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Theme Issue: Exercise and Sports
Benefits of Exercise During Pregnancy
Heidi Prather, DO, Tracy Spitznagle, DPT, Devyani Hunt, MD
Abstract: There is a direct link between healthy mothers and healthy infants. Exercise and
appropriate nutrition are important contributors to maternal physical and psychological
health. The benefits and potential risks of exercise during pregnancy have gained even more
attention, with a number of studies having been published after the 2002 American College
of Obstetrics and Gynecologists guidelines. A review of the literature was conducted by
using PubMed, Scopus, and Embase to assess the literature regarding the benefits of exercise
during pregnancy. The search revealed 219 publications, which the authors then narrowed
to 125 publications. The purpose of this review is to briefly summarize the known benefits
of exercise to the mother, fetus, and newborn.
PM R 2012;4:845-850
INTRODUCTION
The American College of Obstetrics and Gynecologists recommends that, during preg-
nancy, women should perform 30 minutes or more of moderate-intensity exercise on most,
if not all, days of the week [1]. Yet, many healthy pregnant women are either not advised of
the benefits of exercise or choose to not participate in activity as recommended by the
American College of Obstetrics and Gynecologists guidelines [2-4]. Since the 2002 publi-
cation of the American College of Obstetrics and Gynecologists guidelines, multiple re-
searchers have reported the benefits of exercise, in a variety of formats, for the mother, fetus,
and child [5-37]. Charlesworth et al [38] reported that previously inactive and active
healthy women are at low risk for adverse fetal or maternal events if they participate in
routine physical activity during pregnancy. However, once pregnant, women generally tend
to decrease their activity levels [39,40]. Barriers to exercise reported by pregnant women
include lack of motivation, perceived lack of time due to family and work demands, desire
to postpone weight loss until after delivery, and pain with movement [39]. Thus, the means
to motivate women to exercise during pregnancy needs to be explored. Kwolek et al [41]
reported that, in a cohort of pregnant soldiers who exercised, it was the knowledge of the
benefits to the fetus that motivated them to exercise. To motivate healthy pregnant women
to exercise, health care providers should provide education regarding (1) the appropriate
type and amount of exercise that should be undertaken during pregnancy, and (2) the
benefits to the pregnant woman, the fetus, and the newborn infant. The purpose of this
review is to summarize the benefits of exercise during pregnancy to the mother, infant, and
child.
METHODS
The senior author (H.P.) conducted a search by using PubMed, Embase (Elsevier, New
York, NY), and Scopus (Elsevier) programs to identify studies with clinical relevance
regarding the effect of exercise during pregnancy. Only original studies and systematic
reviews were considered for review. The search revealed 219 publications. After a review of
abstracts and articles, the search was narrowed to 86 publications. These publications were
then grouped based on topic to include the effects of exercise on the following: maternal,
fetal, and infant health; maternal psychological well-being; and weight management. All of
the authors have research and clinical experience regarding musculoskeletal care (including
exercise recommendations) for women during pregnancy and post partum.
H.P. Section, Physical Medicine and Rehabil-
itation, Department of Orthopaedic Surgery,
Washington University School of Medicine,
One Barnes Plaza, Suite 11300, St Louis, MO
63110. Address correspondence to: H.P.;
e-mail: pratherh@wustl.edu
Disclosures related to this publication: none.
Disclosures outside this publication: board
membership (paid to institution) North Amer-
ican Spine Society; payment for lectures in-
cluding service on speakers bureaus (paid to
institution) A.T. Still University of Health Sci-
ences, Kirksville, MO; travel/accommodations/
meeting expenses, North American Spine Soci-
ety, American Academy of PM&R (PM&R senior
editor); travel expenses for travel for NASS BOD
meetings and PM&R SE meetings
T.S. Program in Physical Therapy, Washing-
ton University School of Medicine, St Louis,
MO
Disclosure: nothing to disclose
D.H. Section, Physical Medicine and Rehabil-
itation, Department of Orthopaedic Surgery,
Washington University School of Medicine, St
Louis, MO
Disclosure: nothing to disclose
PM&R © 2012 by the American Academy of Physical Medicine and Rehabilitation
1934-1482/12/$36.00 Vol. 4, 845-850, November 2012
Printed in U.S.A. http://dx.doi.org/10.1016/j.pmrj.2012.07.012 845
TYPE OF EXERCISE
Aerobic exercise [5,7,9,11-13,15,21,24,27,28,34], progressive
resistive strengthening [8,10,17,23,25,27,32], stretching exer-
cises [36,37], yoga [6,30], and Qi [20] have all been reported to
be safe to perform when pregnant. The type of aerobic exercise
that has been found to be beneficial during pregnancy is quite
varied. Stationary bicycling, jogging, walking, stair climbing,
treadmill use, water exercise, swimming, and an aerobic dance
class have all been used. The dosage of the intervention (length
of participation, frequency, and duration) also can be quite
varied. Reports of length of participation in exercise ranges from
12 weeks [26,27,32,33] to span an entire pregnancy
[14,19,30,34,36]. The frequency of aerobic exercise participa-
tion is most commonly 3-5 times per week [30,32,34,36]. Yeo et
al [36] reported that the variation of frequency of exercise was
dependent on the phase of the pregnancy. The duration of
aerobic exercise can range from 15 minutes up to 150 minutes
per session. An aerobic exercise prescription of 60 minutes or
longer has been found to be safe for mother, fetus, and infant
[14,19,23,26,30,32-34,36]. The intensity of aerobic exercise
can be safely monitored by using self-pacing techniques [27,28]
or heart rate monitoring using 50%-75% of the age-predicted
maximum [11,25,28,32]. The safe use of progressive resistive
strength training in pregnancy has been reported in only a few
studies [8,10,17]. Progressive resistive strength training, al-
though commonly reported by pregnant women as part of their
exercise program [37], is often combined with aerobic exercises
[23,25-27,32]. Thus, it is difficult to make recommendations
regarding the appropriate dose and potential benefits of isolated
strength training during pregnancy. Dosage of stretching exer-
cises has similarly not been well investigated. Yeo et al [36] used
a 40-minute video that demonstrated comprehensive stretches
to be preformed 5 days per week.
BENEFITS OF EXERCISE: MATERNAL
Fitness
Maternal benefits from exercise during pregnancy include im-
proved cardiovascular function [11,24,25,29,42-45], a lower
risk for gestational diabetes in women who are obese or not
obese [17,46-48], improved strength [28] and lean muscle mass
[8], improved sense of well-being [7,20,26,28,30,34], and en-
hanced sleep [6,49]. In addition, reductions in bone density loss
[50] and physical discomfort [5-7,31] have been reported.
Specific cardiovascular function improvements due to aero-
bic exercise in pregnancy include decreased heart rate at rest and
during exercise [42,43,48] and higher stroke volumes [29,44],
increase in O
2
uptake at the anaerobic threshold [32], and
improved anaerobic ventilatory threshold [25]. Other positive
cardiovascular improvements are increased exercise duration
[12,45], increased peak power output [12], and enhanced fat
versus carbohydrate oxidation [11]. Interestingly, maximum
oxygen uptake VO
2 max
does not change in response to cycling,
swimming, or other forms of aerobic exercise during pregnancy
[51-57].
Besides aerobic exercise, other types of exercise have unique
outcomes that may facilitate motivating pregnant women to
exercise. In a single case report, progressive resistive strength
training across a pregnancy resulted in an increase in lean
muscle mass [8]. For women with gestational diabetes, strength
training or strength training combined with diet changes were
both related to a decreased need for insulin [10,17]. Unique
benefits of stretching exercises include a decreased incidence of
gestational hypertension and an increase in antioxidant markers
at the time of delivery [36,37]. Yoga and Qi, both exercise
interventions that combine some stretching with strengthening,
have been reported to increase quality of life scores in pregnant
women [20,30]. Water exercise has also been found to increase
quality of life scores [19,36] as well as reduce lower extremity
edema and decrease back pain [31]. An individualized exercise
program tailored to specific muscle impairments reduced low
back pain during pregnancy [27].
Weight Management
Weight gain during pregnancy is a natural and necessary pro-
cess. However, excessive gestational weight gain (EGWG) is
associated with maternal complications, including cesarean de-
livery, hypertension, preeclampsia, impaired glucose tolerance,
and gestational diabetes [58]. Studies have assessed the benefits
of exercise in pregnant women with normal weight, overweight,
and obesity with regard to gestational weight gain (GWG) and
EGWG.
Ruchat et al [59] randomized women with normal weight
at 16-20 weeks gestation to 1 of 3 groups: low-intensity
exercise, moderate-intensity exercise, or control. Total GWG
was higher in the control group compared with either exer-
cise group. EGWG was prevented in 70% and 77% of the
low- and moderate-intensity exercise groups, respectively.
The exercise groups retained less weight 2 months post
partum compared with controls. In another recent study, Hui
et al [60] compared physical activity and food intake over 2
months time during pregnancy in women who engaged in
group exercise, home exercise, and nutritional counseling
compared with controls. The intervention group had re-
duced calorie and fat intakes with higher reports of physical
activity (P⬍.01) compared with controls. The prevalence of
EGWG was significantly reduced (P⬍.01) in the interven-
tion group compared with controls. Haakstad and Bo[61]
studied pregnant women with normal weight and compared
a 12-week supervised exercise program with usual care. Only
women who attended 24 exercise sessions demonstrated
significantly less weight gain during pregnancy (P⫽.006)
and less postpartum weight retention (P⬍.01) compared
with controls. Phelan et al [62], in the Fit for Delivery Study,
followed up 401 pregnant women during their pregnancy
and 6 months post partum. Participants were randomized to
846 Prather et al BENEFITS OF EXERCISE DURING PREGNANCY
standard of care (n ⫽200) or to the behavior intervention
group (n ⫽201). The intervention consisted of a face-to-face
visit; weekly mailed printed material on appropriate weight
gain, healthy eating, and exercise; individual graphs of
weight; and telephone-based feedback. This minimal inter-
vention compared with the standard of care decreased the
percentage of women with normal weight who exceeded the
recommended GWG (40.2% compared with 52.1%; P⫽
.003). Exceeding this limit has been associated with in-
creased difficulty in attaining ideal weight post partum, post-
partum depression, and decreased overall well-being. This
intervention consisted mostly of education, a relatively inex-
pensive intervention with a potential for high yield.
Results of studies that involved pregnant women who
were overweight and obese before pregnancy have also
shown the benefits of exercise and nutritional counseling. Sui
et al [63] published a systematic review to assess the harms
and benefits of exercise during pregnancy. Six randomized
control trials and 1 pseudorandomized controlled trial that
involved a total of 276 pregnant women found that 216 of the
women involved in an exercise program had lower gestational
weight compared with controls. Although these effects were
positive, the authors concluded that further studies are needed
to assess maternal and infant general health. In a randomized
control trial, Nascimento et al [64] found no difference in
general health between pregnant women who were obese and
overweight who participated in an exercise program starting
between 14 and 24 weeks gestation compared with controls.
However, the women who participated in the exercise program
gained significantly less weight (P⫽.001) after entering the
program compared with controls. Furthermore, de Keyser et al
[65] studied the effect of a weight-gain restriction program
compared with usual care in pregnant women who were obese.
Comparisons included GWG, mean health care costs during
pregnancy, delivery, and the neonatal period. Women who
restricted weight gain to 4.6-9.5 kg had the lowest costs. How-
ever, the total costs, including the intervention, was higher in the
intervention group compared with usual care (P⫽.025). Col-
lectively, these studies describe the benefits of exercise during
pregnancy for weight management in women who were normal
weight, overweight, and obese.
General Health and Psychological
Well-Being
During pregnancy, health care providers advocate for improved
generalized health and exercise. From 2001-2009, 22,604 preg-
nant women’s healthy behaviors were tracked [66]. Over 8
years, an improved percentage of healthy behaviors occurred. In
2001, 7.3% and, in 2009, 21.2% of pregnant women did not
smoke, did not consume alcoholic beverages, did engage in
leisure time exercise, and did receive an influenza vaccination
[66], which represents progress but is still a relatively small
percentage of the pregnant population that demonstrates
healthy behaviors. A study published in 2011 [67] found that
low-income African American pregnant women had a broad
definition of what constitutes exercise, which ranged from
household duties to running, which suggests that the definition
of exercise in the general public is not well defined, and, there-
fore, that women may inadvertently not participate in activities
that involve aerobic fitness. Further educational intervention is
necessary to improve healthy behaviors, including exercise, of
pregnant women.
The benefits of exercise and psychological well-being are
evident for women and extend into pregnancy. In general,
pregnancy is thought of as a time for emotional well-being for
many women. However, results of a meta-analysis of 21 studies
suggest that the mean prevalence rate for antenatal depression is
10.7%, with a range in the first trimester of 7.4% and in the third
trimester of 12.8% [68]. Researchers have linked exercise to
improved psychosocial well-being. Several studies [66,69-72]
have investigated the effects of a regular exercise program during
pregnancy. A systematic review completed in 2010 found broad
literature support of the antidepressant effects of exercise in the
general population, and a small number of observational studies
reported that regular physical activities improve self-esteem and
reduce the symptoms of anxiety and depression during preg-
nancy [71]. In 2012, Robledo-Colonia et al [70] published a
randomized control trial of exercise during pregnancy that in-
volved 80 nulliparous, pregnant women. The experimental
group completed a 3-month supervised exercise program,
whereas the control group continued usual activities with no
specific exercise program. After the 3-month intervention, the
women who exercised regularly had a statistically significant
decrease in depresssive symptoms compared with the control
group [70]. A randomized control trial of postpartum depres-
sion found that, after a 12-week exercise program of both
aerobic and strengthening exercises, there was no protective
effect on developing postpartum depression except for a sub-
group of women who did not previously exercise before preg-
nancy [72]. Another subgroup, pregnant adolescents, was stud-
ied by Koniak-Griffin [69]. A 6-week aerobic exercise program
in pregnant adolescent women from 14 to 20 years of age had a
significant decrease in depressive symptoms over time and in-
creased total self-esteem. The control group showed a significant
increase in physical discomforts associated with pregnancy [69].
Body image satisfaction during pregnancy is also an impor-
tant determinant of psychological well-being. Researchers
found that a healthy body image was a nonpharmacologic
strategy that could offer protective effects against depressive
symptoms during pregnancy [73]. Regular exercise and activity
may help to achieve this goal.
BENEFITS OF EXERCISE TO THE FETUS
Benefits to the fetus that may be used to motivate women to
exercise during pregnancy include decreased resting fetal heart
rate [11,13,74-76], improvement in the viability of the placenta
847PM&R Vol. 4, Iss. 11, 2012
[9,13,14,75], and increased amniotic fluid levels [31]. Ramierz-
Velez et al [77] reported an increase in endothelium-dependent
vasodilation. This effect of exercise has been postulated to pos-
sibly provide protection against preeclampsia [77]. Caution is
suggested at exercise intensities above 90% of heart rate maxi-
mum. In 1 study, fetal bradycardia and high umbilical artery
pulsatility occurred, which indicates that intense exercise could
potentially compromise fetal well-being [78].
BENEFITS OF EXERCISE TO THE INFANT
Children of women who exercise during their pregnancy have
lower birth weights [12,15,16,79], increased gestational ages
[80-82], and potentially improved neurodevelopment
[12,15,16,61]. Neonates of exercising mothers had a lower
percentage of body fat [12,15,16,81]. This lower weight at birth
was found to be correlated to changes in leptin levels late in
pregnancy, which indicates that the placental response to exer-
cise may be partially responsible for the lower weights [81].
Clapp [12] and Clapp et al [16] reported that neonates of
exercising mothers who were followed-up to 5 years of age
regained typical body fat and weight at 1 year of age but were
leaner at age 5 years. This indicates that, as children of exercising
mothers grow, they maintain a leaner body mass index com-
pared with children of nonexercising mothers. Recently, Mat-
tran et al [79] reported that weight and height-to-weight scores
of 2-year-old children born to active mothers were marginally
associated with late pregnancy activity levels.
With regard to neurodevelopment of the child, there is
still limited research available to use as a motivator for
pregnant women. Long-term neurodevelopmental benefits
for the infant due to maternal exercise during pregnancy are
still unclear. Recently, Apgar scores have been found to be
higher in neonates who are born to exercising mothers [61].
Clapp et al [16] reported improved orientation and the ability
to self-soothe in neonates as well as higher general intelli-
gence and oral language scores in 5 year olds.
MOTIVATION TO EXERCISE DURING
PREGNANCY
Once pregnant, women tend to decrease their activity levels
[39,40]. Barriers to exercise reported by pregnant women in-
clude lack of motivation, perceived lack of time due to family
and work demands, a desire to postpone weight loss until after
delivery, and pain with movement [39]. Motivation to exercise
during pregnancy can be enhanced if the benefits to the mother,
fetus, and child are explained, and if methods to lower the
barriers to exercise are used. Use of the available known benefits
of exercising during pregnancy should be used as well as explor-
ing appropriate educational methods. Reported methods to
improve the process of educating women and to increase their
receptivity to exercise include using an educational video [83],
providing greater support across the pregnancy to facilitate
exercise [84], and providing women with a means for self-
monitoring their activity level [85]. Key behavioral barriers
could be addressed with a simple telephone call [84], thus
providing support as gestation progresses. In addition, provid-
ing a pedometer or other form of activity log for objective means
of documenting activity [85] is a simple inexpensive tool that
could greatly improve the health of the mother, fetus, and child.
SUMMARY
There is considerable evidence that exercise during healthy
pregnancy has positive effects on the mother and fetus. Further-
more, there is some evidence that suggests positive effects on the
child. Women, therefore, should be encouraged to initiate or
continue exercise during a healthy pregnancy. Further research
is required to assess the short- and long-term effects of weight
management on maternal and infant health, the psychosocial
benefit of exercise during pregnancy, and the effect of exercise
during pregnancy on the neurodevelopment of children.
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This CME activity is designated for 1.0 AMA PRA Category 1 Credit™ and
can be completed online at me.aapmr.org. Log on to www.me.aapmr.org,
go to Lifelong Learning (CME) and select Journal-based CME from the
drop down menu. This activity is FREE to AAPM&R members and $25 for
non-members.
CME Question
An aerobic exercise prescription safe to perform when pregnant includes the following EXCEPT:
a. length to span an entire pregnancy
b. frequency of 3-5 times per week
c. 60 minutes or greater per session
d. heart rate of 85% of age predicted maximum
Answer online at me.aapmr.org
850 Prather et al BENEFITS OF EXERCISE DURING PREGNANCY
