authors: The authors use the term “postpartum women” in constancy of the language of the studies being referenced. “Postpartum parent/people” is used when providing the authors' discussion to include the spectrum of the postpartum population including transgender men and nonbinary parents.

ACKNOWLEDGMENTS

The authors thank Leila Ledbetter, Corey Simon, and Derek Clewley, for their guidance during this process.

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Appendix

Literature Search

Search terms used in MEDLINE/PubMed, EMBASE (via Elsevier), Scopus (via Elsevier), and CINAHL (via EBSCO).

(“Postpartum Period”[Mesh] OR “Peripartum Period”[Mesh] OR “Obstetrics”[Mesh] OR “Postnatal Care”[Mesh] OR “Parturition”[Mesh] OR postpartum[tiab] OR post-partum[tiab] OR puerperium[tiab] OR peripartum[tiab] OR peri-partum[tiab] OR postnatal[tiab] OR post-natal[tiab] OR obstetric[tiab] OR obstetrics[tiab] OR parturition[tiab] OR “post-pregnancy”[tiab] OR birth[tiab] OR childbirth[tiab]) AND (“Exercise”[Mesh] OR exercise[tiab] OR exercising[tiab] OR exercises[tiab] OR exercised[tiab] OR “physical activity”[tiab] OR “physical activities”[tiab] OR gymnastics[tiab] OR conditioning[tiab] OR circuit-based[tiab] OR “endurance training”[tiab] OR “high-intensity interval training”[tiab] OR HIIT[tiab] OR “resistance training”[tiab] OR running[tiab] OR jogging[tiab] OR swimming[tiab] OR walk[tiab] OR walking[tiab] OR “cardio”[tiab] OR “stair climbing”[tiab] OR yoga[tiab] OR tai-chi[tiab] OR taichi[tiab] OR “tai ji”[tiab] OR “tai chi”[tiab] OR stretch[tiab] OR stretches[tiab] OR stretching[tiab] OR plyometric[tiab] OR plyometrics[tiab] OR pilates[tiab] OR calisthetics[tiab] OR cycle[tiab] OR cycling[tiab] OR barre[tiab] OR walk[tiab] OR walking[tiab] OR dance[tiab] OR dancing[tiab] OR racquetball[tiab] OR volleyball[tiab] OR sport[tiab] OR sports[tiab] OR swim[tiab] OR swimming[tiab] OR aerobic[tiab] OR anaerobic[tiab] OR “cardio”[tiab] OR “strength training”[tiab] OR basketball[tiab] OR soccer[tiab] OR softball[tiab] OR boxing[tiab] OR lifting[tiab] OR “weight lifting”[tiab] OR weightlifting[tiab] OR workout[tiab] OR “work out”[tiab] OR fitness[tiab] OR kickboxing[tiab] OR “kick boxing”[tiab] OR “low intensity”[tiab] OR “moderate intensity”[tiab] OR “high intensity”[tiab] OR “high impact”[tiab] OR hike[tiab] OR hiking[tiab] OR “weight loss”[tiab] OR spinning[tiab] OR spin[tiab] OR soccer[tiab] OR triathlons[tiab] OR triathlon[tiab]) AND (“Patient Compliance”[Mesh] OR barrier[tiab] OR barriers[tiab] OR compliance[tiab] OR complied[tiab] OR comply[tiab] OR adherence[tiab] OR adhered[tiab] OR adhere[tiab] OR non-adherence[tiab] OR nonadherence[tiab] OR cooperation[tiab] OR co-operation[tiab]) NOT (Editorial[ptyp] OR Comment[ptyp]) NOT (animals[mh] NOT humans[mh])

Keywords:

education; physical activity; pregnancy

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