Running head: EFFECTS OF AEROBIC EXERCISE

Benefits of Participating in Aerobic Exercise for Mom and Baby Versus Not

Colton Graham, Daniel Macinga, Joseph Shushok, Justin Waterbeck, Louis Rescineto

04/15/2020

NURS 3749: Nursing Research

Dr. Valerie O’Dell

EFFECTS OF AEROBIC EXERCISE 12

Abstract

The purpose of this research is to study the relationship between aerobic exercise and the

effects that it has on childbearing mothers during, post pregnancy and their offspring. The focus

aerobic exercise of choice presented in this research is swimming and water aerobics. Aerobic

exercise is shown to have a positive influence on controlling gestational weight gain in pregnant

women. In turn, this leads to a more safe, healthy pregnancy, and post-partum period.

Furthermore, research explains that there is significant evidence that aerobics had a positive

effect on treating mothers with a history of or having risk for postpartum depression. Also, there

is compelling data related to the fact that aerobic exercise in minute or excess amounts imposes

risks on the mother and her fetus, but just the right amount is beneficial. Other additional benefits

such as fetal neural development and its longevity into adulthood are also discussed. However, a

true disconnect exists between the information available to mothers governing the guidelines to

exercise participation and what is being presented by practitioners of all types.

Literature Review

In order to address this issue in the nursing profession, information was found via the

MAAG library databases, EBSCO, & the Maternity and Womens Health Care text. Twelve

sources were reviewed for comprehensive data collection regarding the various effects of aerobic

exercise on mother and baby both during and after pregnancy. Gestational weight gain, water

based aerobic exercise, postpartum depression, preterm and mode of delivery, fetal neural

development, and provider involvement will be discussed.

EFFECTS OF AEROBIC EXERCISE 13

Introduction

Gestational weight gain is the amount of weight a woman gains from conception through

birth. The recommended amount of weight a woman should gain during pregnancy is anywhere

between 25- 35lbs, given they have a normal body mass index pre-pregnancy (Lowdermilk,

Perry, Cashion, Alden, and Olshansky, 2019). However, excessive gestational weight gain can be

correlated to negative health consequences for both the infant and maternal woman. Studies

show that excessive weight gain can lead to retaining this weight postpartum, thus increasing the

risk of developing comorbidities that could potentially rise from obesity (Obinna, Noel Martins,

Ifeanyichukwu, Chidubem, Petronilla, Uchechukwu, & Ekezie, 2019). With that being said,

researchers are exploring different ways to maintain adequate weight gain and a healthy lifestyle

through pregnancy and postpartum.

Maintaining adequate gestational weight gain can be crucial for a woman's health throughout

her pregnancy and even postpartum, after birth. If a woman is to exceed the recommended 35

pounds of weight gain, she is at risk to develop preeclampsia, a severe hypertensive complication

of pregnancy and her chances of cesarean birth are increased (Harris, Liu, Wilcox, Moran, &

Gallagher, 2015). Also, the woman is more likely to retain this weight in the postpartum period.

The increase in weight postpartum can lead to obesity, which poses a plethora of long-term

health risks. These health risks include diabetes, stroke, atherosclerosis, hypertension, and

cardiac disease (Obinna et al. 2019). Furthermore, excessive weight gain is also shown to

negatively affect the fetus and soon to be newborn in numerous ways. These infants are more

likely to be born premature, have a higher birth weight, and pose the risk for rapid weight gain.
EFFECTS OF AEROBIC EXERCISE 14

This increased birthweight and the rapidity of weight gain can place the child at risk for being

overweight or obese later in life (Subhan, Colman, McCargar, & Bell- The APrON Study Team,

2017).

The incidence of childhood obesity is on an incline all around the world. This poses a threat to

future generations and they may not have as much of a say in it as one would think. A study by

the APrON group makes the claim that maternal BMI and gestational weight gain play a crucial

role in influencing childhood obesity (Subhan et al. 2017). As stated previously, the increased

gestational weight gain can be a determining factor in placing the infant at risk for developing

childhood obesity. The AprOn group makes this claim after performing a study amongst 513

women. In this study, of the 513 participants, 57% were identified as gaining above the

gestational weight gain recommendations (Subhan et al. 2017). With this data, the researchers

discovered that women who gained weight in excess during pregnancy had given birth to

newborns with increased birth weight. This study concludes that increased gestational weight

gain can be a useful predictor of both infant and birth weight. It is recommended that healthcare

professionals encourage women to adhere to weight gain guidelines and participate in healthy

behaviors in order to potentially positively affect the newborn (Subhan et al. 2017).

In summary, the complications of excessive gestational weight presented above are

associated with harmful outcomes for both the mother and offspring. Furthermore, this also

creates conflict for the health care professionals and health care team as the risk of pregnancy

increases and postpartum care becomes essential. In attempts to combat this, research is being

conducted to evaluate the benefits of maintaining a gestational weight gain within the

recommended 25-35 pounds. New research shows aerobic exercise may be the answer. “Previous

studies have shown that mothers who engage in exercise during pregnancy can reduce their risks
EFFECTS OF AEROBIC EXERCISE 15

of having complications during pregnancy” (Harris et al. 2015, p. 2). So, in pregnancy, what are

the effects of aerobic exercise on both the maternal and infant compared to those not

participating in exercise?

Water Based Aerobic Exercise

In January of this year, there was a journal written about a clinical trial that pertained to

implementing a water based aerobic exercise program with women who were currently pregnant.

Water aerobics was specifically chosen for this study due to the fact that, “water-based exercise,

compared to that performed in a non-aquatic environment, was less likely to impose an excessive

load on the body”(Rodríguez-Blanque, R., Aguilar-Cordero, M. J., Marín-Jiménez, A. E., Núñez-

Negrillo, A. M. Sánchez-López, A. M., & Sánchez-García, J. C. 2020).

In the beginning, the researchers that were conducting this study reached out to 386

potential participants, detailing what the study would entail, and if they would be interested in

participating. Due to multiple factors, such as refusal to participate for unspecified reasons or

refusal due to fear of exercising during pregnancy, family obligations, or not being able to attend

at the designated times, the study was then narrowed down to 140 willing participants. In week

14 of pregnancy, half of the group was designated to the EG (Exercise group) and the other half

were designated to CG (Control group). In week 20 of pregnancy, the EG would begin the water-

based workout regimen.

The exercise regimen for this study is based on what is referred to as the SWEP method,

which “consists of performing moderate physical exercise in an aquatic environment from weeks

20-37 of gestation” (Rodríguez-Blanque et al. 2020). Each week, there were three weekly

sessions, all lasting sixty minutes. Within each session, there were three sections: a warmup
EFFECTS OF AEROBIC EXERCISE 16

phase, the main strength and aerobic exercise phase, and lastly a stretching and relaxation phase.

For 17 weeks, all participants took part consistently in the regimen, and when it came time for

these women to give birth, the results for the study were obtained.

For this study, the information that was gathered for the results came from both the

delivery process and from the status of the neonate. The apgar score, which stands for

appearance, pulse, grimace, activity, and respirations, was taken for each neonate. For the

exercise group, 67.5% of the neonates had a perfect apgar score of 10 after 5 minutes, compared

to the control group, in which only 32.5% of the neonates had a score of 10 after 5

minutes(Rodríguez-Blanque et al.,2020). Spontaneous birth rates were also measured, which is

the measurement of neonates born via a natural, vaginal delivery. Once again, the women that

followed the SWEP method had a higher spontaneous birth rate of 56.5%, compared to 43.5% of

the women who were in the control group (Rodríguez-Blanque et al. 2020). Due to there being a

lower spontaneous birth rate among the controlled group women, there were more instrumental

deliveries and cesarean sections seen.

Moreover, there is a large percentage of the pregnant female population that does not

utilize any form of exercise during their pregnancy. According to a June 2015 study, out of the

women they selected to be a part of this study, “only (8.4%) women active throughout all three

trimesters of pregnancy” (Nascimento, S. L., Surita, F. G., Godoy, A. C., Kasawara, K. T., &

Morais, S. S. 2015). However, living an active lifestyle has been proven to have many beneficial

health effects, across all walks of life, no matter what age, race, or gender. With women that are

pregnant, it is no different. Childbearing women should be encouraged to live a healthy lifestyle

not only for themselves, but also their unborn child.

EFFECTS OF AEROBIC EXERCISE 17

Furthermore, safety is a significant concern when it comes to staying active while

pregnant, and the fear of being unsafe is the reason many shy away from exercise during this

time. The study that was mentioned previously shows that water aerobic exercise, when properly

supervised, is found to be a safe and beneficial way to stay active and preform aerobic exercise

during pregnancy. Of the 8.4% of women who did stay active in the 2015 study, a significant

population used water aerobic exercise to stay active, displaying, “a consensus among pregnant

women that water aerobics is beneficial to them and their baby”(Nasimento et al. 2015). Water-

based aerobic exercise, a trusted method with research to support the utilization, can provide

women with a safe and beneficial outlet to continue being active during their pregnancy. This

will then help lead to health optimization at the time of birth for both the mother and child.

Postpartum Depression, Preterm and mode of delivery

According to Carter, T., Bastounis, A., Guo, B., & Jane Morrell, C. (2019), Postpartum

Depression can have detrimental effects on the mother’s physical and mental health an on her

child’s growth and development. In a study of primiparous and multiparous women, an

assessment was done to see the effects that physical activity or exercise had on preventing and/or

treating postpartum depression symptoms. According to WHO (2017), about 20% of women

globally experience a perinatal mental health disorder, mainly depression and anxiety, when they

are pregnant or in the perinatal period up to 52 weeks after they have given birth. It is very

important to find and treat these symptoms as early as possible so that there will be minimal

harm to the fetus and the mother during or even after pregnancy. Within the studies,

interventions such as aerobic exercise, muscle stretching and strengthening, motivational health

promotion techniques and coaching were used in order to achieve the results.
EFFECTS OF AEROBIC EXERCISE 18

In this study, 76% (13/17) of the group's interventions lasted up to 12 weeks, with four

testing interventions lasting longer than 12 weeks (Daley et al. 2015; LeCheminant et al. 2014;

Lewis et al. 2014; Surkan et al. 2012). In many of the studies, depression symptoms were

assessed using the EPDS (Edinburgh Postnatal Depression Scale). The meta-analysis was able to

find that there was a significantly moderate effect of treatment with exercise for depression

symptoms in postpartum women up to 52 weeks postpartum. According to McCurdy et al

(2017), subgroup analysis revealed that exercise-based interventions targeting at-risk women

with a history of depression or elevated depression symptoms postpartum yielded increased

treatment effects than universal preventative interventions. This suggests that exercise

interventions are best applied as a targeted preventative treatment measure intervention because

once the mother starts showing signs and physical symptoms of depression, she may be less

interested in participating in any form of exercise related to her feelings of being down, tired,

unmotivated, and much more.

As physical exercise can be beneficial for mother’s struggling with postpartum

depression, it can also play a key factor in many other aspects of pregnancy. In this next study,

the aim was to examine how physical activity and exercise habits before and during pregnancy

influence the pregnancy outcome, particularly preterm delivery and mode of delivery in a large

nationwide population-based study of 92,796 Japanese pregnant women (Takami, M., Tsuchida

et all, 2018).

Physical activity during pregnancy should contribute to cardiovascular and respiratory

improvement but depending on what kind of exercise is being done, and the intensity, it can all

have effects on the mother and her fetus. The initial data collected of mothers and their fetuses

totaled at 104,102, but after strict assessment on each mother’s charts, 11,277 women were
EFFECTS OF AEROBIC EXERCISE 19

excluded because they did not meet the criteria that was set in order to participate in the study.

Physical activity for each participant was calculated using the MET h/week (metabolic

equivalent of a task measured as the number of hours per week (Murase et al, 2014). Physical

activity for this study was defined as anytime spent being physically active whether it be work

related duties, housework, leisure activities such as swimming, running, playing light sports, ect.

Each pregnant woman answered a questionnaire about their “mean physical activity per week

before pregnancy” and also another questionnaire about their “mean physical exercise during

pregnancy”. Preterm delivery was investigated in 86,516 pregnant woman and mode of delivery

was investigated 86,295 pregnant women. The results after using the MET-hr./week tool to

measure showed that the median level of physical activity per week during pregnancy was 8.2

METs-hr./week (Takami, M., Tsuchida et al, 2018, table 1).

The results also showed that the frequency of preterm deliveries in the total deliveries in

the study was 4.5%, while the frequencies of spontaneous delivery, Caesarean delivery and

instrumental delivery (vacuum or forceps) were 75.2%, 18.8%, and 6.0% (Takami, M., Tsuchida

et al, 2018, table 2). In discussion, pre-pregnancy physical activity did not affect preterm birth or

Caesarian section delivery, but both in fact were affected when women participated in physical

activity during pregnancy. The risk of instrumental delivery increased slightly for woman who

engaged in high levels of physical activity and extremely low levels of physical activity. With

extremely low levels of physical activity also the risk of preterm delivery increased, but

moderate physical activity was shown not to increase the risk as much. It is safe to say, that too

little and too much exercise for mothers can impose a risk on her and her fetus, but just the right

amount around the moderate activity range is the best in order to achieve a natural, healthy,

viable fetus.
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Fetal/Infant Neurodevelopment

The impacts and benefits of exercise during the prenatal period go far beyond the mother.

Studies have shown that an active lifestyle during pregnancy also has effects on the fetus that

could last well into adulthood. These effects can include decreased risk of chronic disease and

obesity, improved insulin sensitivity, newborn brain development, as well as an improvement in

early neuromotor skills. It is possible that a fetus of a woman who exercises throughout her

pregnancy receives a greater amount of oxygen, more nutrients, and a greater supply of brain

derived neurotrophic factor. An infant born to a mother who exercised throughout her pregnancy

may reap numerous benefits in both mental and physical development.

Recently, researchers have delved into the impact that exercise during pregnancy has on

the functional neural activation and maturation of newborns. This has been done through EEG

testing and by analyzing an infant’s auditory event-related potentials (ERPs). By presenting the

infant with rare auditory stimuli amongst other various sounds that are considered familiar to the

infant, a slow positive mismatch response (SPMMR) wave should be produced after the infant is

exposed to the stimulus. This response is present after birth and the amplitude of the wave should

decrease throughout the first month of the baby’s life as the brain matures. One study

investigated the effects of the SPMMR in infants with mothers who exercised throughout the

pregnancy versus those who did not in attempts to look at cerebral maturation of the newborn.

In a study executed by Lebonte-Lemoyne, Curnier, and Ellemberg (2017), eighteen

newborns’ brain activity was evaluated. Half of which had mothers who exercised at least three

times a week for twenty minutes and the other half exercised less than one session a week. They

found that the infants of those who exercised three or more times a week had a significantly
EFFECTS OF AEROBIC EXERCISE 1 11

lower amplitude SPMMR response in the frontal brain region. This means that the infants with

exercising mothers displayed a more mature brain response to both sound discrimination and

auditory memory than those with sedentary mothers. This could be a long-term benefit for the

infant being that sound discrimination and auditory memory are key components of language

development.

Another potentially long-term benefit of an infant whose mother was active throughout

pregnancy is improved neuromotor development. Improved neuromotor development at a young

age can lead to various positive outcomes for a child. First, it has been shown that children who

develop motor skills earlier in life are more likely to become active later in childhood. This

phenomenon has the potential to decrease the child’s risk of developing obesity, improve their

mental health, and improve bone density. Furthermore, previous studies have shown a

relationship between earlier gross motor skill development during the first year of life and a

lower level of body fat by the time the same child has reached three years of age.

Specifically, a study executed by McMillan, May, Gaines, Isler, and Kuehn (2019),

looked at one-month old infants of mothers who participated in a supervised aerobic exercise

program versus those who were completely sedentary. They analyzed the data of 60 infants and

found that infants of exercising mothers scored higher on overall Gross Motor Quotient, as well

as Locomotion and Stationary skills (PDMS-2). Other studies have found similar results that

follow the same trend of higher motor skill development in infants to mothers who were

physically active. Children who develop motor skills earlier in their lives may be more likely to

remain active throughout life and may be less susceptible to various sedentary risk factors. The

increase in brain maturation is proven to lead to improvements in overall physical health as these

individuals are often more active and develop a higher level of language development that leads
EFFECTS OF AEROBIC EXERCISE 1 12

to a higher intellectual compacity. The increase in Neurodevelopment that is obtained through

exercise during pregnancy will positively impact the individual far past infancy. The mothers

exercise impacts the infant’s motor skills, and the more developed they are the more active they

infant will be. The infants are less likely to be born as big babies or become obese later in

childhood. By exercising during pregnancy, the mother can acclimate the child early on to

activity and improve their overall motor development leading to increased movement in the

infant.

The Providers Part

While a lack of support system or motivation, an inability to seek out resources, or

participation in exercise during previous pregnancies may deter a woman from seeking guidance,

an additional component to consider should be the provider. A study by Crampton, O’Brien, &

Heathcote (2018) looked at various aspects of knowledge and care provided by midwives and

physiotherapists in the North of England. Baker, 2018 (as cited in Crampton, O’Brien, &

Heathcote 2018) found that “In the UK, more than 50% of women of reproductive age (25-34

years) are overweight or obese” (p.456). The ability of a healthcare provider to positively impact

the expecting mother is not only crucial in terms of her own health while carrying the child, but

also the health of both baby and mom following pregnancy. 320 questionnaires composed of 27

questions scaled on responses of strongly agree, agree, disagree, and strongly disagree were sent

out. 168 went to midwives and 152 went to physiotherapists, encompassing all the maternity

services in the North of England (Crampton, O’Brien, & Heathcote, 2018, p.457). In total, 115

questionnaires were returned: 71 by physiotherapists and 44 by midwives.

EFFECTS OF AEROBIC EXERCISE 1 13

A demographic of the individuals that did respond was obtained, finding that 73.2% of

the physiotherapists and 84.1% of the midwives had worked in the profession and were

considered to have seniority within their department for greater than 11 years (Crampton,

O’Brien, & Heathcote, 2018, p.458). While seniority typically translates to experience, this may

be an indication that some of the individuals who have worked for 30 or 40 years may be out of

touch with the current guidelines and advisories for women considering exercise. In examining

the questionnaire, specific questions and responses by the practitioners were focused on. All

midwives and physiotherapists either agreed or strongly agreed that recreational exercise during

pregnancy is beneficial for both mom and baby. While all physiotherapists and midwives agreed

that providing advice on exercise as part of antenatal care was important, 35.3% of

physiotherapists and 56% of midwives felt no benefit in assessing fitness status before providing

advice (Crampton, O’Brien, & Heathcote, 2018, p.457). According to the article, “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 used the Royal College of Obstetricians and Gynecologists

guidelines”, American College of Obstetricians and Gynecologists, or the National Institute for

Health and Care Excellence (Crampton, O’Brien, & Heathcote, 2018, p.459).

A similar study was conducted involving 500 randomly selected chiropractors actively

practicing and registered through the College of Chiropractors of Ontario. Comparatively to the

study above, only 86 surveys were completed. Specific criteria were taken into consideration,

including gender, experience, and type of practice (Weis, C. A., Baas, E., Ciesla, K., Kimpinski,

C., & Landsman, V., 2019, p.9-10). In looking at results amongst all groups, there was no data of

marginal difference.
EFFECTS OF AEROBIC EXERCISE 1 14

When asked what type of postgraduate education respondents had received regarding

exercise and pregnancy, approximately a third of all participants indicated that they had

received no postgraduate training. Of the knowledge gained after graduation, almost half

of the participants reported that they were self-taught and approximately 40% of

chiropractors learned guidelines through conferences and seminars (Weis, C. A., Baas,

E., Ciesla, K., Kimpinski, C., & Landsman, V., 2019, p.9-10).

Analysis of the study found a near even split between participants when asked about the

likelihood of providing exercise examples, advice, and intensity/duration (Weis, C. A., Baas, E.,

Ciesla, K., Kimpinski,C., & Landsman, V., 2019, p.9). This was further analyzed in the means

that the information being provided to patients was being obtained. 63.5% of participants

reported having not seen the current pregnancy exercise literature, while 11.8% admitted to using

a source that was being updated at the time the study was being conducted (Weis, C. A., Baas,

E., Ciesla, K., Kimpinski,C., & Landsman, V., 2019, p.9). While both studies would benefit from

a larger sample size, both studies showed a range opinion and knowledge amongst providers

(Weis, C. A., et. al (2019); Crampton, O’Brien, & Heathcote, 2018). Another important

component to look at would be the length of visit between provider and patient. If only a short

time frame is made available for each mother, she may feel pressured into not asking questions.

Conversely, the provider may not be as thorough in their assessment of the patient due to time

constraints.

Conclusion

When addressing the question: In pregnancy, how does participating in aerobic exercise,

compared to those not participating in aerobic exercise influence outcomes for both the mother
EFFECTS OF AEROBIC EXERCISE 1 15

and infant during pregnancy and postpartum, studies showed that aerobic exercise had multiple

benefits on the mother and her child in every different stage of pregnancy compared to those who

did not exercise at all. It was also shown that there are imposed risks on the mother and her baby

if she is participating in exercises that are much too extensive for her during the pregnancy

process. Additional studies looking at knowledge base and beliefs of the various providers who

treat these same women found that these individuals were either not confident in providing care

or not updated on the current standards of care.

EFFECTS OF AEROBIC EXERCISE 1 16

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