- Email: [email protected]
Women’s exercise beliefs and behaviors during their pregnancy and postpartum
Women’s Exercise Beliefs and Behaviors During Their Pregnancy and Postpartum Danielle Symons Downs, PhD, and Heather A. Hausenblas, PhD Limited research examines women’s beliefs about the value of exercise and their actual exercise behaviors during pregnancy and postpartum. A retrospective study of 74 postpartum women was conducted to examine women’s behavioral, normative, and control beliefs about exercising during pregnancy and postpartum and to determine their most salient beliefs. In addition, women’s prepregnancy, pregnancy, and postpartum exercise behavior was examined. We found that 1) the most common exercise beliefs during pregnancy were that exercise improves mood and physical limitations (e.g., nausea) obstructed exercise participation; 2) the most common exercise beliefs during postpartum were that exercise controls weight gain and a lack of time obstructed exercise participation; 3) women’s husband/partner and family members most strongly influenced their pregnancy and postpartum exercise behavior; and 4) women exercised more before they were pregnant than during pregnancy and postpartum. Researchers and health care professionals are encouraged to examine and understand women’s beliefs about exercising during their pregnancy and postpartum and design their interventions accordingly, in an attempt to increase women’s exercise behavior during their childbearing years. J Midwifery Womens Health 2004;49:138 –144 © 2004 by the American College of Nurse-Midwives. keywords: exercise beliefs, behavior, pregnancy, postpartum
INTRODUCTION Many scientific and medical innovations have occurred over the past 50 years to increase people’s life span, including organ transplants, microscopic surgery, and gene therapy.1 Despite these advances, chronic behavioral diseases are currently responsible for the greatest mortality among U.S. adults.2,3 A lack of physical activity is a major risk factor for cardiovascular and obesity-related diseases, and it is a central focus for the prevention agenda in the United States and worldwide.3 The people most at risk for a sedentary lifestyle include special populations such as women.2 Promoting physical activity in at-risk populations is difficult due to the unique barriers obstructing their participation, which are not found in non-risk populations. For example, life events unique to women (e.g., pregnancy and postpartum) may place them at greater risk for decreased physical activity than men. The purposes of this study were to examine women’s beliefs about exercising during their pregnancy and postpartum with the objective of determining which beliefs are most salient and to examine women’s prepregnancy, pregnancy, and postpartum exercise behavior. EXERCISE AND PREGNANCY Pregnancy is an important time in women’s lives that may promote decreased physical activity. For example, Zhang and Savitz4 conducted a prevalence study on nearly 10,000 pregnant U.S. women, and they found that almost 60% were sedentary, placing them above the national average (i.e., 30% of U.S. adults are sedentary).2 For many women, exercising during their pregnancy is compromised by the
Address correspondence to Danielle Symons Downs, PhD, Department of Kinesiology, 267-N Recreation Building, The Pennsylvania State University, University Park, PA 16802-5701. E-mail: [email protected]
138 © 2004 by the American College of Nurse-Midwives Issued by Elsevier Inc.
physical and psychological demands that occur during this time.5,6 Consequently, many women find these added demands stressful, and thus, they either decrease or stop exercising during their pregnancy. Thus, although pregnancy is a temporary stage in women’s lives unlike lifelong chronic conditions (e.g., disability or diabetes), it is nonetheless an important event that may promote decreased physical activity. Despite the concerns about exercising during pregnancy, there is a general consensus that most healthy women can exercise during their pregnancy without risk to either themselves or their fetus.5,7 According to the American College of Obstetricians and Gynecologists (ACOG)8 and the American College of Sports Medicine (ACSM),9 pregnant women without obstetric or medical problems are encouraged to engage in at least 30 minutes of moderate exercise a day (i.e., avoiding exercises with risk of abdominal trauma). In addition, some researchers have found that exercising during pregnancy is associated with decreased depression, improved self-esteem and body image, and controlled excessive weight gain.5 Thus, exercise may be beneficial for the nearly 400,000 women in the United States who are diagnosed with postpartum depression each year10 and the 75% of women who are concerned about their weight in the first few weeks of postpartum.11 Although exercise is encouraged by organizations such as the ACOG8 and ACSM,9 the research examining how women feel about participating in exercise during their pregnancy and postpartum is scant. In addition, most of the exercise and pregnancy literature has focused on the physical effects of exercise during pregnancy (i.e., risk to the fetus), and few studies have examined its psychosocial effects on the mother.4 Other limitations of the literature include small sample sizes, few studies examining exercise behavior across pregnancy and postpartum, non-standardized exercise measures, and a lack of theoretical studies.12 Volume 49, No. 2, March/April 2004 1526-9523/04/$30.00 • doi:10.1016/j.jmwh.2003.11.009
Figure 1. Conceptual representation of the theory of planned behavior. (Adapted from Ajzen.14) Behavioral beliefs influence attitude, normative beliefs form subjective norm, and control beliefs influence perceived behavioral control. Attitude, subjective norm, and perceived behavior control influence intention, which in turn, influences behavior. In addition, perceived behavior control may influence behavior directly.
Theoretical research examining women’s exercise beliefs is needed before programs can be designed to effectively promote exercise adoption, motivation, and adherence during pregnancy and postpartum.13 CONCEPTUAL FRAMEWORK FOR STUDYING WOMEN’S EXERCISE BELIEFS One conceptual framework that may provide researchers and health care professionals with a better understanding of women’s exercise beliefs during pregnancy and postpartum is the theory of planned behavior.14 The theory of planned behavior is a social-cognitive framework that suggests a person’s beliefs about a behavior influence his or her way of thinking (i.e., attitude), motivation to comply with the wishes and desires of others (i.e., subjective norm), and evaluation of how easy or difficult it will be to adopt a behavior (i.e., perceived behavioral control). According to the model, there are three types of beliefs (Figure 1). First, behavioral beliefs are determined by an individual’s perceived positive and negative consequences of a behavior, and they form his or her attitude toward the behavior. For example, a woman may believe that exercise will improve her health, but it is also time consuming.
Danielle Symons Downs, PhD, is an Assistant Professor of Kinesiology at The Pennsylvania State University and the director of the Exercise Psychology Laboratory at Penn State, University Park, PA. Heather A. Hausenblas, PhD, is an Assistant Professor of Exercise and Sport Sciences at the University of Florida and the director of the Exercise Psychology Laboratory at Florida, Gainesville, FL.
Journal of Midwifery & Women’s Health • www.jmwh.org
Second, normative beliefs are formed by a person’s perception that important others think he or she should engage in a behavior, and they provide the structure for subjective norm. For example, if a woman believes that her spouse wants her to exercise, and she values her spouse’s opinion, her subjective norm for exercise will be higher. Third, control beliefs are developed from an individual’s perception that he or she has the necessary resources, skills, and power to engage in a behavior, and they establish the framework for perceived behavioral control. For example, the more resources and skills a woman has for exercise (e.g., intrinsic motivation and supportive family and friends) and the fewer obstacles she anticipates (e.g., lack of child care or lack of time), the greater her perceived control for exercising. In short, a main premise of the theory of planned behavior is that a person will intend to engage in a behavior when he or she evaluates it positively (attitude), believes that significant others want him or her to participate in it (subjective norm), and perceive it to be under his or her control (perceived behavioral control).14 The findings from statistical reviews of the theory of planned behavior and exercise literature15,16 support this theory as a framework for explaining people’s exercise beliefs, attitude, subjective norm, perceived behavioral control, intention, and behavior. Although other conceptual frameworks have been used to explain people’s exercise behavior (e.g., health belief model, self-efficacy theory), the theory of planned behavior is the most validated model, and it provides health care professionals with a practical way to identify people’s exercise beliefs. More specifically, 139
the theory of planned behavior uses an elicitation study to identify the salient behavioral, normative, and control beliefs of a population. Ajzen and Fisbein17 recommended that an elicitation study be done by 1) using open-ended questions to retrospectively elicit the beliefs (i.e., retrospective accounts are recommended because there has been time for people’s beliefs to form; KS Courneya, personal communication, 2002); and 2) performing a content analysis (frequency count) to rank-order the beliefs. Then, structured items can be developed from the most salient beliefs to examine people’s attitude, subjective norm, and perceived behavioral control. Once the beliefs are identified, an intervention can then be tailored to meet the specific needs of the participants. Subsequently, the participants’ exercise attitude, subjective norm, perceived behavioral control, intention, and behavior can be assessed at baseline and follow-up to determine the effectiveness of the intervention. Elicitation studies have been used to examine the exercise beliefs of many populations. For healthy populations, salient behavioral beliefs facilitating exercise are that it 1) improves health, 2) elevates mood, and 3) controls weight gain.18 Common normative beliefs are that family members, friends, and health care professionals want people to exercise.19 Frequently reported control beliefs preventing people from exercising include 1) health issues (e.g., pain, injury, or illness); 2) lack of time; and 3) lack of motivation.20 It is important to note, however, that exercise beliefs vary across populations. For example, in a recent review of 47 theories of planned behavior exercise elicitation studies, Symons Downs and Hausenblas21 found that behavioral beliefs were different for cancer patients (e.g., exercise helps with surgery recovery) than for healthy college students (e.g., exercise improves image and controls weight). These findings illustrate the importance of examining exercise beliefs for each population, and they demonstrate that even though there is consistency in exercise beliefs across some populations, unique beliefs (and motivations for exercise) do emerge that may be critical in designing specific exercise interventions. Despite the effectiveness of the theory of planned behavior for explaining exercise behavior and the practical utility of the theory for identifying people’s exercise beliefs, its application for explaining pregnant and postpartum women’s exercise beliefs and behavior is limited. In addition, a comprehensive examination of pregnant and postpartum women’s behavioral, normative, and control beliefs for exercise has not been done. Furthermore, research is needed to examine women’s exercise behavior through different periods in pregnancy and postpartum to determine when, if ever, they return to their prepregnancy exercise level. Thus, the primary purpose of this study was to retrospectively examine the frequency of women’s behavioral, normative, and control beliefs for exercising during their pregnancy and postpartum and to determine their most 140
salient beliefs. Because the aim of elicitation studies is to generate people’s beliefs and because beliefs are expected to vary across time and situation,14 no a priori hypotheses were established for the women’s beliefs. The secondary purpose was to examine the participants’ self-reported prepregnancy, pregnancy, and postpartum exercise behavior. On the basis of previous research,4,16 it was hypothesized that the participants’ mild, moderate, and strenuous prepregnancy exercise behavior would be greater than their pregnancy and postpartum exercise behavior. METHODS Postpartum women within 1 year of a child’s birth were recruited from the office of a private practice physician specializing in obstetrics and gynecology in New Britain, Connecticut. The Leisure-Time Exercise Questionnaire22 assesses the frequency of strenuous, moderate, and mild leisure time exercise done for at least 15 minutes during a typical week. A total exercise index (in weekly metabolic equivalents) is calculated by weighing the frequency of each intensity and summing them for a total score with the following formula: 3 (mild) ⫹ 5 (moderate) ⫹ 9 (strenuous). The Leisure-Time Exercise Questionnaire is a valid and reliable measure of exercise behavior.23 Participants completed this measure with references to their prepregnancy, pregnancy, and postpartum mild, moderate, and strenuous exercise behavior. The participants reported their exercise beliefs during pregnancy and postpartum by using open-ended statements in an Exercise Beliefs Questionnaire developed for this study based on the theory of planned behavior guidelines17 and specific procedures for questionnaire development.24 Following each statement were five blank lines for participants to record as many beliefs that applied to them. Behavioral beliefs facilitating exercise were measured by the following two questions: “List the main advantages of exercising [during your pregnancy, following the birth of your child].” Normative beliefs were measured by the following two questions: “List the individuals or groups who were most important to you when you thought about exercising [during your pregnancy, following the birth of your child].” Control beliefs obstructing exercise were assessed by the following two questions: “List the main factors that prevented you from exercising [during your pregnancy, following the birth of your child].” Content validity was established by having two theory of planned behavior and exercise experts examine the items, and 100% content validity agreement was obtained. Approval was obtained from the University’s Institutional Review Board to conduct this study. Consent was obtained from a private practice physician specializing in obstetrics and gynecology who agreed to assist with the data collection. Postpartum women within 1 year of a child’s birth seeing their physician for a postdelivery or annual check-up were recruited for the study. While they Volume 49, No. 2, March/April 2004
waited for their appointment, those who agreed to participate received from the nurse a packet that contained the consent form, general demographic questions, LeisureTime Exercise Questionnaire, and the Exercise Beliefs Questionnaire. Completion of the packets took about 10 minutes. When finished, each participant was instructed to place their consent form and questionnaires in the sealed envelope provided for them and return it to the receptionist’s desk. From a total of 74 packets that were distributed to the participants in the physician’s office, 74 women completed and returned their questionnaires—a 100% response rate. All participants were treated in accordance with the guidelines for human participants as specified by the American Psychological Association. To assess the salient exercise beliefs, we followed the recommendations of Ajzen and Fishbein17 and used a five-step procedure. First, the raw data themes (i.e., openended responses) were tabulated and categorized by belief type (behavioral, normative, or control) for pregnancy and postpartum. Second, the raw data themes were organized into higher-order themes based on common themes that emerged from the participants’ responses.25 Third, to determine the most salient beliefs, a content analysis was conducted by 1) sorting participant’s responses into sets with the same underlying belief, 2) obtaining a frequency count to determine the most salient beliefs, and 3) doublechecking the belief sets to ensure that they were appropriately sorted.25 Fourth, the belief sets were reviewed by four theories of planned behavior and exercise experts to determine consistency in the classifications. Finally, the beliefs were rank-ordered from the most to the least salient. When we examined the participants’ prepregnancy, pregnancy, and postpartum exercise behavior, we found that the data were significantly skewed at P ⬍ .05. Data such as time, counts, and metabolic equivalents (i.e., the Leisure-Time Exercise Questionnaire) may not be normally distributed, and thus, using parametric analysis of variance procedures would be inappropriate because the assumption of normalcy is not met.26 Instead, non-parametric rank-order procedures based on the general linear model (L statistic) were undertaken for the repeated measures analyses.27 To determine the meaningfulness of these results, effect sizes were calculated by using 2 with .20, .50, and .80 representing small, medium, and large effects, respectively.28
Table 1. Exercise Beliefs Reported During Pregnancy and Postpartum Belief Themes Pregnancy Behavioral Beliefs (Advantages) Improves overall mood Increases energy and stamina/endurance Stay fit (e.g., in shape, keep muscle tone, to walk) Controls weight Assist in labor and delivery (e.g., makes delivery easier/faster) Provides stress reduction/relaxation Normative Beliefs (Influences) Husband or fiance´ Children Other family members (parents, siblings, grandparents) Friends Health care professionals Gym instructors Control Beliefs (Obstructing Factors) Physical limitations and restrictions (e.g., nausea, vomiting) Tiredness and fatigue/no energy Time limits (lacking time) Gaining weight (too big) Caring for other children Fear of harming self/baby Bad weather No motivation/feeling lazy Postpartum Behavioral Beliefs (Advantages) Controls weight Stay fit (e.g., in shape, keep muscle tone, to walk) Improves overall mood Increases energy and stamina Decreases physical discomfort (e.g., relieves cramps, soreness, swelling) Provides stress reduction/relaxation Normative Beliefs (Influences) Husband or fiance´ Other family members (parents, siblings, grandparents) Children Friends Health care professionals Gym instructor Control Beliefs (Obstructing Factors) Time limits (lacking time) Physical limitations and restrictions (e.g., nausea, vomiting) Tiredness and fatigue/no energy Fear of harming self No motivation/feel lazy
N
%*
25 22 16 14
33.8 29.7 21.6 18.9
11 6
14.9 8.1
27 13 11 9 2 2
36.5 17.6 14.9 12.2 2.7 2.7
42 20 19 10 7 7 6 6
56.8 27.0 25.7 13.5 9.5 9.5 8.1 8.1
28 27 23 22
37.8 36.5 31.1 29.7
3 2
4.1 2.7
28 25 7 9 5 1
37.8 33.8 9.5 12.2 6.8 1.4
36
48.6
16 10 8 6
21.6 13.5 10.8 8.1
* May not add up to 100% because some participants reported multiple beliefs.
RESULTS Participants were 74 postpartum women between 6 days and 5 months (mean ⫽ 3.52 months) following the birth of a baby (mean age ⫽ 31.30 years; SD ⫽ 4.37; age range ⫽ 19 – 40 years). Most of the participants were white (81.1%), married (86.5%), college graduates (44.6%), working full time (55.1%), business employees (39.2%), and earning a family income of $40,000 to $100,000 (62.2%). Journal of Midwifery & Women’s Health • www.jmwh.org
Exercise Beliefs A detailed list of the exercise beliefs for pregnancy and postpartum are located in Table 1. The salient behavioral advantages during pregnancy were that exercise: improves overall mood (33.8%), increases energy/stamina (29.7%), assists with staying fit (21.6%), and controls weight. For exercising during postpartum, the salient advantages were 141
Table 2. Mean (M), Standard Deviation (SD), L Statistic, and 2 Values for Mild, Moderate, and Strenuous Exercise Behavior Variable Strenuous exercise Prepregnancy Pregnancy Postpartum Moderate exercise Prepregnancy Pregnancy Postpartum Mild exercise Prepregnancy Pregnancy Postpartum
M*
SD
13.81‡ 3.38 5.48
16.39 9.45 10.71
13.07‡ 8.10 6.50
10.02 8.54 8.12
9.57‡ 7.20 6.38
7.50 6.72 6.25
L
P
2†
19.44
⬍.001
.54
14.25
⬍.01
.41
10.64
⬍.05
.32
* The mean scores are composite scores in total metabolic equivalents (METS) derived from the Leisure-Time Exercise Questionnaire using the formula: mild ⫽ 3 METS (frequency of mild exercise), moderate ⫽ 5 METS (frequency of moderate exercise), and strenuous ⫽ 9 METS (frequency of strenuous exercise); 1 MET is equivalent to a metabolic rate of consuming 1) 3.5 mL of oxygen per kilogram of body weight/minute and 2) 1 kilocalorie per kilogram of body weight/hour.
2 was used to determine the size of the effect with .20, .50, and .80 representing small, medium, and large effects, respectively.28 ‡ Prepregnancy significant at P ⬍ .01 when compared to pregnancy and postpartum metabolic equivalent values in all categories of exercise activity. †
that exercise controls weight (37.8%), assists with staying fit (36.5%), and improves overall mood (31.1%). For exercising during pregnancy, the salient normative influences were family members, including husband or fiance´ (36.5%), children (17.6%), and other family members (e.g., parents, siblings, or grandparents) (14.9%). Similarly, for exercising during postpartum, the most frequently reported normative beliefs were the influence of family members, including husband or fiance´ (37.8%) and other family members (e.g., parents, siblings, or grandparents) (18.9%), followed by friends (14.9%). The salient control beliefs obstructing exercise during pregnancy were physical limitations or restrictions (56.8%), tiredness/fatigue (27.0%), time limits (25.7%), and gaining weight (13.5%). For exercising during postpartum, frequently obstructing control beliefs were time limits (48.6%), physical limitations or restrictions (21.6%), and tiredness/fatigue (13.5%). Exercise Behavior Table 2 displays the mean, standard deviation, L statistic, and 2 values for the exercise scores. Significant differences across time (i.e., from prepregnancy to pregnancy to postpartum) were found for strenuous exercise behavior, L (3) ⫽ 19.44, P ⬍ .001, 2 ⫽ .54. Follow-up pairwise comparisons indicated that women’s prepregnancy strenuous exercise was higher than their pregnancy and postpartum exercise. Similarly, significant differences across time were found for moderate exercise behavior, L (3) ⫽ 14.25, 142
P ⬍ .01, 2 ⫽ .41, with post hoc tests indicating that women’s prepregnancy moderate exercise was higher than their pregnancy and postpartum exercise. In addition, significant differences across time were found for mild exercise behavior, L (3) ⫽ 10.64, P ⬍ .05, 2 ⫽ .32. Post hoc tests found that women’s prepregnancy mild exercise was higher than their pregnancy and postpartum exercise. No significant differences in women’s mild, moderate, and strenuous exercise behavior were found comparing pregnancy to postpartum (P ⬎ .05). DISCUSSION The primary purpose of this study was to examine the frequency of women’s behavioral, normative, and control beliefs for exercising during their pregnancy and postpartum and to determine their most salient exercise beliefs using the framework of the theory of planned behavior.14 The secondary purpose was to examine women’s exercise behavior before pregnancy, during pregnancy, and postpartum. In general, the women reported a variety of exercise beliefs during their pregnancy and postpartum, and they exercised more before pregnancy than during pregnancy and postpartum. Several findings warrant discussion. First, the frequency of behavioral beliefs facilitating exercise varied between pregnancy and postpartum. These findings are consistent with previous research14,20 that has found people’s beliefs can vary depending on the time and situation. For example, the most common behavioral advantage during pregnancy was that exercise improved women’s mood; whereas postpartum, it was that exercise controlled women’s weight. Thus, health care professionals should consider the differences in women’s beliefs about the advantages of exercise when designing exercise interventions. More specifically, they may want to focus on methods that help to elevate women’s mood during pregnancy (e.g., muscle relaxing or imagery techniques) compared with techniques that assist women with controlling their weight in postpartum (e.g., proper dieting and calorie expending activities such as aerobics or running). Second, consistent with previous research,21 the most common normative influence during pregnancy and postpartum was from the women’s husband or fiance´ . Health care professionals designing interventions may want to consider including a woman’s partner to increase exercise behavior during pregnancy or postpartum. It is important to note that the women did not identify their clinician as a salient normative influence for exercising during pregnancy or postpartum. Considering that 70% of adults are examined by a health care provider at least one time per year, some researchers29 have suggested that health care providers may play a valuable role in promoting exercise behavior with their patients. In particular, pregnant women visit their health care provider on a regular basis and often have weekly visits during the third trimester. Thus, they have the opportunity to provide exercise counseling and support to Volume 49, No. 2, March/April 2004
their pregnant and postpartum clients. Further research is needed to examine if health care providers are aware of the current ACOG8 and ACSM9 guidelines for exercising during pregnancy or postpartum and whether they are confident in providing exercise prescriptions to their pregnant patients. Third, the frequency of control beliefs obstructing exercise varied between pregnancy and postpartum. During pregnancy, the most common control beliefs obstructing exercise were physical limitations and restrictions; whereas postpartum, it was having a lack of time. Thus, health care professionals aiming to decrease exercise barriers during pregnancy may consider techniques that make women feel more comfortable (e.g., home exercise programs tailored to women’s specific needs or water calisthenics). Alternatively in postpartum, they may focus on methods that provide women with useful skills for scheduling exercise into their daily routines (e.g., time management, organizing, or goal setting). More research is needed to examine the effectiveness of these techniques for increasing pregnancy and postpartum exercise behavior. Fourth, consistent with the hypothesis, the participants’ prepregnancy Leisure-Time Exercise Questionnaire scores were higher than their pregnancy and postpartum scores. That is, women in this study participated in more mild, moderate, and strenuous exercise behavior before they were pregnant than during their pregnancy and postpartum. In addition, there were no differences between women’s exercise behavior in pregnancy and during the postpartum period evaluated. These findings are consistent with previous researchers’ conclusions that pregnancy and having a child can decrease exercise behavior.2– 4 Although the temporary decrease in exercise during pregnancy and postpartum may not be harmful, over time, lower levels of exercise behavior are associated with an increased risk of cardiovascular-related diseases, overweight/obesity, and decreased longevity.2,3 Thus, more research is warranted that promotes exercising during pregnancy and postpartum and that longitudinally examines women’s exercise behavior to determine when, if ever, women return to their prepregnancy exercise behavior. There are three limitations of this study that should be noted. First, the majority of the participants were middle to upper class White women. Because beliefs and values about exercise can vary across populations, there is limited generalizability of the findings to low socioeconomic and ethnic minority populations. Second, participants were not asked to report the number of children they had; thus, we could not compare the exercise beliefs and behaviors of women with one child to women with more than one child. Third, it was our original intention to compare women’s exercise beliefs and behaviors up to 1 year postpartum. However, most of the women in this study were between 3 and 4 months postpartum; thus, we could not compare the findings from women in early, middle, and late postpartum. Future research is needed to examine postpartum women’s Journal of Midwifery & Women’s Health • www.jmwh.org
exercise beliefs and behaviors at various stages of postpartum to determine when and if women return to their regular exercise routines. CONCLUSION Pregnancy induces a tremendous amount of physical and psychological stress on a woman’s body including changes in weight, posture, diet, and cardiovascular and gastrointestinal functioning.5 Despite these demands, exercise during pregnancy and postpartum is a beneficial and recommended activity for alleviating negative physical and psychological symptoms.8 The findings from our study indicated that women’s beliefs about exercising varied from pregnancy to postpartum and that exercise behavior decreased from prepregnancy to postpartum. Thus, pregnancy and postpartum are critical events in a woman’s life that may further promote a sedentary lifestyle. We recommend that researchers and health care professionals use women’s beliefs about exercise as the framework for designing their intervention programs in an attempt to increase women’s pregnancy and postpartum exercise behavior. The authors thank Dr. Andreoli and the patients and staff at Grove Hill Medical Center in New Britain, CT for their assistance with this study.
REFERENCES 1. Eaton SB, Strassman BI, Nesse RM, Neel JV, Ewald PW, Williams GC, et al. Evolutionary health promotion. Prev Med 2002; 34:109 –18. 2. United States Department of Health and Human Services. Physical activity and health: A report of the surgeon general. Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996. 3. U.S. Department of Health and Human Services. Healthy People 2010: Conference Edition (two volumes). Washington (DC): Centers for Disease Control and Prevention, 2000. 4. Zhang J, Savitz DA. Exercise during pregnancy among U.S. women. Ann Epidemiol 1996;6:53–9. 5. Bungum TJ, Peaslee DL, Jackson AW, Perez MA. Exercise during pregnancy and type of delivery in nulliparae. J Obstet Gynecol Neonatal Nurs 2000;29:258 –64. 6. Carter AS, Baker CW, Brownell KD. Body mass index, eating attitudes and symptoms of depression and anxiety in pregnancy and the postpartum period. Psychosom Med 2000;62:264 –70. 7. Lokey EA, Tran ZV, Wells CL, Myers BC, Tran AC. Effects of physical exercise on pregnancy outcomes: A meta-analytic review. Med Sci Sports Exerc 1991;23:1234 –9. 8. American College of Obstetricians and Gynecologists. Exercise during pregnancy and the postpartum period (ACOG Committee Opinion No 267). Obstet Gynecol 2002;99:171–3. 9. American College of Sports Medicine. Guidelines for exercise testing and prescription, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2000.
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20. Carron AV, Hausenblas HA, Estabrooks P. The psychology of physical activity. New York: McGraw Hill, 2003.
11. Hisner P. Concerns of multiparas during the second postpartum week. J Obstet Gynecol Neonatal Nurs 1986;16:195–203.
21. Symons Downs D, Hausenblas HA. Elicitation studies and the theory of planned behavior: A systematic review of exercise beliefs. Psychol Sport Exerc. In press.
12. Maddux JE, DuCharme KA. Behavioral intentions in theories of health behavior. In: Gochman DS, editor. Handbook of health behavior research. New York: Plenium, 1997:133–51. 13. Dishman RD. The problem of exercise adherence: Fighting sloth in nations with market economies. Quest 2000;53:270 –94.
22. Godin G, Jobin J, Bouillon J. Assessment of leisure time exercise behavior by self-report: A concurrent validity study. Can J Public Health 1986;77:359 –61.
14. Ajzen I. The theory of planned behavior. Organiz Behav Human Decision Process 1991;50:179 –211.
23. Jacobs D, Ainsworth B, Hartman T, Leon A. A simultaneous evaluation of 10 commonly used physical activity questionnaires. Med Sci Sports Exerc 1993;25:81–91.
15. Hagger MS, Chatzisarantis NLD, Biddle SJH. A meta-analytic review of the theories of reasoned action and planned behavior in physical activity: Predictive validity and the contribution of additional variables. J Sport Exerc Psychol 2002;24:3–32.
24. Ajzen I. Constructing a TPB questionnaire: Conceptual and methodological considerations [Internet]. 2002. [Accessed January 25, 2002.] Available from: http://www-unix.oit.umass.edu/⬃aizen/ pdf/tpb.measurement.pdf.
16. Hausenblas HA, Carron AV, Mack DE. Application of the theories of reasoned action and planned behavior to exercise behavior: A meta-analysis. J Sport Exerc Psychol 1997;19:36 –51.
25. Patton MQ. Qualitative evaluation and research methods. 2nd ed. Newbury Park (CA): Sage, 1990.
17. Ajzen I, Fishbein M. Understanding attitudes and predicting social behavior. Englewood Cliffs (NJ): Prentice-Hall, 1980. 18. Terry DJ, O’Leary JE. The theory of planned behavior: The effects of perceived behavioral control and self-efficacy. Br J Soc Psychol 1995;34:199 –220. 19. Norman P, Smith L. The theory of planned behavior and exercise: An investigation into the role of prior behavior, behavioral intentions, and attitude variability. Eur J Soc Psychol 1995;25:403– 15.
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Volume 49, No. 2, March/April 2004
INTRODUCTION Many scientific and medical innovations have occurred over the past 50 years to increase people’s life span, including organ transplants, microscopic surgery, and gene therapy.1 Despite these advances, chronic behavioral diseases are currently responsible for the greatest mortality among U.S. adults.2,3 A lack of physical activity is a major risk factor for cardiovascular and obesity-related diseases, and it is a central focus for the prevention agenda in the United States and worldwide.3 The people most at risk for a sedentary lifestyle include special populations such as women.2 Promoting physical activity in at-risk populations is difficult due to the unique barriers obstructing their participation, which are not found in non-risk populations. For example, life events unique to women (e.g., pregnancy and postpartum) may place them at greater risk for decreased physical activity than men. The purposes of this study were to examine women’s beliefs about exercising during their pregnancy and postpartum with the objective of determining which beliefs are most salient and to examine women’s prepregnancy, pregnancy, and postpartum exercise behavior. EXERCISE AND PREGNANCY Pregnancy is an important time in women’s lives that may promote decreased physical activity. For example, Zhang and Savitz4 conducted a prevalence study on nearly 10,000 pregnant U.S. women, and they found that almost 60% were sedentary, placing them above the national average (i.e., 30% of U.S. adults are sedentary).2 For many women, exercising during their pregnancy is compromised by the
Address correspondence to Danielle Symons Downs, PhD, Department of Kinesiology, 267-N Recreation Building, The Pennsylvania State University, University Park, PA 16802-5701. E-mail: [email protected]
138 © 2004 by the American College of Nurse-Midwives Issued by Elsevier Inc.
physical and psychological demands that occur during this time.5,6 Consequently, many women find these added demands stressful, and thus, they either decrease or stop exercising during their pregnancy. Thus, although pregnancy is a temporary stage in women’s lives unlike lifelong chronic conditions (e.g., disability or diabetes), it is nonetheless an important event that may promote decreased physical activity. Despite the concerns about exercising during pregnancy, there is a general consensus that most healthy women can exercise during their pregnancy without risk to either themselves or their fetus.5,7 According to the American College of Obstetricians and Gynecologists (ACOG)8 and the American College of Sports Medicine (ACSM),9 pregnant women without obstetric or medical problems are encouraged to engage in at least 30 minutes of moderate exercise a day (i.e., avoiding exercises with risk of abdominal trauma). In addition, some researchers have found that exercising during pregnancy is associated with decreased depression, improved self-esteem and body image, and controlled excessive weight gain.5 Thus, exercise may be beneficial for the nearly 400,000 women in the United States who are diagnosed with postpartum depression each year10 and the 75% of women who are concerned about their weight in the first few weeks of postpartum.11 Although exercise is encouraged by organizations such as the ACOG8 and ACSM,9 the research examining how women feel about participating in exercise during their pregnancy and postpartum is scant. In addition, most of the exercise and pregnancy literature has focused on the physical effects of exercise during pregnancy (i.e., risk to the fetus), and few studies have examined its psychosocial effects on the mother.4 Other limitations of the literature include small sample sizes, few studies examining exercise behavior across pregnancy and postpartum, non-standardized exercise measures, and a lack of theoretical studies.12 Volume 49, No. 2, March/April 2004 1526-9523/04/$30.00 • doi:10.1016/j.jmwh.2003.11.009
Figure 1. Conceptual representation of the theory of planned behavior. (Adapted from Ajzen.14) Behavioral beliefs influence attitude, normative beliefs form subjective norm, and control beliefs influence perceived behavioral control. Attitude, subjective norm, and perceived behavior control influence intention, which in turn, influences behavior. In addition, perceived behavior control may influence behavior directly.
Theoretical research examining women’s exercise beliefs is needed before programs can be designed to effectively promote exercise adoption, motivation, and adherence during pregnancy and postpartum.13 CONCEPTUAL FRAMEWORK FOR STUDYING WOMEN’S EXERCISE BELIEFS One conceptual framework that may provide researchers and health care professionals with a better understanding of women’s exercise beliefs during pregnancy and postpartum is the theory of planned behavior.14 The theory of planned behavior is a social-cognitive framework that suggests a person’s beliefs about a behavior influence his or her way of thinking (i.e., attitude), motivation to comply with the wishes and desires of others (i.e., subjective norm), and evaluation of how easy or difficult it will be to adopt a behavior (i.e., perceived behavioral control). According to the model, there are three types of beliefs (Figure 1). First, behavioral beliefs are determined by an individual’s perceived positive and negative consequences of a behavior, and they form his or her attitude toward the behavior. For example, a woman may believe that exercise will improve her health, but it is also time consuming.
Danielle Symons Downs, PhD, is an Assistant Professor of Kinesiology at The Pennsylvania State University and the director of the Exercise Psychology Laboratory at Penn State, University Park, PA. Heather A. Hausenblas, PhD, is an Assistant Professor of Exercise and Sport Sciences at the University of Florida and the director of the Exercise Psychology Laboratory at Florida, Gainesville, FL.
Journal of Midwifery & Women’s Health • www.jmwh.org
Second, normative beliefs are formed by a person’s perception that important others think he or she should engage in a behavior, and they provide the structure for subjective norm. For example, if a woman believes that her spouse wants her to exercise, and she values her spouse’s opinion, her subjective norm for exercise will be higher. Third, control beliefs are developed from an individual’s perception that he or she has the necessary resources, skills, and power to engage in a behavior, and they establish the framework for perceived behavioral control. For example, the more resources and skills a woman has for exercise (e.g., intrinsic motivation and supportive family and friends) and the fewer obstacles she anticipates (e.g., lack of child care or lack of time), the greater her perceived control for exercising. In short, a main premise of the theory of planned behavior is that a person will intend to engage in a behavior when he or she evaluates it positively (attitude), believes that significant others want him or her to participate in it (subjective norm), and perceive it to be under his or her control (perceived behavioral control).14 The findings from statistical reviews of the theory of planned behavior and exercise literature15,16 support this theory as a framework for explaining people’s exercise beliefs, attitude, subjective norm, perceived behavioral control, intention, and behavior. Although other conceptual frameworks have been used to explain people’s exercise behavior (e.g., health belief model, self-efficacy theory), the theory of planned behavior is the most validated model, and it provides health care professionals with a practical way to identify people’s exercise beliefs. More specifically, 139
the theory of planned behavior uses an elicitation study to identify the salient behavioral, normative, and control beliefs of a population. Ajzen and Fisbein17 recommended that an elicitation study be done by 1) using open-ended questions to retrospectively elicit the beliefs (i.e., retrospective accounts are recommended because there has been time for people’s beliefs to form; KS Courneya, personal communication, 2002); and 2) performing a content analysis (frequency count) to rank-order the beliefs. Then, structured items can be developed from the most salient beliefs to examine people’s attitude, subjective norm, and perceived behavioral control. Once the beliefs are identified, an intervention can then be tailored to meet the specific needs of the participants. Subsequently, the participants’ exercise attitude, subjective norm, perceived behavioral control, intention, and behavior can be assessed at baseline and follow-up to determine the effectiveness of the intervention. Elicitation studies have been used to examine the exercise beliefs of many populations. For healthy populations, salient behavioral beliefs facilitating exercise are that it 1) improves health, 2) elevates mood, and 3) controls weight gain.18 Common normative beliefs are that family members, friends, and health care professionals want people to exercise.19 Frequently reported control beliefs preventing people from exercising include 1) health issues (e.g., pain, injury, or illness); 2) lack of time; and 3) lack of motivation.20 It is important to note, however, that exercise beliefs vary across populations. For example, in a recent review of 47 theories of planned behavior exercise elicitation studies, Symons Downs and Hausenblas21 found that behavioral beliefs were different for cancer patients (e.g., exercise helps with surgery recovery) than for healthy college students (e.g., exercise improves image and controls weight). These findings illustrate the importance of examining exercise beliefs for each population, and they demonstrate that even though there is consistency in exercise beliefs across some populations, unique beliefs (and motivations for exercise) do emerge that may be critical in designing specific exercise interventions. Despite the effectiveness of the theory of planned behavior for explaining exercise behavior and the practical utility of the theory for identifying people’s exercise beliefs, its application for explaining pregnant and postpartum women’s exercise beliefs and behavior is limited. In addition, a comprehensive examination of pregnant and postpartum women’s behavioral, normative, and control beliefs for exercise has not been done. Furthermore, research is needed to examine women’s exercise behavior through different periods in pregnancy and postpartum to determine when, if ever, they return to their prepregnancy exercise level. Thus, the primary purpose of this study was to retrospectively examine the frequency of women’s behavioral, normative, and control beliefs for exercising during their pregnancy and postpartum and to determine their most 140
salient beliefs. Because the aim of elicitation studies is to generate people’s beliefs and because beliefs are expected to vary across time and situation,14 no a priori hypotheses were established for the women’s beliefs. The secondary purpose was to examine the participants’ self-reported prepregnancy, pregnancy, and postpartum exercise behavior. On the basis of previous research,4,16 it was hypothesized that the participants’ mild, moderate, and strenuous prepregnancy exercise behavior would be greater than their pregnancy and postpartum exercise behavior. METHODS Postpartum women within 1 year of a child’s birth were recruited from the office of a private practice physician specializing in obstetrics and gynecology in New Britain, Connecticut. The Leisure-Time Exercise Questionnaire22 assesses the frequency of strenuous, moderate, and mild leisure time exercise done for at least 15 minutes during a typical week. A total exercise index (in weekly metabolic equivalents) is calculated by weighing the frequency of each intensity and summing them for a total score with the following formula: 3 (mild) ⫹ 5 (moderate) ⫹ 9 (strenuous). The Leisure-Time Exercise Questionnaire is a valid and reliable measure of exercise behavior.23 Participants completed this measure with references to their prepregnancy, pregnancy, and postpartum mild, moderate, and strenuous exercise behavior. The participants reported their exercise beliefs during pregnancy and postpartum by using open-ended statements in an Exercise Beliefs Questionnaire developed for this study based on the theory of planned behavior guidelines17 and specific procedures for questionnaire development.24 Following each statement were five blank lines for participants to record as many beliefs that applied to them. Behavioral beliefs facilitating exercise were measured by the following two questions: “List the main advantages of exercising [during your pregnancy, following the birth of your child].” Normative beliefs were measured by the following two questions: “List the individuals or groups who were most important to you when you thought about exercising [during your pregnancy, following the birth of your child].” Control beliefs obstructing exercise were assessed by the following two questions: “List the main factors that prevented you from exercising [during your pregnancy, following the birth of your child].” Content validity was established by having two theory of planned behavior and exercise experts examine the items, and 100% content validity agreement was obtained. Approval was obtained from the University’s Institutional Review Board to conduct this study. Consent was obtained from a private practice physician specializing in obstetrics and gynecology who agreed to assist with the data collection. Postpartum women within 1 year of a child’s birth seeing their physician for a postdelivery or annual check-up were recruited for the study. While they Volume 49, No. 2, March/April 2004
waited for their appointment, those who agreed to participate received from the nurse a packet that contained the consent form, general demographic questions, LeisureTime Exercise Questionnaire, and the Exercise Beliefs Questionnaire. Completion of the packets took about 10 minutes. When finished, each participant was instructed to place their consent form and questionnaires in the sealed envelope provided for them and return it to the receptionist’s desk. From a total of 74 packets that were distributed to the participants in the physician’s office, 74 women completed and returned their questionnaires—a 100% response rate. All participants were treated in accordance with the guidelines for human participants as specified by the American Psychological Association. To assess the salient exercise beliefs, we followed the recommendations of Ajzen and Fishbein17 and used a five-step procedure. First, the raw data themes (i.e., openended responses) were tabulated and categorized by belief type (behavioral, normative, or control) for pregnancy and postpartum. Second, the raw data themes were organized into higher-order themes based on common themes that emerged from the participants’ responses.25 Third, to determine the most salient beliefs, a content analysis was conducted by 1) sorting participant’s responses into sets with the same underlying belief, 2) obtaining a frequency count to determine the most salient beliefs, and 3) doublechecking the belief sets to ensure that they were appropriately sorted.25 Fourth, the belief sets were reviewed by four theories of planned behavior and exercise experts to determine consistency in the classifications. Finally, the beliefs were rank-ordered from the most to the least salient. When we examined the participants’ prepregnancy, pregnancy, and postpartum exercise behavior, we found that the data were significantly skewed at P ⬍ .05. Data such as time, counts, and metabolic equivalents (i.e., the Leisure-Time Exercise Questionnaire) may not be normally distributed, and thus, using parametric analysis of variance procedures would be inappropriate because the assumption of normalcy is not met.26 Instead, non-parametric rank-order procedures based on the general linear model (L statistic) were undertaken for the repeated measures analyses.27 To determine the meaningfulness of these results, effect sizes were calculated by using 2 with .20, .50, and .80 representing small, medium, and large effects, respectively.28
Table 1. Exercise Beliefs Reported During Pregnancy and Postpartum Belief Themes Pregnancy Behavioral Beliefs (Advantages) Improves overall mood Increases energy and stamina/endurance Stay fit (e.g., in shape, keep muscle tone, to walk) Controls weight Assist in labor and delivery (e.g., makes delivery easier/faster) Provides stress reduction/relaxation Normative Beliefs (Influences) Husband or fiance´ Children Other family members (parents, siblings, grandparents) Friends Health care professionals Gym instructors Control Beliefs (Obstructing Factors) Physical limitations and restrictions (e.g., nausea, vomiting) Tiredness and fatigue/no energy Time limits (lacking time) Gaining weight (too big) Caring for other children Fear of harming self/baby Bad weather No motivation/feeling lazy Postpartum Behavioral Beliefs (Advantages) Controls weight Stay fit (e.g., in shape, keep muscle tone, to walk) Improves overall mood Increases energy and stamina Decreases physical discomfort (e.g., relieves cramps, soreness, swelling) Provides stress reduction/relaxation Normative Beliefs (Influences) Husband or fiance´ Other family members (parents, siblings, grandparents) Children Friends Health care professionals Gym instructor Control Beliefs (Obstructing Factors) Time limits (lacking time) Physical limitations and restrictions (e.g., nausea, vomiting) Tiredness and fatigue/no energy Fear of harming self No motivation/feel lazy
N
%*
25 22 16 14
33.8 29.7 21.6 18.9
11 6
14.9 8.1
27 13 11 9 2 2
36.5 17.6 14.9 12.2 2.7 2.7
42 20 19 10 7 7 6 6
56.8 27.0 25.7 13.5 9.5 9.5 8.1 8.1
28 27 23 22
37.8 36.5 31.1 29.7
3 2
4.1 2.7
28 25 7 9 5 1
37.8 33.8 9.5 12.2 6.8 1.4
36
48.6
16 10 8 6
21.6 13.5 10.8 8.1
* May not add up to 100% because some participants reported multiple beliefs.
RESULTS Participants were 74 postpartum women between 6 days and 5 months (mean ⫽ 3.52 months) following the birth of a baby (mean age ⫽ 31.30 years; SD ⫽ 4.37; age range ⫽ 19 – 40 years). Most of the participants were white (81.1%), married (86.5%), college graduates (44.6%), working full time (55.1%), business employees (39.2%), and earning a family income of $40,000 to $100,000 (62.2%). Journal of Midwifery & Women’s Health • www.jmwh.org
Exercise Beliefs A detailed list of the exercise beliefs for pregnancy and postpartum are located in Table 1. The salient behavioral advantages during pregnancy were that exercise: improves overall mood (33.8%), increases energy/stamina (29.7%), assists with staying fit (21.6%), and controls weight. For exercising during postpartum, the salient advantages were 141
Table 2. Mean (M), Standard Deviation (SD), L Statistic, and 2 Values for Mild, Moderate, and Strenuous Exercise Behavior Variable Strenuous exercise Prepregnancy Pregnancy Postpartum Moderate exercise Prepregnancy Pregnancy Postpartum Mild exercise Prepregnancy Pregnancy Postpartum
M*
SD
13.81‡ 3.38 5.48
16.39 9.45 10.71
13.07‡ 8.10 6.50
10.02 8.54 8.12
9.57‡ 7.20 6.38
7.50 6.72 6.25
L
P
2†
19.44
⬍.001
.54
14.25
⬍.01
.41
10.64
⬍.05
.32
* The mean scores are composite scores in total metabolic equivalents (METS) derived from the Leisure-Time Exercise Questionnaire using the formula: mild ⫽ 3 METS (frequency of mild exercise), moderate ⫽ 5 METS (frequency of moderate exercise), and strenuous ⫽ 9 METS (frequency of strenuous exercise); 1 MET is equivalent to a metabolic rate of consuming 1) 3.5 mL of oxygen per kilogram of body weight/minute and 2) 1 kilocalorie per kilogram of body weight/hour.
2 was used to determine the size of the effect with .20, .50, and .80 representing small, medium, and large effects, respectively.28 ‡ Prepregnancy significant at P ⬍ .01 when compared to pregnancy and postpartum metabolic equivalent values in all categories of exercise activity. †
that exercise controls weight (37.8%), assists with staying fit (36.5%), and improves overall mood (31.1%). For exercising during pregnancy, the salient normative influences were family members, including husband or fiance´ (36.5%), children (17.6%), and other family members (e.g., parents, siblings, or grandparents) (14.9%). Similarly, for exercising during postpartum, the most frequently reported normative beliefs were the influence of family members, including husband or fiance´ (37.8%) and other family members (e.g., parents, siblings, or grandparents) (18.9%), followed by friends (14.9%). The salient control beliefs obstructing exercise during pregnancy were physical limitations or restrictions (56.8%), tiredness/fatigue (27.0%), time limits (25.7%), and gaining weight (13.5%). For exercising during postpartum, frequently obstructing control beliefs were time limits (48.6%), physical limitations or restrictions (21.6%), and tiredness/fatigue (13.5%). Exercise Behavior Table 2 displays the mean, standard deviation, L statistic, and 2 values for the exercise scores. Significant differences across time (i.e., from prepregnancy to pregnancy to postpartum) were found for strenuous exercise behavior, L (3) ⫽ 19.44, P ⬍ .001, 2 ⫽ .54. Follow-up pairwise comparisons indicated that women’s prepregnancy strenuous exercise was higher than their pregnancy and postpartum exercise. Similarly, significant differences across time were found for moderate exercise behavior, L (3) ⫽ 14.25, 142
P ⬍ .01, 2 ⫽ .41, with post hoc tests indicating that women’s prepregnancy moderate exercise was higher than their pregnancy and postpartum exercise. In addition, significant differences across time were found for mild exercise behavior, L (3) ⫽ 10.64, P ⬍ .05, 2 ⫽ .32. Post hoc tests found that women’s prepregnancy mild exercise was higher than their pregnancy and postpartum exercise. No significant differences in women’s mild, moderate, and strenuous exercise behavior were found comparing pregnancy to postpartum (P ⬎ .05). DISCUSSION The primary purpose of this study was to examine the frequency of women’s behavioral, normative, and control beliefs for exercising during their pregnancy and postpartum and to determine their most salient exercise beliefs using the framework of the theory of planned behavior.14 The secondary purpose was to examine women’s exercise behavior before pregnancy, during pregnancy, and postpartum. In general, the women reported a variety of exercise beliefs during their pregnancy and postpartum, and they exercised more before pregnancy than during pregnancy and postpartum. Several findings warrant discussion. First, the frequency of behavioral beliefs facilitating exercise varied between pregnancy and postpartum. These findings are consistent with previous research14,20 that has found people’s beliefs can vary depending on the time and situation. For example, the most common behavioral advantage during pregnancy was that exercise improved women’s mood; whereas postpartum, it was that exercise controlled women’s weight. Thus, health care professionals should consider the differences in women’s beliefs about the advantages of exercise when designing exercise interventions. More specifically, they may want to focus on methods that help to elevate women’s mood during pregnancy (e.g., muscle relaxing or imagery techniques) compared with techniques that assist women with controlling their weight in postpartum (e.g., proper dieting and calorie expending activities such as aerobics or running). Second, consistent with previous research,21 the most common normative influence during pregnancy and postpartum was from the women’s husband or fiance´ . Health care professionals designing interventions may want to consider including a woman’s partner to increase exercise behavior during pregnancy or postpartum. It is important to note that the women did not identify their clinician as a salient normative influence for exercising during pregnancy or postpartum. Considering that 70% of adults are examined by a health care provider at least one time per year, some researchers29 have suggested that health care providers may play a valuable role in promoting exercise behavior with their patients. In particular, pregnant women visit their health care provider on a regular basis and often have weekly visits during the third trimester. Thus, they have the opportunity to provide exercise counseling and support to Volume 49, No. 2, March/April 2004
their pregnant and postpartum clients. Further research is needed to examine if health care providers are aware of the current ACOG8 and ACSM9 guidelines for exercising during pregnancy or postpartum and whether they are confident in providing exercise prescriptions to their pregnant patients. Third, the frequency of control beliefs obstructing exercise varied between pregnancy and postpartum. During pregnancy, the most common control beliefs obstructing exercise were physical limitations and restrictions; whereas postpartum, it was having a lack of time. Thus, health care professionals aiming to decrease exercise barriers during pregnancy may consider techniques that make women feel more comfortable (e.g., home exercise programs tailored to women’s specific needs or water calisthenics). Alternatively in postpartum, they may focus on methods that provide women with useful skills for scheduling exercise into their daily routines (e.g., time management, organizing, or goal setting). More research is needed to examine the effectiveness of these techniques for increasing pregnancy and postpartum exercise behavior. Fourth, consistent with the hypothesis, the participants’ prepregnancy Leisure-Time Exercise Questionnaire scores were higher than their pregnancy and postpartum scores. That is, women in this study participated in more mild, moderate, and strenuous exercise behavior before they were pregnant than during their pregnancy and postpartum. In addition, there were no differences between women’s exercise behavior in pregnancy and during the postpartum period evaluated. These findings are consistent with previous researchers’ conclusions that pregnancy and having a child can decrease exercise behavior.2– 4 Although the temporary decrease in exercise during pregnancy and postpartum may not be harmful, over time, lower levels of exercise behavior are associated with an increased risk of cardiovascular-related diseases, overweight/obesity, and decreased longevity.2,3 Thus, more research is warranted that promotes exercising during pregnancy and postpartum and that longitudinally examines women’s exercise behavior to determine when, if ever, women return to their prepregnancy exercise behavior. There are three limitations of this study that should be noted. First, the majority of the participants were middle to upper class White women. Because beliefs and values about exercise can vary across populations, there is limited generalizability of the findings to low socioeconomic and ethnic minority populations. Second, participants were not asked to report the number of children they had; thus, we could not compare the exercise beliefs and behaviors of women with one child to women with more than one child. Third, it was our original intention to compare women’s exercise beliefs and behaviors up to 1 year postpartum. However, most of the women in this study were between 3 and 4 months postpartum; thus, we could not compare the findings from women in early, middle, and late postpartum. Future research is needed to examine postpartum women’s Journal of Midwifery & Women’s Health • www.jmwh.org
exercise beliefs and behaviors at various stages of postpartum to determine when and if women return to their regular exercise routines. CONCLUSION Pregnancy induces a tremendous amount of physical and psychological stress on a woman’s body including changes in weight, posture, diet, and cardiovascular and gastrointestinal functioning.5 Despite these demands, exercise during pregnancy and postpartum is a beneficial and recommended activity for alleviating negative physical and psychological symptoms.8 The findings from our study indicated that women’s beliefs about exercising varied from pregnancy to postpartum and that exercise behavior decreased from prepregnancy to postpartum. Thus, pregnancy and postpartum are critical events in a woman’s life that may further promote a sedentary lifestyle. We recommend that researchers and health care professionals use women’s beliefs about exercise as the framework for designing their intervention programs in an attempt to increase women’s pregnancy and postpartum exercise behavior. The authors thank Dr. Andreoli and the patients and staff at Grove Hill Medical Center in New Britain, CT for their assistance with this study.
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