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Journal of Business and Social Review in Emerging Economies Vol. 6, No 2, June 2020
391
Volume and Issues Obtainable at Center for Sustainability Research and Consultancy
Journal of Business and Social Review in Emerging Economies
ISSN: 2519-089X (E): 2519-0326
Volume 6: No. 2,June 2020
Journal homepage: www.publishing.globalcsrc.org/jbsee
Aquatic Exercise to Treat Pregnancy Related Issues in Pregnant Women: A
Systematic Review
1 Asif Ali, 2 Muhammad Azam, 3 Zargham ul Hassan Askry
1 Associate Professor, Department of Physical Education and Sports Sciences, Government College
University, Lahore. Corresponding author: Email: goraya128@hotmail.com
2 Assistant Professor, Department of Physical Education, Government College University Lahore,
Pakistan, goraya78@gmail.com
3 M.sc student, Department of Physical Education, GC University Faisalabad, Pakistan.
ARTICLE DETAILS
ABSTRACT
History
Revised format: May 2020
Available Online: June 2020
Background: Wide ranges of physiological changes occur as a result
of pregnancy in women that, in certain cases, may cause variety of
psychological and physical problems in pregnant women. Aquatic
exercises believed to be safe for pregnant women and believed to
foster positive effect on psychophysical health.
Purpose: This review sought to synthesize qualitatively the existing
research evidences concerning association between aquatic
exercises and psychophysical problems in pregnant women.
Methods: A 1989 records were yielded as result of conducting a
systematic search in nine research data bases. After undergoing
rigorous screening and assessment procedure of eligibility, and
quality appraisal, a total of seventeen research articles were
ultimately selected to include in this review.
Results: Out of seventeen admissible studies, ten studies found that
aquatic exercises exerts positive impact to decreases variety of
physical discomforts such as fatigue, pelvic pain, labor pain, and
edema. The remaining seven studies presented beneficial effects of
aquatic exercises for psychological factors such as body image,
stress, depression, feelings, mood, distress, and anxiety in pregnant
women.
Conclusion: This review found some evidence in support of the
efficacy of aquatic exercises to reduce physical discomfort and
improve psychological factors in pregnant women.
© 2020 The authors, under a Creative Commons Attribution-
NonCommercial 4.0
Keywords
Aquatic exercise, exercise in
water, pregnancy, pregnant
women, pregnancy related
outcomes
JEL Classification:
Corresponding author’s email address: goraya128@hotmail.com
Recommended citation: Ali, A., Azam, M., Askry Z.U.H. (2020). Aquatic Exercise to Treat Pregnancy
Related Issues in Pregnant Women: A Systematic Review. Journal of Business and Social Review in
Emerging Economies, 6(2), 391-400
DOI: 10.26710/jbsee.v6i2.1098
Journal of Business and Social Review in Emerging Economies Vol. 6, No 2, June 2020
392
1. Introduction
Women during pregnancy experience variety of mental and physical disorders. For example, psychological issues including
depression, obsessive compulsive disorder, anxiety, stress, panic disorder, mood disorders, sleep disorders, and psychological
distress appeared to associated with pregnant women (Sharma, Singh, Tempe, & Malhotra, 2017). In particular, recent reviews
reported that prevalence of depression (Woody, Ferrari, Siskind, Whiteford, & Harris, 2017) or disorders relating post-
traumatic stress (Yildiz, Ayers, & Phillips, 2017) was 11.9% and 3.3 % among pregnant women, respectively. In addition,
pregnancy related physical health disorders including sleep disorders, back pain, fatigue, lack of energy, and reduced quality of
life were also reported in this population (Olsson & Lena, 2004). Leaving these issues unaddressed could be problematic that
have associations with wide range of negative outcomes. For example, psychological disorders (i.e., depression, anxiety, mood
disorders) were appeared to be related with variety of preterm labor, obstetric complications, pregnancy symptoms, as well as
various negative neonatal and fetal consequences (Alder, Fink, Bitzer, Hösli, & Holzgreve, 2007). A meta-analytical study
showed that psychosocial stress was linked with increased risk of negative perinatal and neonatal outcomes (Littleton, Bye,
Buck, & Amacker, 2010). Other studies found negative effects of sleep disorders (Chang, Pien, Duntley, & Macones, 2010),
fatigue, pain, edema(Reynolds, 2003), and excessive maternal weight gain(Siega-Riz et al., 2009) on maternal and fetal
outcomes. Taking together, these findings likely to suggest that addressing pregnancy related negative outcomes are critically
essential for better health perspective for pregnant women.
Due to serious concern for maternal and fetal health, professional in health care area have been focusing on interventions that
contribute to reduce and/or treat pregnancy related physical as well as psychological issues among pregnant women. Many
researchers have been interesting on exercise based interventions for addressing pregnancy related issues in pregnant women
(Chan, Au Yeung, & Law, 2019). Aquatic exercises have been considering a form of exercise programs those are planned and
developed to perform in water or swimming pools. This type of intervention have been using for therapeutic purpose for many
years in health care setting. Regular involvement in aquatic exercise programs has been associated with physical and
psychological benefits for women. Aquatic exercise showed indications of reduction in depression, enhanced self-efficacy,
improvements in quality of life and physical fitness in women (Lee, Chang, & Ahn, 2007). It appeared to exhibit positive effect
on sleep(S. Delevatti et al., 2018), edema(Gianesini et al., 2016), fatigue(Cantarero-Villanueva et al., 2013), weight
control(Kasprzak & Pilaczyńska-Szcześniak, 2014), and pain(Munguía-Izquierdo & Legaz-Arrese, 2007) among women.
These findings lead us to conclude that aquatic exercise results in beneficial outcomes regarding physical and psychological
well-being of the women.
To this end, it can be hypothesized that if women during pregnancy experience specific physical issues (i.e., pain, edema,
fatigue, sleep, and weight gain) and negative psychological symptoms (i.e. depression, anxiety, and psychological distress) and
aquatic exercise can potentially contribute to improve these conditions, then, it can be logically assumed that aquatic exercise
may have the potential to deal with these pregnancy related outcomes. Aquatic exercise programs specifically considered
among the most appropriate exercise intervention for pregnant women(Juhl, Kogevinas, Andersen, Andersen, & Olsen, 2010).
It has been suggested to be safe, joyful, offer moderate intensity workload and easy to perform during pregnancy (Backhausen
et al., 2014; Juhl et al., 2010). In particular, exercising in water reduces 83 % weight of pregnant women that results reducing
weight bearing on lower extremities and thus reduces the risk of musculoskeletal injuries during exercise in pregnant women
(Alberton et al., 2019). These findings likely to suggest that aquatic exercise programs seem more tailored in connection with
conditions associated with pregnant women.
Above discussions lead us to conclude that aquatic exercises can be considered an important therapeutic intervention strategy
to deal with variety of pregnancy related outcomes. Best health care practices require evidence based knowledge and evidence
based policies for implementations. These approaches encourage clinicians and practitioners for systematic and critical
evaluation of the effectiveness of the interventions before implementation. However, there is no review exists that critically
assessed existing evidences showing beneficial effects of this intervention for these women. It seems important to present in-
depth and critical analysis concerning efficacy of aquatic exercise programs for reduction and/or treatment of some common
physical and psychological conditions that women generally experience during pregnancy. Therefore, this review sought to
present qualitative syntheses of the existing research on this topic. Another objective of this work was to identify gaps in
existing work and suggest some ideas for future research in this area of research. This work may help professionals in health
care setting to make decisions concerning implementing non-pharmacological treatment interventions while addressing
pregnancy related issues during practice. Aquatic exercise was defined as all type of physical activities and exercise programs
those were designed to perform in water.
2. Methods
2.1 Search Strategy
Published research articles were systematically searched in major research data bases including Science Direct, Taylor &
Francis, PubMed, Medline Plus, PsycINFO, ProQuest, Wiley Online Library, SAGE Journals, and Springer Link in August
2019. Search strategy consisted of using combination of aquatic exercise related keywords (i.e., aquatic exercise, exercise in
water, swimming, water based exercise) along with pregnancy related keywords (i.e., pregnancy, pregnant women, maternal,
gestation, antenatal, and prenatal).
Journal of Business and Social Review in Emerging Economies Vol. 6, No 2, June 2020
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2.2 Inclusion and Exclusion Criteria
Eligibility criteria for inclusion were as follow: 1) studies presented data involving aquatic exercise programs effects on
pregnancy related physical or psychological outcomes, 2) studies used any research designs including randomized control
trials, clinical control trials, cohort, time series designs, case studies, longitudinal designs, qualitative, and cross-sectional
designs, 3) studies selected health or patients pregnant women of any age, 4) published in peer review journals in English
language, and 5) published in any geographical region or any country. Studies were excluded that met following criteria: 1)
unpublished studies, 2) thesis and dissertations, 3) published in languages other than English, and 4) did not exists data related
to variables included in this review.
2.3 Data Extraction
According to set criteria, the studies involving titles and abstracts were retrieved and thoroughly screened for relevancy. A
second expert again screened the selected articles and only those articles were finally selected that were verified by second
expert. Full texts were obtained and in depth and careful screening was carried out based on eligibility criteria set for this
review. Data concerning authors, publishing year, country, sample characteristics, study designs, interventions and exercise
measures, outcomes measures, data analysis, and results and findings were extracted (see table 1). A systematic review thought
to be appropriate due to diverse nature of samples, interventional procedures, study designs, data analysis procedures.
2.4 Quality Appraisal
To evaluate the quality of each selected study, we used “The Quality Assessment Tool for Quantitative Studies” that has been
widely employed for assessing study quality in health care (Chan et al., 2019; Project, 1998). The admissible studies were
ranked as weak, moderate or strong based on assessment guide and dictionary for this tool on six point criteria including i)
selection bias, ii) study design, iii) data collection, iv) confounders, v) rater blinding, and vi) withdrawals. In accordance with
guidelines, studies having no weak rating on any of the six categories were rated as strong on overall rating. The studies had
one weak rating were considered having moderate methodological quality study. All studies that had more than one weak
rating on six point categories were rated as weak methodological quality studies.
3. Results
3.1 Search Results
As a result undertaking systematic search for related studies, a total 1989 records were appeared. Full search results are
presented in Figure 1. After removing the duplicates, 1227 studies left that were selected for carrying out screening process for
eligibility. Studies that did not meet inclusion and exclusion criteria set for this review were excluded. This resulted in 17
articles that were finally selected to include in this review.
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Figure 1. PRISMA flow chart showing procedure for litrature search and selection of studies assessed effects of aquatic exercise on
pregnancy related outcomes
3.2 Quality of the Included Studies
Among 17 included studies, 3 (17.64%) were rated as strong and 14 (82.35%) as moderate with respect to their methodological
quality (see table 1). This shows the quality of studies done in this specific area.
Table 1 Quality appraisal of the included studies assessing aquatic exercise effects on pregnancy issues.
Sr.#
Study/
Design
A
Bias in
Selection
B
Study
Design
C
Confounders
D
Rater
Blinding
E
Data
Collection
F
Withdrawal
Overall
Rating
1
Backhaus, et
al., (2017)
S
S
S
M
S
S
strong
2
Bacchi, et al.,
(2017
S
S
S
M
S
M
strong
3
Cavalcante, et
al., (2009)
M
S
M
M
S
M
strong
4
Lox et al.,
(2000)
Interrupted
time series
M
M
M
W
S
S
moderate
5
Parker, et al.,
2003.
Cohort
M
M
M
W
S
S
moderate
6
Granath, et al.,
(2006)
CCT
S
S
M
W
S
S
moderate
7
Polman, et al.,
(2007)
M
M
M
W
S
S
moderate
8
Kihlstrand, et
al., (1999)
CCT
M
S
S
W
S
M
moderate
9
Cordero, et al.,
(2018)
S
S
S
W
S
S
moderate
10
Scott &
Hellawell,
(2018)
M
S
M
W
S
S
moderate
11
Baciuk, et al.,
(2008
S
S
S
W
S
S
moderate
12
Backhausen, et
al., (2014)
M
M
M
W
S
M
moderate
13
Vallim, et al.,
(2011)
M
S
S
W
M
M
moderate
14
Smith &
Michel, (2006)
M
S
M
W
S
S
moderate
15
Blanquea, et
al., (2017)
M
M
M
W
S
S
moderate
16
Juhl, et. al.,
(2010)
S
W
M
M
S
S
moderate
17
Hartmann, et
al., (2005)
W
M
M
M
S
S
moderate
Journal of Business and Social Review in Emerging Economies Vol. 6, No 2, June 2020
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3.3 Study Characteristics
Table 2 Characteristics of the included studies assessing aquatic exercise effects on pregnancy and overall
health.
Study
Sample
Design
Aquatic Exercise /
Measure
Outcome
Measures
Analysis
Results / Findings
Scott &
Hellawell,
(2018)
23 pregnant
women
with PGP
Age range =
22-37 yrs.
Mean = 31.9 ±
3.95 yrs.
RCT
Aquatic exercise of
moderate intensity
(4 sessions/week)
PGPQ, VAS,
PSFS, ASLR,
SEES
Independent
Student’s t-test
Box-and-
Whisker plot,
Shapiro–Wilk
test
.
Group comparison results
(water-based vs. land-based)
showed the significant
difference for the positive well-
being (p = 0.000), the ASLR (p
= 0.036), and fatigue subscales
of the SEES (p = 0.011).
Aquatic exercise during
pregnancy was considered more
beneficial to reduce fatigue,
foster well-being, and improve
ASLR scores in comparison
with land based exercise.
Vallim, et al.,
(2011)
35 pregnant
women (26 vs.
24 yrs.)
RCT
Water aerobics
classes for 50 min
3 times/week
Self-Developed
Questionnaire
WHOQOL-BREF,
MANOVA
Water
At the time of admission, 71%
pregnant women who were
practicing water aerobics
expected improvements in
physical well-being through
exercise.
At the end of the study, 65%
women believed that water
aerobics classes would make
childbirth easier for them.
Juhl, et al.,
(2010)
48,781
pregnant
women
Nationwide
Population-Based
Cohort
Self-reports,
interview (yes/no)
Ponderal index
Gestational age
(days, weight, and
length)
Cox, linear and
logistic
regression.
Risk of giving preterm birth
slightly reduced in women who
participated in swimming during
pregnancy (R= 0.80, 95% CI:
0.72– 0.88) or the ratio of
congenital malformations with
childbirth minimized (R= 0.89,
CI: 0.80–0.98).
Aquatic exercise had positive
effects in birth related outcomes.
Backhausen,
et al., (2017)
516 pregnant
women of 18
yrs. or older
(gestation
16±17 weeks)
RCT
Twelve-week
aquatic exercise
(twice a week)
Minnesota
Leisure-Time
PAQ.
Low Back Pain
(LBP)
Rating Scale
Unsupervised
water vs.
standard prenatal
care group
Intensity of LBP significantly
reduced in pregnant women who
had aquatic exercise (R= 2.01,
95%, CI: 1.75±2.26) than those
who did not have aquatic
exercise (R= 2.38, 95% CI:
2.12±2.64).
Aquatic practice was suggested
as a beneficial exercise for
reducing low back pain in
pregnancy.
Smith &
Michel,
(2006)
40 pregnant
women
(gestation= 19
weeks)
Quasi-
experimental,
CCT
Six-week
aquatic exercise
(3 sessions of 60
min/week).
PBSQ,
HPLP, SPDII.
ANCOVA,
Independent t-
tests
Health-promoting behaviors and
less physical discomfort were
noted in pregnant women who
took part in aquatic exercise
compared to non-exercisers.
Posttest scores showed women’s
likeliness towards physical
exercise (p = .006), stress
management (p = .001), and
health-promoting behaviors (p =
.05) among exercising women.
Cavalcante, et
al., (2009)
71 pregnant
women
RCT
Fifty-min moderate
water aerobics
exercise (3-times a
week).
Education level,
gestational age,
abortions or
cesarean sections
undergone
previously
MANOVA,
Chi-square,
Student's t-tests
Type of delivery, preterm birth
rate, alteration in maternal body
composition, neonatal weight or
well-being was not associated
with water aerobics.
Water aerobics proved to be safe
and may be considered
beneficial for indirect outcomes
e.g., the greater percentage
(around 10%) of vaginal
deliveries.
Journal of Business and Social Review in Emerging Economies Vol. 6, No 2, June 2020
396
Bacchi, et al.,
(2017)
111 pregnant
women
Mean age =
31.6 ± 3.8 yrs.
RCT
Water aerobics (3-
weekly sessions).
Maternal weight
gain,
BMI,
Birth weight
Student’s t test
Water activities were helpful in
preventing excessive weight
gain in pregnant women and
preserving birth weight.
Rodriguez-
Blanquea et
al., (2017)
134 women,
Age range 21–
43 yrs.
RCT
Three hourly
sessions of aquatic
exercises per week.
PSQIQ.
Mann–Whitney
U test
Number of women with poor
sleep in intervention group (44
(65.67%)) was less than women
in control group (62 (92.54%)).
Aguilar-
Cordero, et.
al., (2019)
136 pregnant
women
Age range 21-
43 yrs.
Randomized
open-label
clinical trial
moderate aquatic
exercise (hourly
sessions, 3
days/week)
Edinburgh
Postnatal
Depression
Scale,
Mann–
Whitney U test
Student’s t test
BMI results revealed significant
differences regarding obesity
(EG, 7.88 ± 3.01; CG, 11.00 ±
1.90) and overweight (EG, 6.13
± 4.05; CG, 10.23 ± 2.42).
Moderate aquatic exercise might
effective in reducing the
symptoms of PPD, and weight
gain during pregnancy.
Lox &
Treasure,
(2000)
44 pregnant
women
Age range 26-
41 yrs.
Interventional
study, pre-post
single group time
series design,
Water aerobics for
6 weeks (2
times/week with 45
min. moderate
intensity)
SEES
MANOVA
Regular aquatic exercise was
associated with improved states
of positive feeling, reduced
states of negative feeling and
fatigue for women during
pregnancy.
Polman,
Kaiseler, &
Borkoles,
(2007)
66 women
RCT
RPE
Profile of mood
states
Aqua, gym
studio, and
parent craft class
Aqua and studio conditions
significantly increased overall
mood states and vigor.
Depression was also decreased
in aqua class.
Granath ,
Hellgren, &
Gunnarsson,
(2006)
390 pregnant
women
RCT
Aquatic vs. land-
based exercise (1
session/week).
LBP, PGP, or
both,
Sick leave.
Mann-Whitney ’
s test,
Student’s t test
Water aerobics compared to
land-based exercise significantly
minimized LBP (p = .04) and
diminished the frequency of sick
leave (p = .03).
Baciuk et al.,
(2008)
71 pregnant
women
RCT
Fifty-min moderate
water aerobics
exercise (3
times/week)
VO2 max, CO,
skin temperature,
physical fitness,
labor/delivery
outcomes
MANOVA,
Friedman's
analysis, chi-
square test.
Student's t
Labor analgesia was
significantly lower in pregnant
women who did water aerobics
(R = 0.42 95%, CI: 0.23-0.77).
Aquatic exercise was beneficial
in reducing labor pain.
Kent et al.,
(1999)
18 women with
20-33 weeks’
gestation
Water aerobics
class for 30 min.
Water aerobics program might
be suggested as an effective
intervention for women with
edema of pregnancy.
Backhausen et
al., (2014)
30 women
Cohort (one
group pre +
posttest design
Water exercise
In depth Interview
Content analysis
Water exercise was suggested to
be beneficial both for physical
health and psychological well-
being.
Hartman &
Huch, (2005)
9 women (with
edema)
Age range 32–
36 yrs.
Cohort (one
group pre +
posttest design
45-min Aqua-Fit1
program.
Lower limbs
edema
The pregnant women showed
strongly positive impressions of
reductions in edema after the
single session of immersion
exercise.
Abbreviations: PGPQ, Pelvic Girdle Pain Questionnaire; RCT, randomized control trial; PSFS, Patient-Specific Functional Scale; ASLR, active straight-leg
raise; SEES, Subjective Exercise Experience Scale; VAS, visual analogue scale; PSQIQ, Pittsburgh Sleep Quality Index Questionnaire; GDM, Gestational
diabetes mellitus; WHOQOL-BREF, World Health Organization Quality of Life.
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3.3.1 Aquatic Exercise Effects on Physical Discomfort (Fatigue, Edema, or Pain)
Ten of the selected articles presented data on the associations of aquatic exercise with physical discomfort. In general, ten
studies included in this review consistently showed significantly positive effect of aquatic exercise on reduction in physical
discomfort (Baciuk, Pereira, Cecatti, Braga, & Cavalcante, 2008; Backhausen et al., 2014; Backhausen et al., 2017; Granath,
Hellgren, & Gunnarsson, 2006; Kent, Gregor, Deardorff, & Katz, 1999; Kihlstrand, Stenman, Nilsson, & Axelsson, 1999; Lox
& Treasure, 2000; Scott & Hellawell, 2018; Smith & Michel, 2006). For instance, these studies demonstrated beneficial effects
of aquatic exercise for back pain (Backhausen et al., 2014; Backhausen et al., 2017; Granath et al., 2006; Kihlstrand et al.,
1999), maternal discomfort (Smith & Michel, 2006), pelvic pain (Scott & Hellawell, 2018), fatigue (Backhausen et al., 2014;
Lox & Treasure, 2000; Scott & Hellawell, 2018), labor pain (Baciuk et al., 2008), and edema related discomfort (Hartmann &
Huch, 2005; Kent et al., 1999). There was no study that reported adverse effects of aquatic exercise on the above-mentioned
variables. In sum, these findings collectively suggest that aquatic exercise interventions can potentially reduce physical
discomfort in pregnant women. However, more studies seem essential to increase strength of the evidence in favor of these
findings.
3.3.2 Aquatic Exercise Effects on Psychological Health
Seven of the included studies assessed aquatic exercise effects on psychological health and well-being. These studies indicated
that aquatic exercises can potentially reduce stress (Parker & Smith, 2003), decrease psychological distress(Scott & Hellawell,
2018),improve stress management and body image(Smith & Michel, 2006), decrease depression (Aguilar-Cordero, Sánchez-
García, Rodriguez-Blanque, Sánchez-López, & Mur-Villar, 2019), foster positive feelings (Lox & Treasure, 2000), improve
mood and vigor, and decrease depression (Polman, Kaiseler, & Borkoles, 2007), and enhance pleasant feelings and decrease
anxiety (Backhausen et al., 2014). In general, these data from these studies provided support for effectiveness of exercises in
aquatic environment for reducing negative psychological conditions and enhancing positive psychological outcomes in
pregnant women. No study showed negative outcome of aquatic exercises interventions on psychological health of the
pregnant women. This highlights that there is some possibility to prescribe exercises intervention in aquatic environment for
pregnant women with experiencing negative feelings, anxiety and depression related symptoms.
3.3.3 Aquatic Exercise Effects on Quality of Life
Of the selected studies, there was only one study that investigated the effects of aquatic exercise on ‘quality of life’ among
pregnant women. In this regard, Vallim, A.L., et al., (Vallim et al., 2011) conducted a study involving 35 women in water
exercise condition in which intervention group underwent three classes of aquatic aerobic exercises per week whereas control
group received normal hath care. The analysis yielded no significant difference on the quality of life measure between both
groups. This suggests that there is no relationship between aquatic aerobics and quality of life among inactive women with
pregnancy. No final conclusion can be drawn based on insufficient data available from only one study.
3.3.4 Aquatic Exercise Effects on Sleep
We found only two studies that presented data regarding relationship between aquatic exercises and sleep in pregnant women.
Both studies reported a significantly positive effect of aquatic exercise on sleep (Backhausen et al., 2014; Rodriguez-Blanque,
Sánchez-García, Sánchez-López, Mur-Villar, & Aguilar-Cordero, 2018). Findings from these two studies appeared to favor the
idea of utilizing aquatic exercises as an effective mean to improve sleep among pregnant women. However, the existing data is
insufficient that hinders drawing definite conclusion regarding effectiveness of this intervention for improving sleep in
pregnant women.
3.3.5 Aquatic Exercise Effects on Maternal Weight Control
We found the data regarding association between aquatic exercise and maternal weight control only in four studies selected for
this analysis (Aguilar-Cordero et al., 2019; Bacchi, Mottola, Perales, Refoyo, & Barakat, 2018; Backhausen et al., 2014;
Vallim et al., 2011). Studies included in this section consistently demonstrated positive impact of involvement in aquatic
exercise programs on controlling excessive maternal weight among the samples of pregnant women. These findings highlight
the efficacy of aquatic exercise programs for excessive weight control during pregnancy. However, with only four studies
provided support for the effectiveness of this intervention for controlling excessive weight gain among these individuals
remains unconfirmed unless availability of more data from further studies on this domain.
4. Discussion
Pregnant women, in many cases, appeared to experience wide range problems concerning physical discomfort (edema, pain,
fatigue), and psychological issues (anxiety, stress, depression, disturbed mood). Women also reported to exhibit problems in
sleep and excessive weight gain during pregnancy. In this connection, effective interventions required to develop for the
purpose of improving these conditions that further could enhance quality of life in these individuals. Past research has
demonstrated that aquatic exercise programs appeared to be particularly beneficial to boost physical and psychological well-
being. It can be hypothetically assumed that exercise programs in an aquatic environment particularly tailored with the needs
and interests of pregnant women would be more effective to deal pregnancy related physical and psychological issues. This
work serves to present qualitative synthesis of evidence based on published research assessing efficacy of water based exercise
interventions on the alleviation and/or enhancement of wide range physical and psychological pregnancy related outcomes.
Journal of Business and Social Review in Emerging Economies Vol. 6, No 2, June 2020
398
One main finding emerged from this data is effectiveness of aquatic exercise programs on improvement in various symptoms
of physical discomfort in pregnant women. This finding found to be consistent in demonstrating such effect across all of the
included studies. None of the studies presented adverse outcomes of the intervention on the any of the physical discomfort
variables. In addition, there were no conflicting results reported in any of the included study. In this regard, aquatic exercise
appeared to be beneficial for improvements in back pain, maternal discomfort, pelvic pain, fatigue, labor pain and edema
related pain. More data from future research would add strength of the evidence for the effectiveness of this intervention.
Another main findings emerged from this data is positive effect of aquatic exercise on improving level of variety of
psychological variables in pregnant women. This effect appeared to be consistent across all of the included studies in this
review. The positive effects were emerged for variety of the psychological outcomes including stress, psychological distress,
body image, positive feelings, mood, vigor, depression, and anxiety. These findings likely to suggest that aquatic exercise
programs can be used to as an effective interventional strategy to improve physical pain, to enhance positive psychological
outcomes and to treat negative psychological symptoms (i.e. anxiety, depression, stress, negative body image) in pregnant
women. This could potentially contribute to physical and psychological well-being of this population.
Furthermore, we found evidence from four included studies exhibiting beneficial effects of aquatic exercise for excessive
maternal weight gain. All of the four studies demonstrated consistent positive effects for controlling weight in pregnant
women. Although this data is promising with respect to such effect on pregnancy related weight gain, however, this data seems
inadequate that hinders drawing of definite conclusion. This indeed fosters the idea of conducting further studies that would
help to reach final conclusion. This review found no evidence for beneficial effects of aquatic exercise for the measures of
quality of life. However, we found little support from two studies for positive effects of aquatic exercise for pregnancy related
sleep problems. Based on insufficient data obtained from two studies in favor of beneficial effects of aquatic exercise for sleep
related issues, we are not confident to suggest this intervention to address sleep related issues in these individuals.
In sum, based on above discussion, it can be concluded that aquatic excise may be suggested as an intervention to address
issues concerning physical discomfort, psychological symptoms, and managing maternal weight in pregnancy. In addition, this
review study found no effect of aquatic exercise on measures of quality of life or insufficient support for sleep related problems
in the samples of pregnant women. However, these findings needed to be verified with more studies addressing these issues.
5. Limitations
Studies in English language were included in this review that led to exclude studies published in other languages. This review
focused only a few common physical and psychological outcomes including edema, fatigue, pain, sleep, quality of life,
maternal weight gain and other psychological variables. This resulted in studies limited to the variables of our interest in this
review. Future review should broaden the scope of the reviews to include birth related outcomes, newborn health, and
pregnancy related defects regarding effectiveness of aquatic exercise programs for women with pregnancy.
6. Practical Implications and Recommendations
Existing evidence regarding positive effects of aquatic exercise on some pregnancy related outcomes likely to suggest that
there is some possibility to use this intervention to reduce and/or treat some issues concerning physical discomfort,
psychological health, and maternal weight management in the population of pregnant women. However, these implications
should be interpreted with caution because these are based on a few published studies on this topic.
It is evident that exercise with various intensities, durations, and frequency have different impact on physical and psychological
health. It has been suggesting that only the appropriate dose of exercise is essential for optimal health related benefits. The
findings emerged from this review need to extend using aquatic exercise intervention with various intensities, duration,
frequency, and different exercise dosages. It would be more interesting to investigate differences with respect to effects on
pregnancy related outcomes comparing samples of professional swimmers versus non-swimmers. This paradigm would
highlight the impact of long-term training versus short-term training on the pregnancy related variables. In particular, this view
identified that studies with strong methodological quality are lacking. Insufficient or no data exists on the investigating effects
of this intervention on sleep and quality of life. These issues need to be addressing in future research.
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