Many studies have confirmed the benefits of recreational exercise during pregnancy for both the mother and the fetus (Magro-Malosso 2017; Rogoziñska et al, 2017). Recreational exercise is defined by the Royal College of Obstetricians and Gynaecologists (RCOG) as ‘planned regular exercise that a woman takes during her pregnancy, which involves energetic (aerobic) exercise (such as swimming or running) and/or strength conditioning exercise’ (RCOG, 2006a:2). Many national and international guidelines recommend that pregnant women should regularly participate in moderate intensity aerobic and strengthening exercises as part of their antenatal care (American College of Obstetricians and Gynecologists (ACOG), 2002; 2015; Department of Health, 2017). Despite these recommendations, research has shown that only approximately 3-15% of pregnant women in the UK and the USA meet guidelines (Currie et al, 2013).
The benefits of exercise for the mother during pregnancy have been well documented in the literature and include a reduction in gestational hypertensive disorders (Magro-Malosso et al, 2017), diabetes mellitus (Da Silva et al, 2017) and excessive gestational weight gain (Rogoziñska et al, 2017), and enhanced psychological wellbeing including reduced anxiety and depressive symptoms (Robledo-Colonia et al, 2012; Daley et al, 2015). A recent study by Shakeel et al (2018) found that pregnant women meeting the physical activity recommendations (>150 minutes of moderate-to-vigorous physical activity per week) also had a lower risk of postpartum depressive symptoms compared to women who were not active during pregnancy.
Benefits have also been identified for the fetus and the infant, including increased fetal heart rate (BØ et al, 2016), which may have a protective mechanism on fetal wellbeing (ACOG, 2009). Despite the considerable wealth of evidence supporting the benefits of exercise, and the fact that 95% of pregnant women believe that exercise is helpful (Krans et al, 2005), many women are still not engaging in the recommended guidelines for exercise (Santo et al, 2017). There are many reasons why pregnant women do not meet the recommended guidelines, which can be social, psychological and/or physical. These include lack of knowledge regarding the safety of exercise during pregnancy, lack of time, motivation, social and emotional support, and energy (Harrison et al, 2018). Some of these issues may be compounded by the variable knowledge among health professionals on guidelines for exercise (e.g. frequency, mode intensity and duration) (Leiferman et al, 2012; Hopkinson et al, 2018). According to Bauer et al (2010), health professionals believe that exercise is a very important part of antenatal teaching for pregnant women; however, evidence has demonstrated that some healthcare providers are using outdated recommendations in relation to exercise prescription (Watson et al, 2015; Hopkinson et al, 2018), which may affect the quality of advice delivered and their confidence delivering it. Most of these studies surveyed obstetricians, general practitioners or midwives; however, in the UK, it is predominantly midwives and physiotherapists who are responsible for the provision of information about exercise in pregnancy. It is therefore important to understand the attitudes and beliefs of these health professionals, in order to identify if any changes are required in relation to the delivery and content of information about recreational exercise for pregnant women.
In the UK, more than 50% of women of reproductive age (25-34 years) are overweight or obese (Baker, 2018). The promotion of recreational exercise during pregnancy as part of wider public health campaigns is key to improving the physical and mental health of women of reproductive age, as well as reducing the economic burden associated with the development of diseases such as type 2 diabetes and cardiovascular disease.
The aim of this study was to investigate the attitudes and beliefs of physiotherapists and midwives in the North of England regarding the provision of recreational exercise during pregnancy, and to identify the sources of information used to influence this.
Participants, ethics and methods
A cross-sectional questionnaire survey was used to capture views on the attitudes and beliefs about recreational exercise during pregnancy from midwives and physiotherapists across the North of England. National and international guidelines on exercise in pregnancy (ACOG, 2002; RCOG, 2006b; National Institute of Health and Care Excellence (NICE), 2010) were used in the development of the questionnaire.
Questionnaire design
The 27-item questionnaire was developed, with sections on demographic information and attitudes and beliefs.
Demographic information
This included questions relating to the participants' professional background, such as grade, number of years working in women's health and number of years working as a health professional.
Attitudes and beliefs about recreational exercise during pregnancy
This section focused on participants' beliefs about the potential benefits and risks of recreational exercise during pregnancy. Closed questions were scored on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree) to assess how much the participants agreed or disagreed with each statement. An even Likert scale was selected to force a positive or negative response from participants (Depoy and Gitlin, 2016). Questions were phrased to include a mix of positive and negative statements, with the intention of increasing respondent engagement and to avoid neutral responses.
To aid in the completion of the questionnaire and to improve consistency of interpretation, definitions for recreational exercise, modified heart rate zone, Talk test, and Borg scale of perceived exertion were provided at the end of the questionnaire. The questionnaire was piloted with two midwives and two physiotherapists working in women's health at a large hospital NHS Trust, who were representative of those in the main study. Minor amendments were made to the structure of the questionnaire following the pilot stage. No other changes were made as the pilot indicated that it addressed the aim of the study.
A cover letter outlining the context and purpose of the study was included with each questionnaire. Questionnaires were answered anonymously but each questionnaire was coded to identify the NHS Trust/midwifery unit to allow for reminder letters to be sent. The majority of the questionnaires were distributed by post; some were distributed electronically via email. Only one questionnaire was returned by email. The unnamed questionnaire attachment was printed out and the email deleted. All questionnaires distributed electronically were followed up with a hard copy due to the poor response rate electronically. Reminder letters were sent out to NHS Trusts and maternity units to improve the response rate. Ethical approval for the study was obtained from Manchester Metropolitan University.
Participants
Letters were distributed to midwifery and physiotherapy leads in all 28 NHS Trusts with maternity services in the North West of England, requesting participation in the study. Trusts included hospital and community-based maternity units. Three questionnaires were included with each letter with a request to distribute them to midwives or physiotherapists working in women's health. A total of 80 questionnaires were distributed to physiotherapy departments and 86 to maternity units in the North West of England.
In order to improve the response rate, a second batch of identical questionnaires was sent to NHS Hospital Trusts in the North East and Yorkshire and Humber regions using the same recruitment method. All Trusts with maternity services were contacted: 12 Trusts in the North East and 15 in Yorkshire and Humber region. A total of 34 questionnaires were sent to physiotherapy departments in the North East of England and 38 to the Yorkshire and Humber region, while 32 were sent to midwifery units in the North East of England and 50 to the Yorkshire and Humber region. An overall total of 320 questionnaires were distributed (168 to midwives and 152 to physiotherapists). All primary care Trusts with maternity services in North West, North East and Yorkshire and Humber regions were included.
Data analysis
Data from the closed questions were entered into SPSS version 19 and frequencies and percentages were calculated. Cross-tabulation with profession was used to show responses by profession and to identify similarities and differences. Results were presented as tables.
Results
In total, 115 completed questionnaires were returned, 71 (61.7%) from physiotherapists and 44 (38.3%) from midwives, giving an overall return rate of 36%. These data, along with the demographic data of the participants, can be seen in Table 1. Percentages were calculated per profession in order to enable comparison between responses from the two professions.
| Variable | n (%) | |
|---|---|---|
| Physiotherapist | Midwife | |
| Profession | 71 (61.7) | 44 (38.3) |
| Professional grade/band | ||
| Band 5 | 4 (5.6) | 0 (0) |
| Band 6 | 27 (38.0) | 31 (70.5) |
| Band 7 | 35 (49.3) | 10 (22.7) |
| Band 8 | 5 (7.0) | 3 (6.8) |
| Practised in women's health (years) | ||
| 0–10 | 46 (64.8) | 7 (15.9) |
| 11–20 | 17 (23.9) | 12 (27.3) |
| 21–30 | 8 (11.3) | 20 (45.4) |
| 31–40 | 0 (0.0) | 5 (11.4) |
| Practised in profession (years) | ||
| 0–10 | 19 (26.8) | 7 (15.9) |
| 11–20 | 28 (39.4) | 13 (29.5) |
| 21–30 | 14 (19.7) | 19 (43.2) |
| 31–40 | 10 (14.1) | 5 (11.4) |
Table 1 shows that almost half (n=35; 49.3%) of the physiotherapists who responded had Band 7 posts, while 27 (38%) had Band 6 posts. This indicates a high level of experience and seniority in the area of women's health, which is a recognised speciality within physiotherapy. The majority of midwives (n=31; 70.5%) had Band 6 posts and 10 (22.7%) had Band 7 posts, again indicating a high level of experience and seniority within the profession.
Table 2 shows the responses to questions on attitudes and beliefs about exercise in pregnancy by profession. Not all participants answered all questions and the resulting differing values for n are shown in Table 2, with percentages calculated accordingly. All participants agreed that giving advice on recreational exercise was an important part of antenatal care, with physiotherapists showing a higher level of strong agreement. Overall, 56% of midwives (n=23) agreed with the statement that ‘assessing a patient's fitness status before providing advice on exercise is not necessary for all patients.' All participants agreed that recreational exercise was beneficial to both the mother and the fetus. The majority of participants stated that they did not think that women should only participate in aerobic exercise, with just 11% (n=12) of participants (8 physiotherapists and 4 midwives) agreeing with the statement. Most physiotherapists and midwives agreed that pregnant women with previously sedentary lifestyles could begin recreational exercise during pregnancy (n=91; 81%). The overall level of disagreement with this was small, but higher for physiotherapists (n=16; 22.7%) compared to midwives (n=5; 11.9%). The majority of midwives (n=38; 90.5%) disagreed with the statement that ‘it is not necessary to discuss the potential risks associated with recreational exercise’. This is in contrast to the physiotherapists, where again the majority disagreed with the statement, but 15 (21.9%) agreed, suggesting that a discussion of potential risks was not necessary. The majority of participants agreed with the statement about setting a maximum heart rate of 60–70% for women who were sedentary before pregnancy, but more than 20% (n=22) of participants disagreed. This question had the lowest response rate for this section.
| Question | Profession | Strongly agree | Agree | Disagree | Strongly disagree |
|---|---|---|---|---|---|
| Providing advice on recreational exercise to patients is an important part of antenatal care | Physiotherapist (n=71) | 55 (77.5) | 16 (22.5) | 0 (0) | 0 (0) |
| Midwife (n=43) | 22 (51.2) | 21 (48.8) | 0 (0) | 0 (0) | |
| Assessing a patient's fitness status before providing advice on exercise is not necessary for all patients | Physiotherapist (n=68) | 7 (10.3) | 37 (54.4) | 13 (19.1) | 11 (16.2) |
| Midwife (n=41) | 1 (2.4) | 17 (41.5) | 16 (39) | 7 (17) | |
| Recreational exercise during pregnancy is beneficial for the mother | Physiotherapist (n=70) | 38 (54.3) | 32 (45.7) | 0 (0) | 0 (0) |
| Midwife (n=42) | 26 (61.9) | 16 (38.1) | 0 (0) | 0 (0) | |
| Recreational exercise during pregnancy is beneficial for the fetus | Physiotherapist (n=68) | 24 (35.3) | 44 (64.7) | 0 (0) | 0 (0) |
| Midwife (n=42) | 17 (40.5) | 25 (59.5) | 0 (0) | 0 (0) | |
| Patients should participate in only aerobic exercise | Physiotherapist (n=68) | 0 (0) | 8 (11.8) | 39 (57.3) | 21 (30.9) |
| Midwife (n=40) | 0 (0) | 4 (10) | 27 (67.5) | 9 (22.5) | |
| Most women who never participated in recreational exercise before pregnancy can begin exercising during pregnancy | Physiotherapist (n=70) | 8 (11.4) | 46 (65.7) | 14 (19.9) | 2 (2.8) |
| Midwife (n=42) | 7 (16.6) | 30 (71.4) | 5 (11.9) | 0 (0) | |
| It is not necessary to discuss the potential risks associated with recreational exercise with all patients | Physiotherapist (n=69) | 2 (2.9) | 13 (18.8) | 32 (46.4) | 22 (31.9) |
| Midwife (n=42) | 0 (0) | 4 (9.5) | 22 (52.4) | 16 (38.1) | |
| A maximum heart rate of 60–70% for women who were sedentary before pregnancy is advocated when participating in recreational exercise | Physiotherapist (n=62) | 7 (11.3) | 41 (66.1) | 8 (12.9) | 6 (9.7) |
| Midwife (n=34) | 2 (5.9) | 24 (70.6) | 8 (23.5) | 0 (0) |
Table 3 shows the sources of evidence used to inform practitioners about exercise during pregnancy. Use of own experience was the most popular source for both physiotherapists (74.2%) and midwives (75.1%). The second most popular was source was NICE guidelines (2010) (which was cited by 57.6% of physiotherapists and 52.8% of midwives). Despite the detailed guidance provided by RCOG (2006b), this source was only third most popular with both the physiotherapists and midwives in this study.
| Occupation | Own experience | RCOG | ACOG | NICE | Other |
|---|---|---|---|---|---|
| Physiotherapist | 49 (74.2) | 31 (47.0) | 19 (28.8) | 39 (57.6) | 12 (18.2) |
| Midwife | 27 (75.1) | 11 (30.6) | 3 (8.3) | 19 (52.8) | 4 (11.1) |
RCOG: Royal College of Obstetricians and Gynaecologists; ACOG: American College American College of Obstetricians and Gynecologists; NICE: National Institute for Health and Care Excellence
Discussion
The majority of findings in this study were positive in relation to attitudes and beliefs about recreational exercise during pregnancy. Notable positive findings included those relating to the importance of participating in recreational exercise during pregnancy, and the benefits of recreational exercise for the mother and fetus. However, there were findings that suggested that some health professionals had outdated views on specific aspects of the guidelines, such as the requirement to assess a woman's fitness before providing advice, advice for women who were inactive before pregnancy, and the type of exercise that should be included as part of an exercise programme.
All participants (n=115) agreed that providing advice about exercise during pregnancy was an important part of antenatal care. Bauer et al (2010) reported similar findings in the US, in a study that focused on midwives, medical doctors and doctors of osteopathy, while Watson et al (2015) reported that 74% of participants believed that exercise promotion was an important component of antenatal care. It is therefore clear that health professionals acknowledge the importance of exercise during pregnancy; however, according to Bauer et al (2010), many do not advise pregnant women about exercise, mostly due to time constraints. The health implications of inactivity during pregnancy are especially relevant when over 50% of women of reproductive age in the UK are overweight or obese (Baker, 2018). Promotion of recreational exercise during pregnancy as part of a wider public health agenda is necessary to enhance the health and wellbeing of both the mother and fetus.
All participants (n=115) reported that exercise was beneficial for the fetus, consistent with the study by Leiferman et al (2012), where 89% of participants agreed. Research has shown that participation in recreational exercise may have many benefits for the fetus (BØ et al, 2016). Health professionals should actively promote these to motivate women, as perceived benefits to the fetus is one of the main reasons why women participate in exercise during pregnancy (Kwolek et al, 2011). Pregnancy is therefore an opportunity to either introduce exercise to previously inactive women, or to reassure those who already participate in physical activity that it is safe to continue. This window of opportunity is an ideal time to encourage a healthy lifestyle that may contribute to future health benefits for society, such as the prevention of chronic disease.
There is also clear evidence that exercise during pregnancy is beneficial for the mother (Rogoziñska et al, 2017). All respondents to this question (n=112) agreed that recreational exercise was beneficial to the mother, consistent with findings in other studies (Leiferman et al, 2012). Evidence suggests that healthcare providers have a positive effect on women's attitudes to exercise (Williams, 2011); therefore, promoting the benefits of exercise may encourage women to participate. This may positively affect antenatal health outcomes (such as weight gain and mental health), the postpartum period and beyond (Leiferman et al, 2012).
Sedentary behaviour in any population is a risk and evidence indicates an association between this and obesity, type 2 diabetes, some cancers and metabolic dysfunction (Department of Health, 2010). Guidance from the Department of Health (2017) suggests that women who were inactive before pregnancy should begin exercise gradually, building up to a total of 150 minutes per week (Department of Health, 2017). Encouragingly, 81% (n=91) of participants agreed that it was safe for inactive women to begin exercise during pregnancy, similar to the findings by Bauer et al (2010) and Watson et al (2015). However, a proportion of participants (n=21; 19%) were still reluctant to encourage sedentary women to begin exercise during pregnancy. Indeed, another UK study reported that 39% of midwives incorrectly believed that sedentary women should not begin exercise during pregnancy (Hopkinson et al, 2018), clearly indicating a difference between guidelines and knowledge. When questioned about the sources of information used to inform practice, 74% (n=49) of physiotherapists and 75% (n=27) of midwives reported using their own experience, while only 47% (n=31) of physiotherapists and 31% (n=11) of midwives used the RCOG guidelines (RCOG, 2006b). This is similar to the findings of the study by Hopkinson et al (2018), who reported that 40% of midwives accessed evidence-based sources. Examples of other sources used were the NICE guidelines (2010), ACOG guidelines (2002), journal articles and peer discussion; however, the most common source of information used was the clinicians' own experience. The findings also suggested that midwives used specific guidelines less than physiotherapists.
‘Pregnancy is an opportunity to either introduce exercise to previously inactive women, or to reassure those who already participate in physical activity that it is safe to continue.’
More than half of the midwives (n=25; 57%) had practised in women's health for more than 20 years, compared to 11% (n=8) of physiotherapists. This may indicate a need for continuing professional development (CPD) for practising midwives on the many changes to advice about recreational exercise over the past two decades (Hopkinson et al, 2018). It may also indicate that physiotherapists who have chosen women's health as a speciality or commenced a rotation in women's health may also require additional CPD to ensure that up-to-date guidelines are used. Leiferman et al (2012) found that lack of confidence in advising about exercise may also be an important factor in determining whether health professionals provided support. This may be improved if health professionals had a good understanding and knowledge of guidelines.
A small percentage of midwives (10%, n=4) and physiotherapists (12%, n=8) believed that women should only participate in aerobic exercise. This was similar to a study by Bauer et al (2010), who found that 24% (n=93) of participants believed that pregnant women should not participate in strength training programmes, and by Watson et al (2015), who suggested that 42% (n=96) of medical practitioners would not advise a strength training programme. Many guidelines recommend strengthening programmes during pregnancy, however, citing improved posture and core strengthening, which may help in labour and prevent musculoskeletal discomforts such as back pain. Pelvic floor muscle strengthening is also an important element of any exercise programme, to reduce the prevalence of urinary incontinence. Overall, it is clear that most of the midwives and physiotherapists believed that strengthening exercises should be included as part of an exercise regime, although more research is required to investigate the specific type of exercise that should be recommended.
Fitness status should be assessed before recommending an exercise programme, to ensure that it suits the needs of each individual and excludes any contraindications. In this study, only 57% (n=62) of participants believed that it was not necessary for all women to be assessed before advice was given, similar to the findings by Leiferman et al (2012). This may be due to a lack of time or confidence in delivering this information. In a study by Boyle et al (2016), some appointments were reported to last between 5-10 minutes; therefore, in order to facilitate behaviour change, women need time to discuss and clarify any information they receive with a health professional.
Limitations
The study used a small convenience sample of midwives and physiotherapists, meaning that findings may not be generalisable. However, the participants provided a good cross-sectional representation of the target population. The method of distribution may have limitations with regard to the actual number of questionnaires that were distributed to physiotherapists and midwives and this may have resulted in selection bias. Although follow-up letters and e-mails were used to increase the response rate, it was relatively low, so further research is required to include a larger sample size and geographical area. A combination of positively and negatively worded questions were included, such as ‘Recreational exercise during pregnancy is beneficial for the fetus’ and ‘It is not necessary to discuss the potential risks associated with recreational exercise’. Although this may encourage participants to focus on the question, it does require more attention and some participants may have misinterpreted some questions.
Conclusion
Health professionals have an important role in advising pregnant women to meet recommended behaviours in pregnancy. This is particularly relevant in view of the increase in obesity among women of reproductive age (Baker, 2018). It is also important for combatting perinatal mental illnesses, which affect 1 in 5 women (NICE, 2018), as evidence suggests that engaging in exercise reduces anxiety and depressive symptoms (Robledo-Colonia et al, 2012; Daley et al, 2015).
This study found that the beliefs and attitudes of midwives and physiotherapists about the provision of recreational exercise for pregnant women in the North of England were largely positive. However, a number of health professionals had outdated attitudes and beliefs about some aspects of the guidelines, including recreational exercise for previously inactive women, the specific types of exercise that should be undertaken, assessing women's fitness levels before advising them, the maximum heart rate of previously inactive women and whether to discuss the potential risks of exercise. This suggests that further evidence-based information and training is required to ensure that midwives and physiotherapists are aware of guidelines. There may also be a need to increase content on exercise during pregnancy in the undergraduate curriculum for both midwives and physiotherapists.
Promoting healthy behaviours as part of a wider public health agenda is essential in influencing change in pregnant women. Health professionals, especially midwives, are ideally positioned to promote healthy lifestyles as part of antenatal and postnatal care, while exercise promotion and prescription are key elements of physiotherapy practice. Physiotherapists and midwives must work together to advocate a change in behaviour during this window of opportunity and make every contact count with women during pregnancy.