Exercise and Pregnancy Knowledge Among Healthcare Providers

Introduction

Healthcare providers should be aware of current recommendations for maternal physical activity (PA) and the research base behind them. This awareness will facilitate their ability to give proper advice to patients about how PA affects the normal physiological changes that occur during pregnancy, including the possible benefits and risks of exercise for the mother and fetus. ¹

Historically, PA was not universally recommended for pregnant women because of limited research and fear of unknown risks to the mother and fetus. In 1985, the American College of Obstetricians and Gynecologists (ACOG) published its first guidelines for exercise during pregnancy and based them on the limited research available at the time. The guidelines were somewhat restrictive and cautious regarding maternal heart rate and activity duration. ² Specifically, the guidelines cautioned that maternal heart rate should not exceed 140 beats per minute (bpm) and strenuous activities should be limited to 15 minutes.

In recent decades, many studies have been conducted on PA during pregnancy. The research has shown that maternal benefits include improved cardiac function, decreased risk for gestational hypertension and diabetes, limited weight gain and fat retention, improved mental state, improved fitness, and less complicated labor. ^3,4 Fetal benefits may include improved stress tolerance and enhanced neurobehavioral maturation. ⁴ In general, the research has shown that exercise during pregnancy should rarely be contraindicated but rather may be beneficial for mother and child. ^{3 –7} During pregnancy, changes in heart rate (an increase in resting and decrease in maximal heart rate) render heart rate as a less precise way to monitor exercise intensity. ⁸ To address this issue, Canadian guidelines (PARmed-X for Pregnancy) advise using target heart rate target zones representing 60%–80% of age-specific aerobic capacity and Borg's Rating of Perceived Exertion scale (6–20) to monitor intensity during pregnancy. ^8,9

The ACOG revised its guidelines for exercise during pregnancy in 1994. ¹⁰ Specific restrictions for heart rate and exercise duration were removed, and the authors recommended that individualized exercise prescription and health assessment be included as part of prenatal care. ¹⁰ The ACOG guidelines were refined further in 2002. Pregnant women are now encouraged to follow general adult recommendations for PA developed jointly by the American College of Sports Medicine (ACSM) and Centers for Disease Control and Prevention (CDC), suggesting ≥30 minutes of moderate PA be performed on most days of the week. ¹¹ Women currently exercising are encouraged to continue, and sedentary pregnant women are encouraged to begin an exercise program if there are no contraindications. ¹¹

Most recently, the first U.S. Physical Activity Guidelines for Americans were released in fall, 2008. A section was included on PA during pregnancy and the postpartum period. ³ Current evidence shows that PA performed by women undergoing a normal pregnancy is associated with very little risk may decrease a woman's risk for complications during pregnancy (hypertension, gestational diabetes), and may enhance weight loss postpartum. ¹² Thus, women are encouraged to perform the minimum amount of PA suggested for all Americans, that is, 150 minutes of moderate to vigorous physical activity per week. ³

The authors of the new Physical Activity Guidelines for Americans stress that healthcare providers and other PA experts should share the latest information about exercise behavior with everyone, including pregnant women. ³ In the United States, obstetric care is primarily provided by obstetricians, family practitioners, and certified nurse midwives (C.N.M.). As training, technical proficiency, and philosophical orientation differ among these healthcare providers, ¹³ it is not clear how much education each group receives about the most current recommendations for PA during pregnancy. Differences in training and education may result in exercise recommendations and restrictions that differ among subspecialty practices. For instance, C.N.M.s and Doctors of Osteopathy (D.O.) are typically trained to follow a more holistic approach to medicine compared with Doctors of Medicine (M.D.). ¹⁴ However, it is not known if different approaches to healthcare would affect the way practitioners would interact with pregnant patients regarding exercise behavior. The purpose of this study, therefore, was to examine the beliefs, attitudes, knowledge, and practices of obstetric healthcare providers toward exercise during pregnancy.

Materials and Methods

Study participants were a convenience sample of 93 practicing healthcare providers, including M.D.s (n = 45), D.O.s (n = 14), and C.N.M.s (n = 34), from hospitals and birth centers across Michigan. Each participant was surveyed using a pen and paper instrument consisting of 31 forced choice (1–4 Likert scale) and open-ended questions. Surveys were administered primarily during grand rounds meetings, workshops, and professional medical conferences. We were informed of the various conferences in the mid-Michigan area by administrators housed in the Department of Obstetrics and Gynecology in the Michigan State University College of Human Medicine. Bulk mailings were used to reach providers who did not attend area meetings or who requested a mail survey. The majority of respondents were contacted in person. It is not possible to calculate an actual response rate, as recruitment methods included in-person contact and subsequent mailing practices. Participants indicated their consent by voluntarily completing the survey. The University Committee for Research Involving Human Subjects gave approval to conduct the study.

The departments of Kinesiology and Sociology at Michigan State University collaborated to create the survey. The survey was pilot tested (n = 8) using medical residents from the College of Human Medicine at Michigan State University. Their comments and suggestions were incorporated into the final instrument used in this study.

The initial 9 questions were designed to assess demographic information, including participant degree, practice location, years experience, specialty, gender, age, race, patient population, and percent of practice involving obstetrics. The next 11 questions were designed to assess participants' beliefs and attitudes toward exercise during pregnancy. A 4-point Likert scale was used to assess how much the provider agreed or disagreed with a statement. Response choices were strongly agree, agree, disagree, and strongly disagree. Statements included in this portion of the questionnaire are shown in the Appendix. Questions were written in both positive and negative tone in order to reduced response bias. A neutral response was not included in the Likert scale, as it has been found to be a questionable scaling option. ¹⁵

The final portion of the survey (11 questions) was designed to assess current provider practice regarding exercise advice to patients (Appendix). The majority used a 4-point Likert scale to assess how often a provider gives advice or restrictions about exercise during pregnancy, with responses including never, seldom, often, and always. Participants were also asked specific open-ended questions about what exercise advice and restrictions they commonly provide their pregnant patients. The most recent guidelines ACOG (2002) were not published when the survey was designed, so the participants were asked about their awareness of the 1994 guidelines.

Participants were grouped by age (10-year intervals starting with <30 to >60 years of age), gender, degree (M.D., D.O., C.N.M.), and years of experience (<5, 5–10, 11–15, and >15 years). Descriptive statistics were calculated for all questions to determine group means and standard deviations (SD). Because of the nature of the data and lack of homogeneity of variance, group comparisons were performed using chi-square analysis. Comparisons were performed on all knowledge, attitude, and belief questions to assess differences based on provider gender, age, degree, and experience.

Results

Demographic information is reported in Table 1. The majority of providers were women (72%), M.D.s (48%), and between the ages of 40 and 49 years (32%). The sample included several family practice residents with limited obstetric experience. Most C.N.M.s were contacted via phone and preferred bulk mailings, whereas the majority of M.D. and D.O. providers were contacted at grand rounds meetings and workshops.

Beliefs and attitudes responses were largely positive regarding exercise and pregnancy. A breakdown of key question responses by providers is reported in Table 2. Ninety-nine percent of respondents believe exercise during pregnancy is beneficial, and 90% recommend exercise to their pregnant patients. Eighty-nine percent believe that sedentary women with uncomplicated pregnancies can safely begin an exercise program, 97% believe chronic exercisers should be encouraged to continue exercising throughout pregnancy, and 76% believe women should participate in strength-training programs during pregnancy. As for the maternal and fetal effects of exercise during pregnancy, 89% believe that they are minimal to nonexistent, and 93% do not believe exercising during pregnancy increases a woman's risk of delivering a low birth weight baby.

Approximately 66% of physicians' offices give advice to patients about pregnancy and exercise, but this percentage decreased to <50% in younger physicians (<30 years of age), most of whom were residents. In contrast, 97% of C.N.M.s reported their offices provide such advice.

Although the data suggest providers are positive about giving exercise recommendations to their pregnant patients, the advice does not always align with the current research or ACOG recommendations. Fifty-six percent of respondents do not routinely give exercise restrictions, but 64% (regardless of gender, age, or degree) believe that maternal heart rate should not exceed 140 bpm during exercise. In addition, 60% of M.D.s, 86% of D.O.s, and 85% of respondents <30 years of age were not familiar with the 1994 ACOG guidelines for exercise and pregnancy. Chi-square analysis between subspecialty and awareness of the 1994 ACOG guidelines was performed. No significant differences were found.

Discussion

Research has shown that exercise during pregnancy can be beneficial to both the mother and the fetus. ^{1,4,16 –18} The role of healthcare providers in disseminating this information remains unclear, especially between the different degrees or provider subspecialties. We sought to examine the beliefs, knowledge, and practices of healthcare providers about exercise during pregnancy. Healthcare providers throughout the state of Michigan were surveyed at local workshops and by bulk mailings. The majority of responses were positive about women exercising during pregnancy, and few insisted on general activity restrictions for patients. Most providers, however, regardless of medical training, lacked knowledge and awareness of current exercise recommendations, and many insisted that women limit their activity intensity based on a suggestion that has not been applicable for several years. We believe this to be a significant finding.

Prescribing and monitoring exercise intensity during pregnancy is difficult. During pregnancy, changes in heart rate (an increase in resting and decrease in maximal heart rate) render heart rate as a less precise way to monitor exercise intensity. ⁸ To address this issue, Canadian guidelines (PARmed-X for Pregnancy) advise using target heart rate zones representing 60%–80% of age-specific aerobic capacity along with Borg's Rating of Perceived Exertion scale (6–20) to monitor exercise intensity. ⁹ It is important to note that current ACOG and U.S. government recommendations for exercise during pregnancy advocate for at least moderate intensity activity and do not set an upper limit for intensity. ^3,11 More research on the effects of vigorous exercise during pregnancy is needed to formulate more specific recommendations.

When asked about time spent in exercise advice sessions, the current survey study found the C.N.M.s had more personal contact with their patients. Similar results were shown by Yankou et al., ¹⁹ indicating that C.N.M.s schedule a first prenatal visit for an average of 49.3 minutes, whereas M.D.s first visits average 29.8 minutes. The authors also determined that although both subspecialty groups believed exercise to be a very important topic for prenatal teaching, C.N.M.s conducted 96% of the prenatal exercise teaching compared with M.D.s, who conducted 42% of the prenatal exercise teaching. ¹⁹ These findings are also supported by Zeanah and Schlosser, ²⁰ who examined the effects of maternal adherence to ACOG guidelines on pregnancy outcomes. The authors found that few physicians referred to the ACOG guidelines when the study participants inquired about appropriate exercise levels during pregnancy. ²⁰

Lewis and Lynch ²¹ investigated physician counsel advice and exercise behavior. They found many physicians did not give exercise advice to nonpregnant patients, the main reason being lack of time. The authors also found that when physicians were trained to use a simple exercise advice-giving protocol, the frequency with which advice was given doubled. ²¹ Williford et al. ²² suggested that possible reasons for not counseling patients about exercise may be related to lack of confidence in counseling, lack of insurance reimbursements, lack of education related to medical aspects of exercise, and a lack of standard formats for assessing and prescribing exercise. The current study found that >61% of providers spent 5–10 minutes or less advising patients on exercise, supporting the results found by Lewis and Lynch ²¹ and by Williford et al. ²²

The lack of time spent with patients, as well as misinformation given by physicians, can have a negative effect on a woman's PA behavior during pregnancy. A study by Petersen et al. ²³ evaluated the adherence of pregnant and nonpregnant women to the current ACSM/CDC PA recommendations using data from the Behavioral Risk Factor Surveillance System. The data showed pregnant women were less likely than their nonpregnant counterparts to meet vigorous or moderate PA recommendations, and walking was the most popular mode of PA among both pregnant and nonpregnant respondents. Pregnant women who met the PA recommendations tended to be younger, non-Hispanic white, better educated, nonsmokers with higher incomes. ²³

Studies about the effect that provider recommendations have on exercise behavior have generally shown that patient attitudes are responsive to exercise advice from healthcare providers. ^4,24 Even with the data to support physician-based exercise counseling, there is no currently accepted way for physicians or their staff to counsel patients, pregnant or not, on exercise. The issue of physicians' willingness and ability to counsel patients on exercise is being addressed by the new Exercise Is Medicine program developed by the ACSM. ²⁵ Toolkits are being developed to assist physicians and other healthcare providers with this process.

The current study showed differences among provider beliefs in the importance of exercise counseling and individual consults, as well as staying up-to-date with published guidelines. The differences in training and philosophy among the providers may be the reason for differences in care. Table 2 shows response differences by provider for specific questions relating to current recommendations and misperceptions. Regardless of subspecialty, a majority of the participants in this study were not aware of the 1994 ACOG guidelines for exercise during pregnancy, and more than half still used outdated recommendations, such as heart rate restrictions. This shows a great need for better dissemination of the current guidelines, including the 2002 ACOG guidelines for exercise during pregnancy and the 2008 Physical Activity Guidelines for Americans as well as current research on exercise during pregnancy, to all practicing healthcare providers.

Seventy-six percent of participants indicated an interest in attending exercise and pregnancy workshops. This willingness for continuing education could help to increase provider knowledge of current research and guidelines for exercise during pregnancy and help fill in the large gaps that exist.

A limitation to this study was that it was conducted on a convenience sample of healthcare professionals throughout the state of Michigan. The results may not be generalizable to providers across the nation. Because of the nonrandomization of the sample, response bias may also be a possible limitation of this study. Time has passed since the survey was created and conducted; therefore, the results about healthcare provider education and awareness of exercise during pregnancy may have changed. The use of the 1994 ACOG guidelines is also a limitation to this study; however, the 2002 ACOG guidelines were directed more at women who exercise currently.

Future studies should include a larger sample obtained from regional or national cohorts. Additionally, provider education or training interventions should be researched in order to evaluate issues of information dissemination and patient compliance.

Conclusions

Although healthcare providers' beliefs about the benefits of exercise during pregnancy were largely positive, not all were aware of or followed current ACOG guidelines for exercise during pregnancy. In addition, compared with physicians, C.N.M.s were more aware of the 1994 ACOG exercise recommendations and more likely to provide exercise information and counseling in their practices. Even so, over half of respondents, regardless of training, recommended that heart rates should not exceed 140 bpm, a recommendation that has not existed since the original 1985 ACOG guidelines.

Research on the topic of exercise and pregnancy has increased greatly in the past two decades. Healthcare providers should be familiar with the most current ACOG and general population PA guidelines and be able to adjust the overall recommendations based on the individual woman's needs. Strategies for dissemination of recent research findings on exercise and pregnancy may be warranted, especially for medical residents who care for obstetric patients. Innovative ways to add information about maternal PA counseling to the educational curricula of healthcare providers should be considered.