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Abstract

Pregnancy causes psychological changes. Various distress can occur and some previous studies have shown the positive impact of exercise on the psychological condition of pregnant women. The aim of this study was to conduct a systematic mapping review of the literature that explored the psychological effect of sport in pregnant women. A literature search was carried out on articles published between 2010-2020 on PubMed, Science Direct, Cochrane Library, EBSCO, Cinahl and ProQuest. The search identified quantitative research studies on the psychological effect of exercise for pregnant women. Each study's bias was assessed using Review Manager 5.3. Nine articles were analyzed through data extraction. The types of exercise discussed in this systematic review include supervised exercise sessions, aerobic dance, endurance training, interval stationary cycling and the intervention followed American College of Obstetricians and Gynecologists (ACOG) guidelines. Pregnant women who have exercise have improved psychological conditions such as decreased sadness, hopelessness, anxiety and the incidence of antenatal depression. Furthermore, pregnant women also showed an enjoyment to exercise. Exercise may have a positive effect on psychological state and reduce risk of psychological distress for pregnant women. Keywords: exercise, pregnancy, pregnant women, psychological effect, sport Nasution LA, Darmawati I (2020) Psychological effects of exercise for pregnant women: a systematic review. Eurasia J Biosci 14: 6983-6990.
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EurAsian Journal of BioSciences
Eurasia J Biosci 14, 6983-6990 (2020)
Psychological effects of exercise for pregnant women: a
systematic review
Lina Anisa Nasution 1*, Irma Darmawati 1
1 Program Study of Nursing, Faculty of Sports Education and Health, Universitas Pendidikan Indonesia, West Java,
INDONESIA
*Corresponding author: linaanisa@upi.edu
Abstract
Pregnancy causes psychological changes. Various distress can occur and some previous studies
have shown the positive impact of exercise on the psychological condition of pregnant women. The
aim of this study was to conduct a systematic mapping review of the literature that explored the
psychological effect of sport in pregnant women. A literature search was carried out on articles
published between 2010-2020 on PubMed, Science Direct, Cochrane Library, EBSCO, Cinahl and
ProQuest. The search identified quantitative research studies on the psychological effect of exercise
for pregnant women. Each study’s bias was assessed using Review Manager 5.3. Nine articles were
analyzed through data extraction. The types of exercise discussed in this systematic review include
supervised exercise sessions, aerobic dance, endurance training, interval stationary cycling and the
intervention followed American College of Obstetricians and Gynecologists (ACOG) guidelines.
Pregnant women who have exercise have improved psychological conditions such as decreased
sadness, hopelessness, anxiety and the incidence of antenatal depression. Furthermore, pregnant
women also showed an enjoyment to exercise. Exercise may have a positive effect on psychological
state and reduce risk of psychological distress for pregnant women.
Keywords: exercise, pregnancy, pregnant women, psychological effect, sport
Nasution LA, Darmawati I (2020) Psychological effects of exercise for pregnant women: a
systematic review. Eurasia J Biosci 14: 6983-6990.
© 2020 Nasution and Darmawati
This is an open-access article distributed under the terms of the Creative Commons Attribution License.
INTRODUCTION
Pregnancy is the women's special period that is
complex and specific, which is related to various
physical and psychological changes that a pregnant
woman experience (Bjelica et al., 2018; Isaacs &
Andipatin, 2020). Psychological conditions of pregnant
women have implications for fetal development,
childbirth, maternal adaptation during pregnancy, and
maternal adaptation after delivery (Guszkowska et al.,
2015; Hidayat et al., 2019). Psychological changes in
pregnant women can be adaptive as a result of hormonal
changes during pregnancy, but it can also be
maladaptive or known as prenatal distress (Isgut et al.,
2017; Lorén-Guerrero et al., 2018).
Some examples of prenatal distress such as anxiety,
antenatal depression, or body image disorders can
develop into serious disorders such as pregnancy
disorders, maternal and fetal health problems (Lorén-
Guerrero et al., 2018; Obrochta et al., 2020). Mothers
with prenatal distress, if treated improperly, have the
possibility of experiencing stress until delivery even after
delivery (postpartum) (Hidayat et al., 2019; Obrochta et
al., 2020). Thus, it is important to prevent and overcome
prenatal distress for pregnant women (Hoover & Louis,
2019; Silva et al., 2019).
One recommendation from The American College of
Obstetricians and Gynecologists (ACOG) is related to
efforts to optimize the physical and psychological health
of pregnant women by doing exercise (Gregg &
Ferguson, 2017; The American College of Obstetricians
and Gynecologists, 2015). Physical exercise during
prenatal can reduce gestational hypertension, reduce
back pain during pregnancy, shorten the duration of
labor, reduce the risk of cesarean delivery, and improve
fetal well-being (Magro-Malosso et al., 2017; The
American College of Obstetricians and Gynecologists,
2015). Psychologically, physical exercise can improve
well-being and prevent depression (Guszkowska et al.,
2015; Hinman et al., 2015).
Physical exercise is an essential element of a healthy
lifestyle to achieve optimal health. Pregnant women are
recommended to do physical exercise at least 150
minutes per week (Hinman et al., 2015; The American
College of Obstetricians and Gynecologists, 2015).
Physical exercise in pregnant women also varies,
namely swimming, static cycling, light aerobics, yoga,
Received: May 2019
Accepted: March 2020
Printed: December 2020
EurAsian Journal of BioSciences 14: 6983-6990 (2020) Nasution and Darmawati
6984
pilates, and strength training (The American College of
Obstetricians and Gynecologists, 2015).
Earlier studies have shown that pregnant women
who do physical exercise have better mental health and
higher psychological well-being than those who don't
(Davenport et al., 2018; Guszkowska et al., 2015;
Haakstad et al., 2016). The systematic review article
aims to explore the psychological effects of physical
exercise on pregnant women. The population studied
was pregnant women. The intervention was the physical
exercise done by a group of pregnant women. The
outcome was the measurement of a psychological
effect.
METHODOLOGY
Inclusion criteria
The inclusion criteria set out in the selection of
research articles are as follows.
1.Research type: Research with RCT type, quasi-
experimental, cohort, case study.
2.Participant/respondent type: The population in the
systematic review study was pregnant women.
3.Type of intervention: physical exercise.
4.Language and publication date: published in
English between 2010 and 2020.
5.The type of outcome measured: psychological
aspects such as anxiety, depression, coping, comfort,
emotional well-being, and psychological condition.
Exclusion criteria
Research with respondents of pregnant women who
have mental disorders.
Search strategy
The search strategy included the following terms:
‘sport’, ‘exercise’, ‘psychological effect’, ‘pregnant
women’ and ‘pregnancy’. The search range was
between 1 January 2010 and 1 May 2020. Databases
used for searching literature included PubMed, Science
Direct, Cochrane Library, EBSCO, Cinahl and ProQuest.
The systematic review study uses the procedures
recommended in Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA)
(Liberati et al., 2009). The article search results based
on keywords yielded 223 articles. The results were
screened and filtered based on the availability of the full
text, the non-duplication of the text, and the year of
publication. A total of 18 articles were obtained by seeing
the suitability of the article title. After reviewing the full
text and the inclusion and exclusion criteria set, we
found nine articles that met all of the criteria set for
further review. The process of article finding is shown in
Figure 1.
Critical Appraisal and Risk of Bias
Assessment
Research criticism was carried out on nine selected
articles using The Critical Appraisal Skills Program
(CSAP). The research critique analysis method using
the CASP instrument was carried out based on each
research design. A total of seven articles with RCT
designs were analyzed with CSAP for RCT type
research. Two research articles with Cohort research
designs were analyzed by using CSAP for Cohort.
Nine articles were analyzed through data extraction.
Variables acquired through data extraction were:
authors name(s), year of study and publication,
intervention method, and study findings. All the items
Fig. 1. Result of a systematic search in databases related
to psychological effect of exercise for pregnant women
Fig. 2. Risk of bias summary: review authors’ judgements
about each risk of bias item for each included study used
RevMan 5.3
Fig. 3. Risk of bias graph: review authors’ judgements for
each included study used RevMan 5.3
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were included in the table of data extraction. We used
the Cochrane Collaboration free software called Review
Manager (RevMan version 5.3) which is useful for
analyzing results and risk-of-bias. The results of bias
assessed are shown in Figures 2 and 3.
RESULTS
The characteristics of search results articles
The characteristics of the selected studies are
outlined in Table 1. A study conducted by Garnaes et
al., (2019) fulfill the conditions that had been set out in
this systematic review. The design of this study was RCT
with 46 pregnant women respondents in the intervention
group and 45 in the control group. This research was
conducted by supervising physical exercise. The
outcome measured was psychological well-being.
Psychological well-being was measured using the
Psychological General Well Being Index (PGWBI) at 12-
18 weeks of gestational age, 34-37 weeks of gestation
and postpartum (Garnæs et al., 2019).
Furthermore, the research by Guelfi et al., (2016) is
an RCT study by measuring the effect of physical activity
on static cycling for 14 weeks (supervised) towards
respondents in the intervention group. There 90 people
in the intervention group and 90 people in the control
group. The respondents were pregnant women who had
a history of gestational diabetes. The secondary
outcome measured was the respondents' psychological
condition, including stress, anxiety, and depression
during pregnancy. The instruments used to measure
these conditions include Maternal Psychological Well
Being Assessed through the Edinburgh Postnatal
Depression Scale, Depression Anxiety and Stress
Scale, and Social Physique Anxiety Scale (Guelfi et al.,
2016).
A study conducted by Haakstad et al., (2016) with
RCT designs tested the effects of physical exercise
conducted based on guidelines from The American
College of Obstetricians and Gynecologists (ACOG).
The physical exercise included one hour of aerobics
class for 2-3 times per week (minimum 12 weeks, did not
include jumping or running) and was carried out by being
accompanied by a supervisor. There were 52 people in
the intervention group and 53 in the control group.
Outcomes measured were four psychological variables
(welfare, quality of life, self-image, and bad-mood -
symptoms) using a modified instrument from WHOQOL
and SF-36 (Haakstad et al., 2016).
A later study conducted by Kocsis et al., (2017)
testing the effects of physical activity examines the 10
week gymnastics effects on pregnant women with a
gestational age of 18-22 weeks on their emotional
psychological status. The outcome measured was the
stress and anxiety of pregnant women. The number of
respondents was 79 intervention groups and 53 control
groups (Kocsis et al., 2017). Furthermore, the RCT
study conducted by Kim & Park (2017) examines the
relationship between physical exercise in the form of
structured bed exercise (SBE) on physical discomfort,
anxiety, and depression in high-risk pregnant women.
Intervention group respondents were 23 people and the
control group were 22 people. Measurement of
Table 1. Description of studies included in the systematic review
No
References
Study Design
Exercise/ Intervention
Result
1.
Garnaes et al.
RCT
Supervised physical
exercise
There were no significant differences between the
intervention and control groups regarding psychological
well-being during pregnancy. Both groups showed good
psychological condition from the beginning of pregnancy
until delivery. Respondents in the intervention group had
better self-control and very few symptoms of depression.
2.
Guelfi et al.
RCT
Static cycling for 14 weeks
There was a decrease in psychological distress in
respondents in the intervention group in the intervention
3.
Haakstad et al.
RCT
Exercise according to
ACOG guidelines
The intervention group experienced an improvement in
psychological conditions, namely a decrease in sadness,
hopelessness, and anxiety when compared with the
control group. There were no significant differences
between the two groups about self-image and the
incidence of depression.
4.
Kim & Park
RCT
Structured bed exercise
Respondents in the intervention group experienced a
decrease in anxiety significantly decrease.
5.
Kocsis et al.
RCT
Specific gymnastics
programs for 10 weeks
There was a decrease in anxiety and stress in the
intervention group.
6.
Ong et al.
Experimental study
Continuous Cycling
Exercise (CONT) for 30
minutes
Respondents showed that they enjoyed the exercise
7.
Padmapriya et al.
Cohort
Supervised physical
exercise
The physical activities carried out were associated with a
decrease in the incidence of antenatal depression and
anxiety.
8.
Szegda, et al.
Cohort
Supervised physical
exercise
Decreased symptoms of depression in early, mid and late
pregnancy
9.
Wit et al.
RCT
Supervised physical
exercise
Depression is more common in pregnant women with little
physical activity
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psychological outcomes was carried out using the
Physical Discomfort Scale, the State-Trait Anxiety
Inventory, and the Edinburgh Postnatal Depression
Scale Korean Version (Kim & Park, 2018).
An experimental study conducted by Ong et al.,
(2016) examined 12 healthy pregnant women with an
intervention in the form of continuous cycling exercise
for 30 minutes. The mother's psychological output
measured is the enjoyment of exercise with the Physical
Activity Enjoyment Scale (PACES) instrument (Ong et
al., 2016). Furthermore, the study conducted by Wit et
al., (2015) examined the relationship between moderate
to vigorous physical activity (MVPA) on the emotional
well-being of obese pregnant women. Wit et al., (2015)
measured the emotional wellness index using the WHO
well-being index (WHO-5) instrument and measured
pregnancy-related concerns as measured using the
Cambridge Worry Scale (CWS) instrument (de Wit et al.,
2015).
The other two studies in this systematic review are
cohort studies. The Padmapriya et al., (2016) study
examined the relationship between pregnant women
who did measure physical activity and/or physical
exercise compared to pregnant women who did not do
physical exercise during pregnancy. Padmapriya et al.,
(2016) measured anxiety with the State-Trait Anxiety
Inventory (STAI) and depression instruments with the
Edinburgh Postnatal Depression Scale (EPDS)
(Padmapriya et al., 2016). Study conducted by Szegda
et al., (2018) which is a study prospective cohort
examining the relationship of pregnant women who do
physical exercise and exercise with symptoms of
depression. Physical exercise was measured with the
Pregnancy Physical Activity Questionnaire and minor or
major depression outcomes with the Edinburgh
Postnatal Depression Scale (EPDS) instrument (Szegda
et al., 2018).
Physical exercise during pregnancy
The studies in this systematic review involve
respondents of pregnant women, both the healthy and
the high-risk pregnancy. Both of these populations still
have the type of physical training done following the
characteristics of the respondents' physical conditions.
For the respondent of healthy pregnant women, physical
exercise was carried by following the guidelines of The
American College of Obstetricians and Gynecologists
(ACOG) (Garnæs et al., 2019; Guelfi et al., 2016;
Haakstad et al., 2016; Kocsis et al., 2017).
Measured physical training conducted in RCT
research with respondents of healthy pregnant women
doing either gymnastics, aerobics, static cycling, or other
physical exercises. A study conducted by Garnaes et al.,
(2019) involved the intervention in the form of
programmed physical training according to ACOG
guidelines, supervised by a therapist, consisting of 35
minutes of walk on a treadmill and 25 minutes of
resistance training including pelvic muscle training.
Besides, respondents were also asked to do 50 minutes
of physical exercise at home at least once a week
(Garnæs et al., 2019). The physical exercise conducted
in Guelfi’s study was carried out by static cycling for 14
weeks. The duration of static cycling was increased from
20 minutes, 30 minutes to 60 minutes per session with a
total of 2-3 sessions per week (Guelfi et al., 2016).
Similarly, the study of Ong et al. (2016) examined the
intervention of static cycling for 30 minutes (including
warming-up and cool down) (Ong et al., 2016).
Research Haakstad et al. (2016) examined 2-3
aerobic sessions per week which were conducted one
hour in each session. The physical exercise begins with
five minutes of warm-up, 35 minutes of endurance, and
aerobic exercise including cool down. During the next 15
minutes, strength training is focused on stabilizing the
inner abdominal muscles (internal oblique and
transverse abdominal muscles), pelvic muscles, and
back muscles (Haakstad et al., 2016).
The research involving physical exercise was
conducted by Kocsis et al. (2017) in the form of special
exercise for pregnant women with supervision. This
physical exercise focuses on strengthening muscle tone,
the duration of exercise following the capacity of
pregnant women, including the existence of breathing
exercises, and psychosomatic relaxation (Kocsis et al.,
2017). Gymnastics procedures were performed on a
research duration of 2 hours per session, were carried
out twice a week for 10 weeks. The physical exercise
focuses on improving posture, strengthening muscle
tone, strengthening posterior and pelvic muscles,
breathing, relaxation techniques, and Schultz's
autogenic exercise techniques that can reduce stress
and psychosomatic symptoms (Kocsis et al., 2017).
Obese pregnant women and high-risk pregnant
women are also still recommended for physical exercise.
Wit et al., (2015) examined obese pregnant women,
gestational age of 15-28 weeks to conduct moderate-to-
vigorous physical activity (MVPA) measured using
accelerometers ranging from moderate physical
exercise including swimming (de Wit et al., 2015). In the
Kim & Park's study (2018), mothers with high-risk
pregnancies with gestational ages of more than 24
weeks, who received bed rest care, continued to do
physical exercise in the form of structured bed exercise
(Kim & Park, 2018).
Structured bed exercises consist of isometric
exercises that can stimulate increased flexibility and
muscle strength and isotonic exercises that can increase
muscle length (Kim & Park, 2018). The procedure of this
exercise is a five-minute warm-up exercise, strength
training for 20 minutes, and a cooling exercise for five
minutes (Kim & Park, 2018). Warm-up and cool down
exercises structured bed exercise consist of stretching
the thighs, calves, back of the neck to the back,
shoulders, and arm circumference. Furthermore,
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strength training focuses on muscle strength such as leg
extension and exercises knee-chest (Kim & Park, 2018).
The two cohort studies in this systematic review used
measured physical exercise as the study intervention. A
study conducted by Padmapriya et al., (2016), physical
activities were categorized as light-moderate (leaves the
person tired but not exhausted), moderate (leaves the
person exhausted but not breathless), and vigorous
intensity (makes the heart beat rapidly and leaves the
person breathless). All physical exercises are recorded
in duration and frequency every week (Padmapriya et
al., 2016). Likewise, in the research of Szegda et al.,
(2018) who measured energy expenditure (metabolic
equivalent hours/week) (Szegda et al., 2018).
Psychological effects of physical exercise
during pregnancy
Nine studies had measured the effect of physical
exercise on the psychological condition of pregnant
women (both in healthy pregnant women and high-risk
pregnant women). A study conducted by Garnaes et al.,
(2019) had a measured outcome in the form of the
psychological well-being of pregnant women. The
physical exercise showed no influence on the
psychological well-being of pregnant women, but the
researchers considered that it was influenced by the
weakness of the intervention protocols they established
so that further research with greater research power was
needed (Garnæs et al., 2019).
Unlike the case with research by Garnaes et al.,
(2019), Guelfi et al., (2016) measure the effect of
physical exercise on stress, anxiety, and depression
during pregnancy show a decrease in prenatal distress.
Likewise, RCT's research by Haakstad et al., (2016)
shows that physical exercise has a good effect on well-
being, quality of life, self-image and reduces symptoms
of bad mood (Haakstad et al., 2016). Research by
Kocsis et al., (2017) and Wit et al., (2015) that examined
physical exercise against stress and anxiety shows that
regular physical exercise in pregnant women can
maintain psycho-emotional stability and general quality
of life.
Furthermore, the studies by Kim & Park's (2017),
Padmapriya et al., (2016) and Szegda et al., (2018)
examining physical discomfort, anxiety, and depression
shows that physical activity affects both outcomes (Kim
& Park, 2018; Padmapriya et al., 2016; Szegda et al.,
2018). Similarly, research by Ong et al., (2016) prove
that pregnant women who perform physical activity show
a psychological response in the form of enjoyment of
exercise (Ong et al., 2016).
DISCUSSIONS
Pregnancy is a pleasant moment. However, distress
often occurs during pregnancy that is better known as
prenatal distress (Obrochta et al., 2020; Vehmeijer et al.,
2019). Prenatal distress can be defined as stress, the
appearance of symptoms of depression and anxiety.
This affects the health of the mother and fetus and
neglecting it can cause death to the mother or fetus and
both (Vehmeijer et al., 2019). For the fetus, prenatal
distress can cause low body weight, small head
circumference, intrauterine growth retardation, and
preterm birth. Prenatal distress can also cause cardio
metabolic disorders, neuro developmental disorders,
respiratory and skin disorders in children (May et al.,
2016; Silva et al., 2019).
Various adverse effects of prenatal distress cause
the importance of preventing prenatal distress and
strengthening the psychological condition of pregnant
women (Hoover & Louis, 2019). One of the activities of
pregnant women that can be pursued to improve
psychological well-being is a physical activity that is
routinely carried out both individually or in groups
(Knight & Foster, 2017; Kocsis et al., 2017; The
American College of Obstetricians and Gynecologists,
2015). Physical exercise in pregnant women is certainly
different from physical exercise in general. Modification
is needed associating with general changes in maternal
anatomy and physiological changes of the mother and
fetus. Physical exercise for pregnant women is
influenced by gestational age, maternal health
conditions, and fetal conditions (The American College
of Obstetricians and Gynecologists, 2015).
The purpose of physical activity for pregnant women
is to maintain their physical health and their
psychological well-being (Shiri et al., 2018; The
American College of Obstetricians and Gynecologists,
2015). Some examples of physical exercises
recommended for pregnant women include swimming,
pregnancy exercise, static cycling, light aerobics, yoga,
pilates, and endurance exercises (Garnæs et al., 2019;
Guelfi et al., 2016; Haakstad et al., 2016; Kim & Park,
2018; Kocsis et al., 2017; Ong et al., 2016; Padmapriya
et al., 2016; Szegda et al., 2018; The American College
of Obstetricians and Gynecologists, 2015). The nine
studies in this systematic review study show variations
of physical exercise carried out certainly fit the condition
of pregnant women (healthy pregnant women and
mothers with high-risk pregnancies). All physical
exercises carried out were based on the supervision of
the researchers. Based on the results of critical
appraisal and bias evaluation, it was found that the
majority of studies show good quality and low bias
(Figures 2 and 3).
The physical exercise on the psychology of pregnant
women shows good effects (Garnæs et al., 2019; Guelfi
et al., 2016; Haakstad et al., 2016; Kim & Park, 2018;
Kocsis et al., 2017; Ong et al., 2016; Padmapriya et al.,
2016; Szegda et al., 2018). Physical activity can reduce
anxiety, minor or major depression in the prenatal
period, increased positive self-image, increased
psychological well-being of pregnant women. The
duration of physical exercise is varied but routine per
EurAsian Journal of BioSciences 14: 6983-6990 (2020) Nasution and Darmawati
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week, especially during the gestational age of more than
12 weeks (Haakstad et al., 2016; Yu et al., 2018).
The lack of systematic review studies is that it still
limited in the number of respondents, that, in each of the
related articles, are still varied and cannot be
generalized because of the number of samples that are
not representative. However, the advantages of the
systematic review study results are nine articles
published in the last five years so the results obtained
include the latest research. These results focus on the
psychological impact of physical activity on pregnant
women. Furthermore, critical appraisal and bias
measurements have been carried out for each article
included in this systematic review study using a reliable
instrument, namely CASP and RevMan 5.3.
CONCLUSION
Pregnancy causes physical and psychological
changes in pregnant women. This, of course, affects the
health of the mother and fetus during the prenatal period
to the postpartum. Pregnant women need an effort to
prevent perinatal distress, one of them is by doing
physical activity. This systematic review study involves
nine articles related to the effect of physical activity on
the psychological condition of pregnant women.
Physical activity can be done in the form of pregnancy
exercises, aerobic exercise, static cycling, or other
physical training following the conditions of each
pregnant woman. Physical activity that is carried out
regularly can improve emotional well-being including
reducing anxiety, reducing stress and depression as well
as improving self-image and psychological condition of
pregnant women.
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