Interventions to increase self-reported physical activity during pregnancy: A systematic review

Abstract

Background:

Only 52% of pregnant women achieve the recommended amount of physical activity throughout pregnancy. Many studies have aimed to improve health-related outcomes by introducing physical activity interventions during pregnancy. A systematic search summarizing studies using self-reported physical activity measures is necessary, as this is a clinical outcome measure that can be utilized routinely in clinical practice.

Objectives:

The purpose of this systematic review was to synthesize, critically appraise, and determine the effectiveness of interventions designed to improve self-reported measures of physical activity in pregnant women.

Design:

Systematic review.

Data Sources and Methods:

EBSCO and PubMed were searched from January 1, 2014, through January 1, 2024. A hand search of references was also performed. Included studies must have utilized a randomized controlled trial or clinical trial design where a physical activity intervention was implemented, included healthy pregnant women, and utilized a self-reported physical activity measure pre- and post-intervention. Two reviewers independently appraised each article with the Physiotherapy Evidence Database scale. The Strength of Recommendation Taxonomy was used to make an overall strength of recommendation.

Results:

Twelve studies met the inclusion criteria for this systematic review. Seven studies were ranked as “fair” quality, and five studies were ranked as “good” quality. The primary groupings of the interventions included the following: phone or app-based, face-to-face counseling, or group fitness classes/access to local resources. Eight studies provided sufficient data to calculate effect sizes and associated 95% confidence intervals. The largest effect sizes were calculated for the phone or app-based interventions.

Conclusions:

A level B strength of recommendation was given to evidence supporting phone or app-based interventions, counseling interventions, and group fitness or access to local resources interventions. Future research should focus on further investigating the use of phone or app-based interventions or counseling interventions to promote physical activity among pregnant women.

Registration:

Prospero CRD42024526761

Keywords

subjective physical activity maternal health fetal health

Introduction

There are many known benefits, for both the mother and fetus, of women participating in regular physical activity (PA) during pregnancy. PA during pregnancy is associated with decreased risk of developing depression, preeclampsia, and gestational diabetes,¹ as well as improved symptoms of pregnancy-related pain^2,3 and decreased fatigue.³ In addition, both light intensity and moderate to vigorous intensity PA during pregnancy have been found to have a negative linear relationship with the incidence of spontaneous rupture of the fetal membrane before onset of labor.⁴ Consistent participation in PA throughout pregnancy has also been shown to benefit the fetus by reducing the risk of macrosomia, or excessive weight at birth, which increases the likelihood of operative deliveries, birth trauma, and postpartum hemorrhage.⁵ Conversely, a lack of participation in PA throughout pregnancy has been linked to negative health outcomes for expectant mothers and their babies.^6
–8 Women who were sedentary during pregnancy have reported a higher incidence of excessive gestational weight gain, gestational diabetes mellitus, hypertensive disorders, preterm birth, and cesarean section deliveries, which introduce risk to the birthing process and overall health of the mother.^6,8 PA dose has a linear relationship with infant heart measures.⁷ Decreased PA during pregnancy is associated with decreased infant cardiac function (stroke volume, cardiac output, cardiac index) and increased infant heart rate, while increased PA during pregnancy is associated with increased infant cardiac function and decreased heart rate.⁷ There are many positive outcomes associated with participation in PA for both the mother and fetus, and inversely, negative outcomes for both the mother and fetus when there is a lack of PA during pregnancy. The U.S. Department of Health and Human Services Physical Activity Guidelines for Americans recommends at least 150 min of moderate intensity aerobic PA per week throughout pregnancy for optimal health outcomes.⁹ In addition to this, it is recommended that activity is spread throughout the week, and women who engaged in vigorous intensity aerobic PA prior to pregnancy continue such activities during pregnancy.⁸ The American College of Obstetricians and Gynecologists recommends that pregnant women follow the U.S Department of Health and Human Services Physical Activity Guidelines of at least 150 min of moderate intensity aerobic PA weekly throughout pregnancy, as long as they have been screened by a clinician and are free of contraindications to exercise.⁸ Pregnant women are encouraged to achieve at least 20–30 min/day of moderate intensity PA.⁸ Although these widely accepted guidelines exist for PA during pregnancy, it is estimated that only 52% of pregnant women achieve the recommended 150 min of moderate aerobic PA weekly during the duration of their pregnancy.⁶ With the inconsistency of PA among pregnant women comes a need to identify interventions that are effective in improving PA engagement in this population. In addition, we must identify a reliable self-report measure of PA during pregnancy to more accurately assess how much PA pregnant women are actually engaging in.

Many studies have aimed to improve health-related outcomes by introducing PA interventions during pregnancy. Previous systematic reviews have been conducted to identify interventions that increase PA during pregnancy. However, this work focused on objective measures of PA (Fitbit and other wearables)¹⁰ or included trials that did not have physical activity as a primary outcome measure.¹¹ This method of measuring PA, however, is not commonly utilized in a clinical setting due to the cost of distributing wearable devices and associated programming.¹² A recent systematic review of the literature examined the effectiveness of intervention strategies to improve objective measures of PA during pregnancy. This review included 18 studies in total, 13 of which encompassed multi-component lifestyle interventions for pregnant women that included PA, and 5 which were strictly interventions designed to improve PA in pregnant women.¹⁰ The results of the systematic review⁸ determined that pregnant women in a PA intervention group completed 435–449 more steps per day, as well as gained 0.69 kg less than women in control groups.¹⁰ In addition, larger effect sizes were seen in studies with multi-component lifestyle interventions that promoted PA in comparison to studies that were interventions to promote PA alone.¹⁰ While this review was informative, specific to increasing objective PA, it can be rather difficult and costly to measure PA objectively for all pregnant women. An exploration of the existing literature specific to existing interventions designed to increase self-reported PA may provide healthcare providers with additional successful interventions to implement with their patients and resources available within their clinic. Therefore, the purpose of this systematic review was to synthesize, critically appraise, and determine the effectiveness of interventions designed to improve self-reported measures of PA in pregnant women.

Methods

Literature search strategy

The reporting of this study conforms to the PRISMA statement.¹³ In January 2024, the primary author conducted an advanced computerized search of EBSCO Host (Academic Search Complete, CINAHL Complete, MEDLINE, SportDiscus) and PubMed to identify studies that implemented an intervention to increase subjectively measured PA participation in pregnant women. The Boolean search terms used are shown in Table 1. The search was limited to studies published from January 1, 2014, to January 1, 2024. In addition to the electronic search, a hand search of references was performed to identify any additional articles to be screened for inclusion.

Table 1.

Search strategy.

Step	Search terms	Boolean operator	EBSCO host	PubMed
1	Physical activity, intervention, pregnant women, randomized controlled trial	AND	449	347
2	1, low-back pain, depression, post-natal	NOT	384	303
Duplicates removed			147	0
Total			237	303

Eligibility criteria

The primary author screened the articles returned by the systematic search for inclusion. First, titles were screened for inclusion. Second, if a title was unclear, the primary author reviewed the abstract. All studies that were not excluded based on the title and abstract were further screened for inclusion by full text. A second reviewer was consulted if the primary author was unable to determine whether the study should be included in the final analysis.

Inclusion criteria

Only studies that utilized a randomized controlled trial or clinical trial design with both a control and intervention group were included. Only studies that included healthy pregnant women, regardless of trimester or PA status, were included in this systematic review. The studies must have implemented an intervention specifically designed to increase PA in pregnant women. There were no additional limitations on PA interventions. Studies must have included a self-reported PA assessment as a primary outcome and must have assessed PA pre- and post-intervention at a minimum. All studies must have been published in English and peer-reviewed journals.

Exclusion criteria

Studies were excluded if they included pregnant women with known health conditions (e.g., hypertension, low-back pain, diabetes (type 1, type 2, or gestational), depression, or other mental-health disorders). Studies were also excluded if PA was only measured objectively or if the intervention was not specifically designed to increase PA. In addition, studies were excluded if not written in English or did not utilize a randomized controlled/clinical trial design.

Quality assessment

Each article was assessed for methodological quality using the 11-item Physiotherapy Evidence Database (PEDro) scale.¹⁴ Items were scored as present (1) or absent (0) with a total possible score of 10. The PEDro scale has demonstrated fair to excellent inter-rater reliability when assessing the quality of randomized controlled trials reporting interventions.¹⁵ Overall study quality was deemed poor if the PEDro scores ranged from 0 to 3, fair if they ranged from 4 to 5, good if they ranged from 6 to 8, and excellent if scores ranged from 9 to 10.⁸ Two reviewers independently assessed the methodological quality of each study using the PEDro scale. If a protocol paper was published and referenced within the study being assessed for methodological quality, then it was pulled and reviewed while completing the PEDro scale. Any disagreements on quality were resolved by discussion or a third reviewer.

Data extraction

Following the literature search, pertinent data were extracted from all identified studies meeting the inclusion criteria by the primary author. For this systematic review, authors’ names, year of publication, study design, and location of study were extracted. In addition, inclusion and exclusion criteria of the participants, description of the intervention and control/comparison, measure of subjective PA utilized, assessment timepoints, and overall findings were also extracted. All extracted data were logged in a data extraction table.

Data analysis

Hedge’s g effect sizes and 95% confidence intervals were calculated for the studies that provided means and standard deviations to examine the magnitude of the difference in PA between groups for each PA outcome at the post-intervention time point. The included studies utilized five PA outcome measurements: the Pregnancy Physical Activity Questionnaire (PPAQ), International Physical Activity Questionnaire (IPAQ), Physical Activity Readiness Medical Examination (PARMED-X) for Pregnancy, Survey of Lifestyle, Attitudes, and Nutrition (SLAN), and the Short Questionnaire to Assess Health-Enhancing Physical Activity (SQUASH). For all outcome measures analyzed, a positive effect size indicated a higher self-reported PA level in the intervention group compared to the control/comparison group post-intervention. Interventions were interpreted as having a small effect size (0.20), a medium effect size (0.50), or a large effect size (0.8).¹⁶

Level of evidence and strength of recommendation

The primary author assessed the level of evidence of the included studies using the Strength of Recommendation Taxonomy (SORT).¹⁷ The SORT method was chosen to grade each body of evidence based on the straightforwardness of the SORT grading guidelines, as well as its applicability to grade evidence based on patient-oriented outcomes.¹⁷ The SORT grades the body of evidence as A, B, or C based on the level of evidence of independent studies, the type of outcomes measured (e.g., patient-reported outcomes), the number of studies and the consistency of outcomes across the evidence as a whole, and the relationship between benefits, harm, and costs.¹⁷ A SORT recommendation of “A” is given if the included studies are consistent and of good-quality patient-oriented evidence, a “B” if studies are inconsistent in their findings or limited-quality patient-oriented evidence, and a “C” if studies are based on consensus, usual practice, disease-oriented evidence, case series for studies of treatment or screening, and/or opinion.¹⁷

Results

Search strategy

The initial search strategy in EBSCOhost retrieved 237 articles after the removal of duplicates. Of the 237 articles assessed for eligibility, 19 articles met the inclusion criteria for this systematic review (Figure 1). An additional search of PubMed retrieved 303 articles, where 6 more articles met the inclusion criteria for this systematic review. Five additional articles were retrieved through a hand search of references.

Figure 1.

Systematic search results.

After full-text review of 30 articles, 9 articles were excluded due to self-reported measures of PA only being used at one time point in the study,¹⁸ patient populations that did not meet the inclusion criteria,^19
–24 utilizing only objective measures of PA,²⁵ or were a protocol paper only and did not include any data.²⁶ Nine additional articles were excluded as PA was not measured as a primary outcome.^27
–35 This left a total of 12 articles to be reviewed.

Quality assessment

Initially, the two reviewers agreed on 91.7% of items (121/132) on the PEDro scale. Disagreements on items were resolved by discussion among the reviewers. Overall, the quality assessment scores of the studies ranged from 4/10 to 7/10 on the PEDro scale, with seven studies^36
–42 earning a rating of “fair” and five studies^43
–47 earning a rating of “good.” The majority of studies lost points due to failing to blind all subjects, therapists, and assessors.^36,38
–46 In addition, many studies did not describe concealment,^{36
–39,41,42,44,47} did not retain at least 85% of participants for data analysis,^36
–42,45 or did not describe an intention to treat method for data analysis.^36,37,40,42 Results of the quality assessment are shown in Table 2.

Table 2.

Data extraction.

Author/year/country	Study design/number of participants	Inclusion/exclusion criteria	Intervention	Comparison group	Physical activity measure	Assessment timepoints	Primary findings	Additional findings	PEDro score	Level of evidence score
Abbaspoor 2018,⁴⁴ Iran	RCT, 89	I: FBS 93–125 mg/dl, 12–14 weeks of gestation, able to use sms, no diet/exercise, literate, and able to use phoneE: physical or psychological diseasenot attending 2 or more sessions or responding to 2 or more messages dbs levels higher than 125	Face-to-face training (4 sessions over 12 weeks) on educational needs for pregnancy/Gestational diabetes, 2 SMS every other day	Face-to-face training (4 sessions over 12 weeks) on educational needs for pregnancy/GDM	IPAQ	Pre-intervention, immediately post	Significant difference in PA levels between groups, higher PA levels in the intervention group	Blood sugar lower in the intervention group, difference in foods consumed between groups	6/10	Level 1
Ainscough 2019,⁴⁰ Ireland	RCT, 565	I: 10–18 weeks of gestation, singleton pregnancy, 18–45 y/o, BMI >25 but <39.9, smartphoneE: previous GDM or any medical condition requiring treatment	Behavioral change techniques, dietary advice and energy advice, access to a smartphone app, follow-up emails to reach goals, and face-to-face meetings at weeks 28 and 34 gestation	Standard prenatal care, no diet/PA advice	SLAN	Pre-intervention, 28 weeks	Maintained PA was higher in the intervention group, post-intervention, compared to the control groupThe intervention group had higher total PA and moderate intensity PA per week than the control group	App influenced less sugar and higher fiber intake in both groups, app did not influence PA	5/10	Level 2
Eslami 2017,⁴³ Iran	RCT, 140	I: 18 years+, gestational age 16–20 weeks, secondary school education minimum, singleton pregnancy, BMI over 25.0, owns a cell phoneE: diagnosed physical/mental illness hospitalization in pregnancy, risk of preterm labor, and acute emotional problems	Lifestyle training package with routine care (group training + Q&A educational booklet, given at the end of session educational text messages every other day)	Routine care and booklet only, no group training	IPAQ	Pre- intervention, 4 weeks post-intervention, and 8 weeks post-intervention	Reduced PA in both groups post-interventionIntervention group PA increased 8 weeks post-intervention compared to 4 weeks post-intervention, but not a significant change	Vegetable and fruit consumption increased in intervention groups 4 and 8 weeks post-intervention, sweets consumption increased in the control group when compared between groups	7/10	Level 1
Gonzalez-Plaza 2022,⁴⁵ Spain	RCT, 120	I: pre-pregnancy BMI over 30, 12–18 weeks of gestation, singleton pregnancy, over 18 y/o, smartphone + internetE: already used app for weight management, psychiatric/physical disorders, contradictions to exercise or mobility issues, difficulty understanding Spanish	Standard prenatal care according to pregnancy monitoring protocol health education in PA and dietary habits smartband + mi fit app health counseling support via hangouts app (midwife instruction)	Standard prenatal care according to pregnancy monitoring protocol health education in PA and dietary habits	IPAQ	Pre- intervention and between weeks 35 and 37 of pregnancy	The intervention group had higher PA at the end of the study compared to the beginning, higher PA levels in the intervention group than the control group, and women in the intervention group had less sedentary time than the control group	GWG is lower in the intervention group than the control	6/10	Level 1
Hawkins 2014,⁴⁷ United States	RCT, 260	I: 1st trimester, 16–40 y/o, high risk for GDME: contraindications to PA, unable to read English, more than 30 min of PA 3 days or more per week, diabetes, or other chronic disease, current medication, nonsingleton pregnancy	1 in-person session setting goals, booster phone calls weeks 2, 6, and 10, tip sheets for the first 4 weeks, digital pedometer and activity diary, tailored exercise program	1 in-person session setting goals, booster phone calls weeks 2, 6, and 10, tip sheets for the first 4 weeks, informational booklets	PPAQ	Pre-intervention and post-intervention 12 weeks	The intervention group had a smaller decrease in PA than the control, the intervention group had a higher percentage of women meeting PA recommendations than the control; light PA increased in the intervention group and decreased in the control group	Increase in sports activity in the intervention group	7/10	Level 1
Hoffmann 2019,³⁶ Germany	RCT, 2101	I: pre-pregnancy BMI between 18.5–40, singleton pregnancy, 18–43 y/o spoke German, gestational age under 12 weeksE: severe pre-existing disease multiple or complicated pregnancy	Control intervention + lifestyle intervention program (3 counseling sessions), GWG and PA recommendations, exercise information, given a pedometer	Routine care and general healthy pregnancy information are given	PPAQ	Pre-intervention and 29 weeks of gestation	Sedentary time increased in both groups decreased PA in both groups, the intervention group increased time in sport activity, compared to the control group	No effect of PA intensities on overall GWG	4/10	Level 2
Hui 2014,⁴⁶ Canada	RCT, 113	I: less than 20 weeks pregnant, no existing diabetes, signed consentE: existence of medical or obstetric contraindication	Community-based weekly exercise group class or digital video disk for home, log book to record exercise, and dietary consultation	No intervention, standard prenatal care	PARMED-X	Pre-intervention and 2 months post	Only women with pre-pregnancy BMI less than 24.9 showed higher PA levels at the end of the study, no difference in PA level in the above normal BMI group	GWG 20% lower in the intervention group, birth weight of infants was lower in the intervention group, and improved nutritional intake in the intervention group	7/10	Level 1
Jing 2015,³⁷ China	RCT, 221	I: singleton pregnancy, 18 y/o understand Chinese, no preexisting diabetes, signed consentE: general medical conditions or pregnancy, related complications	Health education manuals diet and PA manuals, 3 20-min counseling sessions, and access to graduate students for questions	Standard health manuals provided by hospital	PPAQ	Pre-intervention, weeks 16–20 of pregnancy and weeks 20–24 of pregnancy	The intervention group spent more time doing a mild activity than the control group, less time resting than the control group	The intervention group rested less and had a higher intake of healthy foods	5/10	Level 2
Knudsen S de 2022,³⁸ Denmark	RCT, 219	I: healthy inactive pregnant women less than 15 weeks of gestationE: didn’t match inclusion, medical conditions	EXE group: 1 h group exercise 3× a week + standard careMOT: 4 individual and 3 group PA motivational counseling sessions, 1 weekly personalized text for PA standard care	Standard maternal care	PPAQ	Pre-intervention/visit 1, visit 2/GA 28 weeks, and visit 3/GA 34 weeks	PA decreased from visits 1 to 3 in all groups, the MOT group increased PA at vigorous intensity from visits 1 to 2 and 1 to 3, sports activity increased for both intervention groups, sports activity is higher in the EXE group	EXE grp performed more mod to vigorous PA (20 min more per week) than the control, no significant differences between the exe and the mot, both groups higher than the control	5/10	Level 2
Szmeja 2014,⁴¹ Australia/New Zealand	RCT, 1108	I: BMI greater than 25, singleton pregnancy, between 10 and 20 weeks of gestationE: women with type 1 or type 2 diabetes, GDM	A DVD about healthy habits consultations, standard written materials, individualized advice on diet and PA, encouraged to achieve goals and identify barriers, 2 face-to-face visits, 3 phone calls	Standard written materials and consultations	SQUASH	Pre-intervention and 28 and 36 weeks of gestation	No difference in PA behavior or GWG at 36 weeks between groups	Better scores on the dietary questionnaire in the intervention group at 36 weeks	5/10	Level 2
Talebi 2022,³⁹ Iran	RCT, 71	I: under 20 weeks of gestation, able to read/write, no chronic disease/contra to exercise, no mental illness, history of hospitalization, smartphone + internet accessE: diseases in pregnancy or pregnancy complications, specific diet restrictions due to disease	Same materials as the control, but also received materials to improve PA in pregnancy and individual diet, 16 online sessions over 8 weeks reminder messages sent 2× weekly	Routine maternal care joined WhatsApp group, access to diet advice and GWG materials	PPAQ	Pre-intervention and post-intervention	A greater increase in light to mod PA is seen in the intervention group compared to the control, increased exercise and home activity in the intervention group compared to the control	No significant difference in sedentary time between groups	5/10	Level 2
Tinius 2019,⁴² United States	RCT, 70	I: 18–44 y/o, singleton pregnancy English speaking, clearance from the providerE: medical conditions that would impact PA	Educational brochure and list of local PA resources (free to use)	Standard care	PPAQ	Pre-intervention and 34–37 weeks of gestation	The intervention group spent less time sedentary in the 3rd trimester compared to the control group, the control group increased sedentary time, and the intervention group decreased sedentary time, PA levels decreased across both groups, 42% of the intervention group utilized community resources	Women found the brochure helpful, motivation to exercise increased	4/10	Level 2

PEDro: Physiotherapy Evidence Database; PA: physical activity; PPAQ Pregnancy Physical Activity Questionnaire; IPAQ: International Physical Activity Questionnaire; PARMED-X: Physical Activity Readiness Medical Examination; SLAN: Survey of Lifestyle, Attitudes, and Nutrition; SQUASH: Short Questionnaire to Assess Health-Enhancing Physical Activity; BMI: body mass index; RCT: randomized controlled trial; y/o: years old.

Data extraction

Included participants

Data from a total of 4157 healthy pregnant women living in Iran,^39,43,44 Spain,⁴⁵ Canada,⁴⁶ Germany,³⁶ China,³⁷ Denmark,³⁸ Ireland,⁴⁰ Australia,⁴¹ and the United States^42,47 were included in this systematic review. The ages of included participants ranged from 16 to 45 years old, with a gestational age at the start of intervention ranging from 10 to 20 weeks (first and second trimesters). All participants had singleton, non-complicated pregnancies.

Self-reported measures of physical activity

Five different PA measures were utilized by the studies included in this systematic review. The PPAQ was utilized by six of the included studies in this systematic review.^{36
–39,42,47} The PPAQ is a widely available questionnaire with multiple versions in different languages that assesses hours spent per week in leisure activity, as well as light, moderate, and vigorous PA.⁴⁸ The PPAQ is recommended as a tool used to assess PA during pregnancy; however, only the French and Turkish versions of the questionnaire show sufficient validity and reliability.⁴⁸ The IPAQ was utilized by three of the included studies in this systematic review.^43
–45 The IPAQ is a similar PA assessment tool that assesses vigorous PA, moderate PA, and walking over the last 7 days.⁴⁹ It is comprised of a set of four questionnaires with two different versions: the long version, which consists of five PA activity domains, and the short version, which has four generic items.⁴⁹ The IPAQ has been shown to have acceptable reliability and validity measurement properties for use in many settings and different languages, and is suitable for population-based prevalence studies of participation in PA.⁴⁹ The PARMED-X for Pregnancy was utilized by one study in this systematic review.⁴⁶ The PARMED-X for Pregnancy is a questionnaire developed by the Canadian Society for Exercise Physiology that assesses PA habits and intentions during pregnancy through four questionnaire sections: General Health Status, Status of Current Pregnancy, Activity Habits During the Past Month, and Physical Activity Intentions.⁵⁰ An adapted version of the SLAN survey was used by one study to assess light, moderate, and vigorous PA.⁴⁰ The SLAN survey is a general health and wellness survey developed in Ireland and comprises 9 total sections, of which Section B assesses PA habits through 10 questions.⁵¹ There is little evidence regarding the reliability and validity of the SLAN survey. The SQUASH was used by one study to assess total METs expended per week during pregnancy.⁴¹ The SQUASH is a Dutch-developed short questionnaire that includes 11 questions within the domains of leisure time, commuting, work, and household weekly PA within the last month.⁵² The SQUASH has been shown to have good test–retest reliability; however, the validity of this tool is less established.⁵²

Physical activity interventions

The 12 eligible studies were classified into the following categories based on intervention administered: phone or app-based intervention,^{39,40,43
–45} face-to-face counseling,^36,37,41,47 and group fitness class intervention or access to free fitness facilities.^38,42,46 Eight of the 12 articles provided sufficient data to calculate effect sizes.^{36,37,39,40,43
–45,47} Table 3 summarizes the effect sizes and 95% confidence intervals for the comparison of PA level post-intervention between the intervention group and control group for each outcome assessed in the studies. Positive effect sizes with confidence intervals that do not cross zero are displayed in bold.

Table 3.

Effect sizes and confidence intervals of included studies.

Author/year	Type of physical activity	Physical activity measurement	Mean (SD) control	Mean (SD) intervention	Effect size (95% CI)
Abbaspoor 2018⁴⁴	Light	IPAQ	18 (40)N = 44	10 (22.72)N = 44	−0.24 (−0.66, 0.18)
Abbaspoor 2018⁴⁴	Moderate	IPAQ	27 (60)N = 44	34 (77.27)N = 44	0.10 (−0.32, 0.52)
Ainscough 2019⁴⁰	Light	SLAN	84.8 (66.3)N = 153	96.8 (71.9)N = 153	0.17 (0.05, 0.40)
	Moderate	SLAN	50.1 (60.1)N = 153	78.1 (69.5)N = 153	0.43 (0.20, 0.66)
	Vigorous	SLAN	3.1 (13.9)N = 153	8.0 (25.1)N = 153	0.24 (0.02, 0.47)
Eslami 2017⁴³	Moderate	IPAQ	55 (78.6)N = 70	47 (67.10)N = 70	−0.11 (−0.44, 0.22)
	Vigorous	IPAQ	6 (8.60)N = 70	4 (5.70)N = 70	−0.27 (−0.61, 0.06)
	Walking	IPAQ	56 (80)N = 70	56 (80)N = 70	0.00 (−0.33, 0.33)
Gonzalez 2022⁴⁵	Moderate	IPAQ	48 (81.00)N = 51	40 (78.00)N = 59	−0.10 (−0.48, 0.27)
	Vigorous	IPAQ	47 (92.0)N = 51	49 (83.0)N = 59	0.02 (−0.35, 0.40)
	Walking	IPAQ	0 (0)N = 51	1 (2)N = 59)	0.68 (0.29, 1.06)
Hawkins 2014⁴⁷	Light	PPAQ	118.6 (57)N = 128	129.2 (59.7)N = 132	0.18 (−0.06, 0.42)
Hawkins 2014⁴⁷	Moderate	PPAQ	58.7 (50.7)N = 128	76.21 (61)N = 132	0.31 (0.07, 0.56)
Hoffman 2019³⁶	Light	PPAQ	90.2 (42.0)N = 926	90.7 (41.80)N = 937	0.01 (−0.08, 0.10)
	Moderate	PPAQ	39.2 (39.7)N = 921	38.3 (33.6)N = 922	−0.02 (−0.12, 0.07)
	Vigorous	PPAQ	0.6 (2.20)N = 938	0.9 (2.50)N = 959	0.13 (0.04, 0.22)
	Sport Activity	PPAQ	9.8 (9.10)N = 931	11.9 (9.10)N = 938	0.23 (0.14, 0.32)
Jing 2015³⁷	Light	PPAQ	8.13 (2.52)N = 106	8.89 (2.12)N = 115	0.33 (0.06, 0.59)
Jing 2015³⁷	Moderate	PPAQ	1.4 (1.52)N = 106	1.35 (1.35)N = 115	−0.03 (−0.30, 0.23)
Talebi 2022³⁹	Light	PPAQ	5.35 (3.17)N = 36	12.77 (4.32)N = 35	1.94 (1.38, 2.51)
	Moderate	PPAQ	1.61 (2.58)N = 36	8.31 (4.88)N = 35	1.70 (1.16, 2.25)
	Vigorous	PPAQ	0.08 (0.29)N = 36	1.61 (3.69)N = 35	0.58 (0.11, 1.06)
Szmeja 2014⁴¹	METs Per Week	SQUASH	5865.81 (3858.77) N = 564	5756.54 (4062.39)N = 541	−0.03 (−0.15, 0.09)

PPAQ: Pregnancy Physical Activity Questionnaire; IPAQ: International Physical Activity Questionnaire; SLAN: Survey of Lifestyle, Attitudes, and Nutrition; SQUASH: Short Questionnaire to Assess Health-Enhancing Physical Activity; SD: standard deviation; CI: confidence interval.

Phone or app-based intervention

Five of the 12 studies utilized a phone or app-based intervention to increase PA.^{39,40,43
–45} Three of the five studies were based on the use of reminder text messages to exercise,^39,43,44 while the remaining two studies focused on the use of a fitness smartphone app (Table 2).^40,45 One of these studies utilized a smartphone app that was study-specific and intended for pregnant women,⁴⁰ while the other study utilized a general fitness tracking app called Mi Fit.⁴⁵ The interventions ranged from 4 weeks up to 23–25 weeks long, with the largest effect sizes seen in the 8-week intervention for light, moderate, and vigorous PA.³⁹

Effect sizes ranged from −0.24 to 1.94 for light PA, suggesting that this type of intervention had a negative to very large effect in increasing participant engagement in light PA. For moderate PA, effect sizes ranged from −0.11 to 1.70, indicating a negative to very large effect in increasing moderate PA. For vigorous PA, effect sizes ranged from −0.27 to 0.58, indicating a negative to medium effect in increasing vigorous PA. The study with the largest effect sizes for light, moderate, and vigorous PA (light 1.94, confidence interval 1.38, 2.51, moderate 1.70, confidence interval 1.16, 2.25, vigorous 0.58, confidence interval 0.11, 1.06) included an intervention that combined standard maternal care with access to educational materials, online maternal counseling sessions, and reminder text messages (2× weekly) and measured PA using the PPAQ.³⁹ Only two studies using a phone or app-based intervention assessed walking activity post-intervention. The effect sizes of these two interventions ranged from 0.00 to 0.68, indicating no effect to a medium effect on increasing participant walking activity. The study with the largest effect size (0.68, confidence interval 0.29, 1.06) included an intervention that combined standard maternal care with access to a smart-band, the Mi Fit app, and health support counseling via the Hangouts app and measured PA using the IPAQ.⁴⁵

Counseling intervention

Four of the 12 studies utilized a face-to-face counseling intervention to increase PA.^36,37,41,47

Two of the studies provided face-to-face counseling sessions, as well as PA recommendations and a pedometer to track steps.^36,47 One study provided face-to-face counseling sessions as well as access to a graduate student for dietary and exercise advice,³⁷ and an additional study included a take-home DVD with information about healthy habits during pregnancy, along with face-to-face counseling (Table 2).⁴¹ The interventions included in these studies ranged from 12 weeks up to 16–26 weeks long, with the largest effect sizes seen in the 8- to 12-week intervention.³⁷

Effect sizes ranged from 0.01 to 0.33 for light PA, suggesting that this type of intervention had a very small to small effect in increasing participant engagement in light PA. The study with the largest effect size (0.33, confidence interval 0.06, 0.59) included an intervention that provided educational materials, three 20-min counseling sessions on diet and PA, and access to a graduate student for questions and reported PA using the PPAQ.³⁷ For moderate PA, effect sizes ranged from −0.03 to 0.31, indicating a negative to small effect in increasing moderate PA. The study with the largest effect size (0.31, confidence interval 0.07, 0.56) included an intervention that included an in-person session setting PA goals, phone calls, and a tailored exercise program with an activity diary and pedometer, and measured PA using the PPAQ.⁴⁷ Only one study utilizing a counseling intervention assessed vigorous PA. The effect size (0.13, confidence interval 0.04, 0.22) indicates a very small effect in increasing participant engagement in vigorous PA. This intervention consisted of standard maternal care combined with three lifestyle intervention sessions, PA and gestational weight gain recommendations, and access to a pedometer and utilized the PPAQ to measure PA.³⁶

Group fitness or access to local resources

Three of the 12 studies utilized a group fitness intervention or provided access to local fitness resources to increase PA.^38,42,46 Two of the studies enrolled participants in weekly group-fitness classes,^38,46 and an additional study provided participants with an educational brochure and list of free local fitness resources.⁴²

None of the studies utilizing a group-fitness or access to local resources intervention provided sufficient data to calculate the effect size.^38,42,46 Therefore, the data from these studies could not be synthesized to determine the magnitude of the difference between groups. These interventions consisted of a community-based weekly exercise group class, a DVD for home with dietary advice, and a log book to record exercise,⁴⁶ 1 h of group exercise three times weekly combined with standard maternal care,³⁸ and an educational brochure and list of free local PA resources.⁴²

Level of evidence and strength of recommendation

Based on inconsistent and limited-quality evidence of studies utilizing a phone or app-based intervention, we assigned a level B strength of recommendation to this body of evidence. The level B strength of recommendation was also given to evidence supporting a counseling intervention, as well as group fitness and access to local resources to increase PA, due to inconsistent and limited-quality evidence of the studies utilizing those interventions.

Discussion

Although there are numerous health benefits for both mother and fetus to participating in PA throughout pregnancy, currently only half of the pregnant population achieves the recommended amount of PA during pregnancy.⁶ This inconsistency of PA among pregnant women presents a dire need to identify interventions that are effective in improving PA engagement in this population, as well as a reliable self-report measure of PA during pregnancy to foster healthier pregnancies and babies.

The purpose of this systematic review was to synthesize, critically appraise, and determine the effectiveness of interventions designed to increase self-reported PA in pregnant women. Our findings suggest that while multiple studies showed a positive effect on self-reported PA outcomes, few studies were of high-quality evidence with low risk of bias to support the recommendation of an intervention to improve PA in pregnant women.

A recent systematic review assessed the effectiveness of PA interventions designed to increase objective PA in pregnant women.¹⁰ This previous review focused on studies utilizing objective PA measures, such as Fitbit and pedometers, and assessed the overall effectiveness of interventions using objective measures to improve PA. This previous systematic review included 18 relevant studies that were categorized as multi-component lifestyle sessions that included PA or exclusively PA interventions, and measured PA in steps-per-day and minutes spent doing light, moderate, and vigorous PA per week.¹⁰ It was reported that no significant differences were found between intervention groups and control groups at last follow-up for total PA with a Cohen’s d effect size of 0.12 (confidence interval −0.03, 0.27).¹⁰ However, multi-component lifestyle interventions had a larger effect on total PA than exclusively PA-based interventions (0.16, confidence interval −0.02, 0.34).¹⁰ The overall findings of this systematic review and meta-analysis found that PA interventions have a small effect on increasing device-measured total steps per day and moderate to vigorous PA.¹⁰ These findings from Sharp et al.¹⁰ that included objective measures of PA assessment are similar to what was determined in this current study, which assessed self-reported measures of PA, that PA interventions have a positive effect on increasing PA in pregnant women; however, this is not consistent across all intervention types.

The largest effect sizes for light, moderate, and vigorous PA included in this systematic review of self-reported measures of PA were identified in the studies that included a phone or app-based intervention group.^39,40 In addition, the greatest effect size for walking activity was also seen in the phone or app-based intervention group.⁴⁵ Evidence suggests that app-based interventions may be effective in improving health-related outcomes, including a wide variety of conditions and disorders such as type 2 diabetes, hypertension, obesity, and depression.⁵³ The use of health-focused apps and technology has fostered self-engagement and compliance by providing patients with access to online education, support, monitoring, and coaching.⁵³ Given the findings from this systematic review and the existing literature supporting the use of health-focused apps and health outcomes, it is recommended that clinicians and researchers further investigate these types of interventions to increase PA in pregnant women.

Small, positive effect sizes were also seen in studies that included a counseling intervention group.^36,37,47 Evidence has shown that face-to-face interventions have been effective in promoting PA and producing a moderate positive effect on increasing self-reported PA.⁵⁴ It is possible that the benefits of face-to-face counseling interventions to promote PA are similar for face-to-face counseling interventions that aim to increase PA in pregnant women, which may account for the positive effect sizes seen in this intervention group. However, given the size of the effect and resources needed to conduct face-to-face counseling at the population level, this type of intervention may not be feasible for all pregnant women. Additional research is needed to further explore patient characteristics that may warrant a face-to-face type of intervention over the app-based intervention. Perhaps there are personal characteristics that would be more successful with phone-based or app interventions, and those that would be more successful with face-to-face counseling interventions, providing an opportunity for all women to increase their PA during pregnancy through an intervention that supports their personal needs.

Of the five PA outcome measures utilized by the studies in this systematic review, the majority of the studies used the PPAQ or the IPAQ to measure the PA of pregnant women pre- and post-intervention. The PARMED-X for Pregnancy Canadian version, the SLAN survey, and the SQUASH were only utilized by one study each. Though the PPAQ is a widely accepted PA questionnaire designed specifically for pregnant women and translated to multiple languages, only the French and Turkish versions of this survey have been shown to have both sufficient validity and reliability.⁴⁸ However, when considering all versions together, the PPAQ shows sufficient reliability in assessing total PA as well as vigorous PA.⁴⁸ The majority of the studies utilizing the PPAQ used the English version, which suggests sufficient reliability but a lack of validity.⁴⁸ Evidence suggests that the IPAQ has acceptable reliability and validity across different languages, settings, and populations.⁴⁹ However, the IPAQ lacks pregnancy-specific considerations such as trimester and changes in intensity, type, and duration of PA throughout pregnancy, which may not make it the ideal outcome measure in a PA intervention for a pregnant population.⁴⁸ The PARMED-X for Pregnancy is most often utilized as a medical screening tool to evaluate a pregnant woman’s readiness for exercise activity; therefore, its efficacy as an outcome measure to determine self-reported PA is unknown.⁵⁰ The SQUASH survey is shown to have a high test–retest reliability, but the validity of this tool has yet to be established.⁵² There is also a lack of evidence regarding the reliability and validity of the SLAN survey to assess self-reported PA in pregnant women. Overall, the PPAQ is recommended to determine self-reported PA in pregnant women, irrespective of language, as this survey has the highest reliability and validity of current pregnancy-specific PA outcome measures.⁴⁸

Future directions

Future research should aim to strengthen the study design of phone or app-based interventions to better assess the effectiveness of PA interventions by blinding subjects and assessors. While it may be difficult to blind the therapist administering the intervention and the subjects to the group they are in, blinding of data assessors and those involved in data analysis would aid in limiting the introduction of bias and strengthen the overall quality of phone or app-based interventions. It was determined that phone or app-based interventions were the most effective. While it is assumed that this may be a cost-effective and efficient way to reach and influence a large number of pregnant women, there are limitations associated with proper technology and access to resources (e.g., WIFI). Future research should explore the implementation of app-based or phone interventions within clinical practice, perhaps considering the utilization of these apps as a part of clinical care during pregnancy. Additional cost analysis and comparisons should also be performed. Though this systematic review included only healthy pregnant women, women with known pregnancy-related health conditions (e.g., gestational diabetes) may benefit from PA during pregnancy. In addition, though this systematic review included interventions across all trimesters of pregnancy, the final 12 studies did not have any participants in their third trimester of pregnancy. Since women with these conditions and women in their third trimester were not included, we cannot assume that the interventions utilized in this systematic review would have a similar effect in improving self-reported measures of PA of these women. More research should be done to assess the application of the mentioned interventions in these special populations of pregnant women, focusing on specific information tailored to various health conditions to ensure safe PA engagement.

Limitations

One limitation to this study is that none of the studies in the group fitness/access to local resources group provided sufficient data to calculate effect sizes and 95% confidence intervals.^38,41,42,46 Without effect sizes and confidence intervals to interpret, we are limited to making an assessment of the quality of this evidence based on the PEDro assessment and therefore cannot give a complete recommendation on the utilization of these interventions. In addition, due to the heterogeneity of the PA outcome measures and interventions utilized within each category, a graphical representation of the effect sizes and meta-analysis was not performed. Though confidence intervals can be interpreted, an overall synthesis may provide a better understanding of the effectiveness of these interventions distributed across studies. Another limitation of this systematic review is that women with known health conditions were not included as participants; therefore, the effects of the utilized interventions are unknown in this population. In addition, none of the included studies had participants who were in their third trimester of pregnancy. While we did not limit the trimester of pregnancy, we cannot generalize that the interventions utilized would have a similar effect on pregnant women in their third trimester. An added complication is that studies varied across when pre- and post-intervention measures were assessed, as well as the duration of the interventions themselves. Therefore, it is difficult to provide a recommendation on the timing and frequency of outcome assessment, as well as the duration of intervention. Lastly, the systematic search was limited to studies published between January 1, 2014, and January 1, 2024, which may have limited the inclusion of other applicable and potentially informative studies outside of this time frame.

Conclusions

Due to the many health benefits for both the mother and fetus, regular participation in PA should be promoted throughout pregnancy. When comparing the interventions that have been done to increase the self-reported PA of pregnant women, the greatest effect sizes were seen in interventions that utilized a phone or app-based intervention. The majority of studies earning a “good” quality score on the PEDro scale were also interventions that utilized a phone or app-based intervention. Future research should aim to improve the quality of studies and explore the use of phone or app-based interventions to increase self-reported PA of pregnant women when provided during routine clinical care with providers.

Supplemental Material

sj-docx-1-whe-10.1177_17455057251351729 – Supplemental material for Interventions to increase self-reported physical activity during pregnancy: A systematic review

Supplemental material, sj-docx-1-whe-10.1177_17455057251351729 for Interventions to increase self-reported physical activity during pregnancy: A systematic review by Kallie Nowell, Deirdre Dlugonski, Emily DeFranco, Linda May and Johanna M. Hoch in Women’s Health

Footnotes

Acknowledgements

None.

ORCID iDs

Kallie Nowell

Johanna M. Hoch

Ethical considerations

Not applicable.

Consent to participate

Ethics approval and consent to participate were not applicable, as the study is based exclusively on published literature.

Consent for publication

Not applicable.

Author contributions

Kallie Nowell: Conceptualization; Investigation; Writing – original draft; Methodology; Formal analysis; Data curation.

Deirdre Dlugonski: Writing – review & editing; Methodology; Investigation.

Emily DeFranco: Writing – review & editing; Methodology; Formal analysis.

Linda May: Writing – review & editing; Methodology; Formal analysis.

Johanna M. Hoch: Conceptualization; Writing – original draft; Writing – review & editing; Methodology; Supervision; Formal analysis.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

Not applicable.

Supplemental material

Supplemental material for this article is available online.

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