[PDF] EXERCISE, NUTRITION, AND WEIGHT MANAGEMENT DURING PREGNANCY

1 EXERCISE, NUTRITION, AND WEIGHT MANAGEMENT Jennifer Jones, MEd Jeff Housman, PhD Willis McAleese, PhD DURING PREGNANCY...

American Journal of Health Studies: 25(3) 2010

EXERCISE, NUTRITION, AND WEIGHT MANAGEMENT DURING PREGNANCY Jennifer Jones, MEd Jeff Housman, PhD Willis McAleese, PhD Abstract: The purpose of this study was to investigate pregnancy related knowledge and behavior among of sample of pregnant women. Research indicates moderate exercise, specific dietary practices and weight management are beneficial to women before, during, and after pregnancy. Healthy lifestyle practices among pregnant women are associated with positive birth outcomes, and exercise and weight management during pregnancy alleviates discomfort and aides in better births and patient recovery. Foods consumed during pregnancy are the primary sources of nutrients for a growing baby. Economic, racial, and educational disparities were found for knowledge and behavior regarding exercise, nutrition, and weight management during pregnancy.

INTRODUCTION

Research indicates moderate exercise, specific dietary practices and weight management are beneficial to woman before, during, and after pregnancy, and are associated with positive birth outcomes (ACOG Ed. Pamphlet AP001, 2008; Polley, Wing, & Sims, 2002; ICEA, 2000). Moderate exercise is recommended during childbearing years to alleviate discomfort, aide in fewer delivery complications, improve recovery, and promote better birth outcomes for both mother and child (ICEA, 2000). Foods consumed during pregnancy are the primary source of nutrients for a growing baby, and weight management is important for the health of both the mother and baby (ACOG Ed. Pamphlet AP001, 2008). Although research indicates the importance and benefits of healthy lifestyle practices during pregnancy, few studies assessing knowledge and behavior regarding exercise, nutrition, and weight management during pregnancy exists. The purpose of this study was to assess the knowledge and behavior of a sample of pregnant women regarding exercise, diet, and weight management during pregnancy. EXERCISE Pregnant women are a population with special guidelines for exercise, diet, and weight management. Following the guidelines outlined

by the American Congress of Obstetricians and Gynecologists (ACOG) improves the likelihood of a healthy pregnancy (ACOG Ed. Pamphlet AP001, 2008). Moderate exercise is safe for most pregnant women and can lessen or prevent discomforts, contribute to better births and recoveries, and promote better fetal and maternal outcomes (ICEA, 2000). According to the ACOG, exercising 30 minutes each day at a moderate pace can result in numerous health benefits for pregnant women including prevention or treatment of gestational diabetes, increased stamina, improved sleep, and reduction of pregnancy symptoms such as backache, constipation, bloating, and edema. Exercise may also improve coping skills during labor and help women return to their previous fitness level more quickly after giving birth (ACOG Ed. Pamphlet AP119, 2008). Additionally, regular prenatal exercise, including exercise conducted before conception and during pregnancy, may act through several mechanisms to prevent obesity related complications and adverse pregnancy outcomes (Weissegerber, Wolfe, Davies, & Mottolla, 2006). Improved outcomes may include reduction in risk for gestational diabetes, pre-eclampsia, and excessive weight gain during pregnancy. Many forms of exercise are beneficial for pregnant women, but all exercise programs should consist of a warm up, cool down and Kegal exercises.

Jennifer Jones, MEd, is affiliated with Idaho State University, 921 S. 8th Avenue, Pocatello, ID 83209, E-mail: [emailprotected], Tel: 282-282-2729, Fax: 208-282-4903. Jeff Housman, PhD, is affiliated with Texas State University, 601 University Drive, San Marcos, TX 78666. E-mail: [emailprotected], Tel: 512-245-1314, Fax: 512-245-8678. Willis McAleese, PhD, is affiliated with Idaho State University, 921 S. 8th Avenue, Pocatello, ID 83209, E-mail: [emailprotected], Tel: 282-282-2729, Fax: 208-282-4903. Corresponding Author: Jeff Housman. -120-

Jones, Housman & McAleese Kegal exercises are contractions of the pelvic floor using the muscles that stop the flow of urine (Jeffreys & Nordahl, 2002). Recommended modes of exercise include aquatic exercises, pregnancy designed yoga or Pilates, walking, and other mixed cardiovascular activities. Aquatic exercises are beneficial because they provide buoyancy and reduce pressure on joints (ICEA, 2007). Walking provides a total body workout, has minimal impact on joints and muscles, and is a great way to begin an exercise program (ACOG Ed. Pamphlet AP119, 2008). Other mixed cardiovascular activities such as low-impact aerobics are also beneficial. Although most women can successfully exercise throughout their pregnancies, woman should be conscious of warning signs that it is time to stop. Women should not exercise if they have risk factors for preterm labor, have vagin*l bleeding, or have a premature rupture of membranes (ACOG, 2007). It is also recommended that pregnant women consult their physician before beginning an exercise regimen. NUTRITION In addition to exercise, the ACOG provides guidelines for dietary behaviors throughout the pregnancy process. Foods consumed by women during pregnancy are the primary source of nutrients for a developing fetus. The ACOG recommends women carefully plan meals to ensure a balanced diet, consume additional iron and folic acid, and become aware of foods and substances to avoid. Women should avoid alcohol and foods that may lead to listeriosis (a bacterial infection) or other food borne illness. Additionally, foods containing caffeine should be used sparingly because large amounts of caffeine have been shown to increase risk of miscarriage (ACOG Ed. Pamphlet AP001, 2008). Dundas and Yarbro (2000) reported most women seem to either consume too few or too many calories with few women consuming appropriate caloric levels for optimal health during pregnancy. Research suggests that many factors including dietary knowledge, discomfort, and doctor interaction influence dietary behavior during pregnancy. Begley (2000) suggested that women feel they are lacking general nutrition knowledge while Dundas and Yarbro (2000) reported that low and high levels of calorie consumption may be affected by discomfort. Pregnant women have reported eating small amounts of food more frequently to counteract the feeling of fullness during their third trimester, and because many believed that their baby would be healthier if they ate more frequently. Furthermore, physical sensations associated with food deprivation changed during pregnancy making them feel hunger more often in some cases and less in others (Fairburn & Welch, 1989).

Pregnant women have also expressed concern regarding their doctors’ level of nutritional knowledge and felt doctors did not have adequate time to discuss nutrition concerns. Many indicated materials they received at the doctors’ offices were not detailed enough to meet their needs. Begley (2000) suggests there is a lack of consistent education on nutrition for pregnant women and there is a need to design and implement new more effective nutrition programs. Most physicians and their patients understand that proper nutrition during pregnancy is important, but many are not aware of specific recommendations and how to achieve these behaviors. In many cases, healthcare providers simply tell women to eat a healthy diet and gain appropriate weight during pregnancy. However, to achieve this, healthcare providers need to give women the tools and direction to do so properly (Vause, Martz, Richard, & Gralich, 2006) WEIGHT MANAGEMENT Weight management during pregnancy influences health during pregnancy and the post-partum period. Gaining too little weight during pregnancy can result in a baby born of low birth weight while gaining too much weight can lead to other risks including gestational diabetes, preeclampsia, and postpartum weight retention (Polley, Wing & Sims, 2002; Perry, Zyrkowski, Clark, Yu, 1994). Recommended weight gain during pregnancy is based on pre-pregnancy weight. The ACOG recommendations for adequate weight gain during pregnancy are: 28-40 pounds if a woman is under weight, 25-35 pounds if a woman is normal weight, and 15-25 pounds if a woman is overweight (ACOG Ed. Pamphlet AP001, 2008). Underweight, normal weight, overweight, and obese categories are defined as a BMI of less than 19.8, 19.8 to 26, 26.1-29, and over 29, respectively (IOM, 1990). Although ACOG guidelines include recommendations for pregnancy weight management for overweight and obese women, some experts consider the current pregnancy weight gain guidelines too high and suggest weight gain should be limited to 15 pounds (Vogel, 2006). Overweight and obesity have been known to complicate pregnancy and may cause an increased rate of morbidity for both the mother and baby (Reece, 2006). Increased morbidity likely stems from issues with blood pressure and diabetes since they are more common in overweight women (Vogel, 2006). Dundas and Yarbro (2000) suggest physicians, dietitians, and other health care providers should discuss appropriate weight gain with pregnant women early in pregnancy so that women can make efforts during the first trimester to overcome poor eating habits and reach specific weight goals. Excess or inadequate weight gain may be influenced -121-

American Journal of Health Studies: 25(3) 2010 by lack of knowledge and understanding regarding the importance of a nutritious diet or the failure of health professionals to properly educate patients on this topic. Polley, Wing, and Sims (2002) found that interventions for normal weight women, including education and behavioral strategies that promote healthy low-fat eating, exercise, and appropriate pregnancy weight gain, had a significant effect on the amount of weight gained.

human subjects committee of Institutional Review Board at the corresponding university. Surveys were completed by participants while waiting for regular prenatal visits. During prenatal office visits, patients were asked to voluntarily complete surveys distributed by clinic staff. Participants read and signed an informed consent form before completing the survey. Of 204 potential participants, 83 completed the survey yielding a response rate of 40.7%.

KNOWLEDGE AND BEHAVIOR Research supports the idea that knowledge influences behavior. Increased nutritional knowledge has been shown to contribute to increase changes in healthy eating habits as well as healthier lifestyles (Fahlman, Dake, McCaughtry, & Martin, 2008). Petrini, Hamner, Flores, and Mulinare (2006) reported that women who were least likely to consume adequate amounts of folic acid were those who had the least knowledge about folic acid and its benefits for pregnancy, and Shanker (2004) found that the second strongest indicator of female’s food choices was nutritional knowledge. It is important for a person to have a basic threshold of knowledge in order to make rational behavioral altering choices (Sapp, 2002). In addition to education, O’Brien and Davis (2007) reported that knowledge is more salient when transmitted in the context of specific behavior and suggested the integration of nutrition education into behavioral programs targeting dietary behavior change.

INSTRUMENTATION Data were collected using a survey instrument developed with ACOG guidelines for exercise, nutrition, and weight management during pregnancy. The instrument contained items measuring exercise knowledge (11), nutrition knowledge (11), weight management knowledge (3), exercise behavior (5), nutrition behavior (3), and weight management behavior (1) during pregnancy. The instrument was reviewed by a panel of 7 experts with expertise in the content (4) and survey construction (3). Each knowledge item consisted of a statement that was true or false according to ACOG guidelines. For example, “Pregnant women should consume at least 400 micrograms of folic acid each day.” Participants were asked to identify if they agreed or disagreed with each statement. Each behavior item indicated a behavior that should or should not be conducted during pregnancy according to ACOG guidelines. For example, “I exercise 3 or more days a week during pregnancy.” Participants’ were asked to identify whether or not each statement was representative of their behavior during pregnancy. Exercise knowledge items assessed participants’ knowledge of safe exercise during pregnancy, appropriate frequency, duration, mode, and intensity of exercise during pregnancy, and the relationship between exercise and pregnancy outcomes (i.e. gestational diabetes, backaches, swelling). Nutrition knowledge items assessed participants’ knowledge of caloric requirement during pregnancy, serving amounts and size, nutrient need (folic acid, iron), and safety of consuming certain foods (albacore tuna, cold deli meat, soft cheeses). Weight management knowledge items assessed participants’ knowledge of appropriate weight gain during pregnancy (using ACOG guidelines). Exercise behavior items assessed participants’ frequency, duration, and intensity of exercise during pregnancy. Nutrition behavior items assessed participants’ food group servings, vitamin use, and consumption of cold lunch meat, albacore tuna, and soft cheeses during pregnancy. Weight management behavior items assessed participants’ weight gain during pregnancy. Exercise knowledge, nutrition knowledge, weight management knowledge, exercise behavior, nutrition behavior, and weight management behavior scores ranged from 0-11, 0-11, 0-3,

METHODS PARTICIPANTS AND SETTING Participants (n = 83) were pregnant women (age: M = 22.4, SD = 3.7, range = 18-40) receiving prenatal care at two clinics in southeast Idaho. Participants were mostly White/Caucasian (68.1%) with the remaining participants identified themselves as Hispanic/Latino (28.1%), Asian (1.2%), or “other” (1.9%). The community from which participants were recruited was a rural population of approximately 20,000 with a median income of $24,000 per year. Forty percent of participants had a high school diploma or GED, 37% had some college, and 23% had a 2-year, 4-year or graduate degree. The majority (88.5%) of patients were in their second or third trimester (13-40 weeks gestation) while 11.5% were in the first trimester (1-12 weeks gestation). Patients were asked to voluntarily complete surveys as they waited for their obstetrics and gynecological appointments during scheduled prenatal visits for a 30 day period. PROCEDURE The protocol for this study was approved by the -122-

Jones, Housman & McAleese 0-5, 0-3, 0-1, respectively. A higher score indicated a greater level of knowledge or compliance with behavioral guidelines. The survey instrument also contained demographic and open-ended items to assess participants’ sources of information, beliefs about the quality of information received, and perceived needs for further information from qualified professional regarding exercise, nutrition, and weight management during pregnancy. To determine validity and reliability, a pilot study was conducted with a convenience sample of 30 pregnant women in southeast Idaho. In addition, a panel of experts on exercise, diet, and weight management during pregnancy were consulted during development of the instrument to address content validity. Feedback from the panel was used to refine the instrument prior to testing. Reliability analysis of pilot data yielded Cronbach alpha reliability estimates of 0.673, 0.664, 0.679, 0.614, and 0.598 for exercise knowledge, nutrition knowledge, weight knowledge, exercise behavior, and nutrition behavior, respectively. Weight management behavior was measured with one item, “Are you gaining weight according to ACOG guidelines.” Therefore, we were unable to calculate a reliability estimate for the weight management variable. One item was removed from both the exercise knowledge and nutrition knowledge scales prior to final data collection to maximize reliability estimates. Although pilot data reliability estimates were marginal, Cronbach alpha coefficients are always dependent on sample size (Thompson, 2003). Cronbach alpha reliability estimates for the final data set were 0.761, 0.719, 0.727, 0.701, and 0.698 for exercise knowledge, nutrition knowledge, weight knowledge, exercise behavior, and nutrition behavior, respectively. STATISTICAL ANALYSIS Descriptive statistics and general linear model methods including multivariate analysis of variance and correlational calculations were used to analyze the data. Frequencies and descriptive statistics were used to evaluate responses to individual instrument items. A series of 4 one-way MANOVA’s with Bonferroni post hoc calculations were performed to determine the effect of each independent variable on the six dependent variables. Independent variables

were age, race, income and education, and dependent variables (DV) were exercise knowledge, nutrition knowledge, weight management knowledge, exercise behavior, nutrition behavior, and weight management behavior. Items from each variable were summed to create the variable score. A higher score indicated greater knowledge or behavioral compliance for each variable. Approximately 3% of data were missing from the final data set. Because missing data points did not appear conditional or systematic, missing data were deemed missing at random (MAR) (Buhi, Goodson, & Neilands, 2007; Allison, 2002). “Data that are MAR are termed ignorable, because when this pattern occurs, the analyst can ignore the reason(s) data are missing and employ a missing data technique to manage the problem” (Buhi, Goodson, & Neilands, 2007, p. 84). Missing data were replaced through multiple imputation (MI) using NORM statistical utility. MI corrects the lowered variance problem created by mean substitution, and it allows analysts to examine the variance to compute statistical significance correctly (Switzer & Roth, 2002). With the exception of MI, all analyses were performed with PASW version 18.

RESULTS

For knowledge variables (see Table 1) participants’ scores were highest for weight management knowledge (M = 2.410, SD = 0.716; range = 1-3) followed by exercise knowledge (M = 7.65, SD = 1.77; range = 3.00-11.00) and nutrition knowledge (M = 5.85, SD = 2.10; range = 1.00-11.00). Participants responded correctly to 80.0%, 69.9%, and 52.7% for weight management knowledge, exercise knowledge, and nutrition knowledge, respectively. For behavior variables, participants’ scores were highest for nutrition behavior (M = 2.16, SD = 0.72; range = 0.00-3.00) followed by weight management behavior (M = 0.59, SD = 0.49; range = 0.00-1.00) and exercise behavior (M = 1.80, SD = 1.24; range = 0.00-4.00). KNOWLEDGE Analysis of knowledge items indicated that the majority of participants understood that it is safe to exercise during pregnancy (97.6%), that it is unsafe

Table 1. Descriptive statistics for knowledge and behavior variables. Exercise Knowledge

Nutrition Knowledge

Weight Management Knowledge

Exercise Behavior

Nutrition Behavior

Weight Management Behavior

Mean

7.65

0.41**

0.33**

0.35**

.22

0.034

Nutrition Knowledge

0.41**

0.40**

0.18

0.33**

0.21

Wt. Management Knowledge

0.33**

0.40**

0.15

-0.06

0.20

Exercise Behavior

0.35**

0.18

0.15

0.10

0.15

0.22

0.33**

-0.06

0.10

0.25*

0.20

0.15

0.25*

Nutrition Behavior

Wt. Management 0.03 0.21 Behavior ** Correlation is significant at the 0.01 level * Correlation is significant at the 0.05 level to lift large amounts of weight during pregnancy (85.5%), and that they should talk with their doctor before beginning an exercise program (95.2%). Additionally, the majority of participants knew they should stop exercising if they experienced a headache or dizziness (88.0%), that exercise was effective in decreasing backaches, constipation, and swelling (78.0%), and that they should consume fluids regularly during exercise (69.9%). Participants scored lower on items regarding management of gestational diabetes (54.9%) and the safety of running during pregnancy (39.4%). Nutrition knowledge was more limited. The majority of participants (95.2%) knew the best way to ensure consuming enough nutrients was to eat a balanced diet, and that diets should include protein, carbohydrates, fats, vitamins and minerals (90.4%). Participants (72.3%) knew the recommended number of servings of fruits and vegetables for pregnancy and that iron supplementation was sometimes needed (86.7%). Only half of participants knew the recommended amount of folic acid needed daily during pregnancy. Less than half of participants knew to begin eating a healthy diet prior to conception (37.3%), and less than half knew the number of additional calories (300 kcal/day) needed for pregnancy (45.8%). Only a few participants (13.3%) knew they should begin taking folic acid before pregnancy and fewer knew about food safety regarding fish (31.3%), deli meats (19.3%), and soft cheeses (38.6%). Finally, the majority of participants (89.2%) knew the ACOG guidelines for weight gain during pregnancy. BEHAVIOR Analysis of behavior items indicated that the -124-

majority of participants (71%) reported exercising during pregnancy, but few reported exercising the recommended frequency, duration or intensity. The majority of participants (92.8%) reported taking a prenatal vitamin, but only 24.1% avoided cold lunch meats, albacore tuna, or soft cheeses during pregnancy. Less than half of participants (49.3%) reported eating 5 fruits and vegetables per day and a little over half of participants (59%) reported gaining weight within the ACOG guidelines. KNOWLEDGE AND BEHAVIOR Pearson r correlation coefficients (see Table 2) indicated relatively small, but statistically significant relationships between nutrition and exercise knowledge (r = .409, p < 0.01), exercise and weight management knowledge (r = .326, p < 0.01), nutrition and weight management knowledge (r = .396, p < 0.01), and nutrition and weight management behavior (r = .249, p < 0.05). Correlations between exercise knowledge and behavior (r = .352, p < 0.01) and nutrition knowledge and behavior (r = .328, p < 0.01) were also statistically significant. Results from MANOVA calculations indicated participants who had attend at least some college had significantly higher scores on exercise knowledge (F(4,58) = 5.533, p = 0.021; M = 8.021, SD = 1.713), nutrition knowledge (F(4,58) = 26.972, p = 0.000; M = 6.745, SD = 1.939), nutrition behavior (F(4,58) = 3.892, p = 0.05; M = 2.298, SD = 0.740), and weight management behavior (F(4,58) = 5.798, p = 0.001, M = 0.702, SD = 0.462) than participants with no college education. Participants older than 22 years of age scored significantly higher on exercise knowledge (F(4,58) = 8.369, p = 0.005; M = 8.036, SD = 1.724), nutrition knowledge (F(4,58) = 4.688,

Jones, Housman & McAleese p = 0.033; M = 6.196, SD = 2.057), and nutrition behavior (F(4,58) = 4.047, p = 0.048; M = 2.268, SD = 0.862) than those 18 to 22 years of age. Participants 18-22 years of age scored significantly higher on weight behavior management (F(3,58) = 3.467), p = 0.022; M = 0.950, SD = 0.236). Participants that classified themselves as White, scored significantly higher on exercise knowledge (F(2,77) = 4.119, p = 0.020; M = 7.938, SD = 1.763) than those classifying themselves as Hispanic/Latino, or other, and participants earning more than $40,000 a year scored significantly higher on exercise knowledge, (F(5,69) = 4.874, p = 0.031; M = 8.512, SD = 1.602) and weight management knowledge (F(5,70 = 4.136, p = 0.002; M = 2.455, SD = 0.772). Partial η² calculations indicated that being White was the best predictor of exercise knowledge (η² = 0.242) while having some college was the best predictor of nutrition knowledge (η² = 0.359), weight management knowledge (η² = 0.198), exercise behavior (η² = 0.123), nutrition behavior (η² = 0.094), and weight management behavior (η² = 0.262). Responses to open-ended items indicated the majority of participants received health-related pregnancy information from their doctor, books, and magazines. Other responses included family and friends, the internet, college classes, television, experience, WIC, and common sense. Participants also believed walking, swimming, yoga, and low impact aerobics were safe modes of exercise during pregnancy. Other answers included stretching, bike riding, running or jogging, yard work, light weight lifting, and “anything you did before.” Participants reported nutrition as a primary concern for having a healthy pregnancy while weight gain, age, smoking, exercise, prenatal vitamins, and blood pressure were also reported as important. Finally, participants indicated a desire for more information regarding nutrition (how much and what to eat), exercise, stress, sexual relations, and medications.

DISCUSSION SUMMARY OF FINDINGS Overall, participants seemed to have adequate knowledge regarding appropriate weight management and exercise during pregnancy, but lacked knowledge of recommended dietary practices during pregnancy. Approximately half of participants remained within ACOG guidelines for weight management and consumed enough fruits and vegetables. Fewer than half knew the recommended amount of folic acid for pregnant women, or exercised with appropriate intensity, during, or frequency during pregnancy. Approximately a quarter of participants avoided cold lunch meat, albacore tuna, and soft cheeses. Of particular concern was the lack of

knowledge regarding folic acid (consumption and supplementation) and avoidance of foods related to listeriosis (e.g. soft cheeses and cold lunch meat). Too little folic acid before and during pregnancy has been linked to birth defect such as spina bifida, and consumption of soft cheeses and cold lunch meat during pregnancy is associated with infection of the fetus. Participants had adequate knowledge of ACOG guidelines for exercise during pregnancy, but most failed to exercise according to recommendations. Previous research suggests pregnant women acquire information regarding exercise before or during pregnancy to avoid excess weight gain out of fear they will not be able to return to their pre-pregnancy weight (Fairburn & Welch, 1989). Others have suggested woman acquire exercise knowledge during pregnancy to ensure the health of their offspring however, barriers such as lack of motivation, lack of time, and lack of support can inhibit maintenance of an exercise regimen (Derbyshire, 2007; Begley, 2002). Participants indicated having limited knowledge of appropriate dietary practices during pregnancy. The majority of participants received nutrition information from doctors, books, the internet, and magazines. Patients often look to doctors for nutritional information, but not all doctors have sufficient dietary knowledge to guide patients. Some medical schools have attempted to improve nutrition education, but most graduating medical students continue to rate their nutrition preparation as inadequate (Adams, Lindell, Kohlmeier, & Zeisel, 2006). Acquiring information from books, magazines, and the internet can also be problematic. There are no regulations for information presented through these media, and books, magazines, and websites often contain unclear, misleading or incorrect information. Characteristics of participants with higher levels of knowledge included a higher level of education and income. Additionally, being classified as White and being older than 22 years of age were associated with pregnancy related knowledge and nutrition behavior. Participants in these categories were more likely to eat the at least 5 servings of fruits and vegetables a day, consume 800mcg of folic acid a day, and avoid cold lunch meat, soft cheeses, and albacore tuna. LIMITATIONS Through the analyses presented here, our understanding of pregnancy related knowledge and behavior among pregnant women is enhanced and adds to the literature regarding healthful habits during pregnancy. Nevertheless, it is important to review results of this study in light of its limitations. -125-

American Journal of Health Studies: 25(3) 2010 The sample in this study was one of convenience and data were self-reported. Additionally, the sample was relatively small and limited to a specific geographic location. Generalization of study findings is limited to similar populations. Aware of these potential weaknesses, we made concerted efforts to minimize other possible threats to validity of our findings. One example of our efforts is the consultation of experts in development of the measurement instrument. Further research into this topic would benefit from a larger randomized sample, and further exploration explanatory constructs (i.e. attitude, self-efficacy, social norms).

CONCLUSION

It is well established that healthful behaviors before, during, and after exercise are associated with positive birth outcomes however, gaps seem to exist in knowledge and behavior exhibited by women during to pregnancy (Martens, Hernandez, Strickland, & Boatwright, 2006). Although rates of infant and maternal deaths related to pregnancy complications have decreased over the last few decades, disparities among minority, low income, and less educated populations remain. Pregnancies in Hispanic and African American populations are more likely to be complicated and end in infant or maternal death. (CDC, 2005). Research indicates healthful behaviors during pregnancy can significantly reduce maternal and infant risk factors and would assist in efforts to reduce disparities among populations (ACOG, 2008; “Healthy People 2010,” n.d.). Our results support previous findings in that respondents’ scoring lowest on education and behavior variables identified themselves as Hispanic or other. Additionally, participants who were younger, had less education and lower income were more likely to have limited knowledge and display less healthful behavior during pregnancy. Furthermore, in most cases, higher levels of knowledge did not highly correlate with more healthful behavior. Research indicates that knowledge is often necessary, but not sufficient for behavior change (O’Brien & David, 2007). Pregnancy education is a first step to healthful pregnancy behaviors, but promotion of healthful behaviors during pregnancy needs to be expanded and/or improved. Health education programs are available in many communities, but gaps remain in lower socioeconomic and rural areas, and health promotion activities are limited in many areas (CDC, 2002). Where available, existing health education and promotion programs have been shown to increase healthful behaviors during pregnancy and reduce negative birth outcomes (USDHHS, 2003). Study participants indicated a desire to receive further education regarding exercise, diet, and sexual relations -126-

during pregnancy, but had limited access to health professionals with sufficient knowledge or skills to offer. Improving access to effective health education and promotion programs in lower income and rural areas would benefit less served populations. Health education and promotion regarding exercise and behavior during pregnancy may have the greatest impact on younger women, minority women, and less educated women. Effective pregnancy related health promotion programs provide timely and accurate information while promoting appropriate diet, exercise, and weight management behaviors (Fahlman, Dake, McCaughtry, & Martin 2008). Education activities should provide pregnant women with appropriate information while addressing specific needs of each individual (ACOG, 2008). Learner materials should contain clear and concise information and instructors should address the needs of varied learners. Instructor availability is also an important element in effective education. Having instructors available to attendees via electronic media (e.g. videostreaming, chat rooms, etc) has been shown to enhance communication between instructors and learners (Saba, 2003). In addition to education, pregnancy related health promotion programs aim to increase healthful behavior through promotion activities and elimination of barriers. Barriers such as lack of motivation, time, and support have been shown to reduce healthful pregnancy behavior, however health promotion activities conducted at primary care, clinic, or hospital settings can reach large number of pregnancy women because most visit these facilities before or during their pregnancies (Lu, M et al., 2006; “Sexual health,” 2008; Clark 1999). Furthermore, because pregnant women feel more comfortable in “like” groups, health promotion programs that encourage group participation often see higher rates of participation than those that don’t (Clark, 1999). Overall, many participants scored relatively high on knowledge of ACOG guidelines regarding exercise and weight management during pregnancy, but lacked knowledge of dietary concerns. In many cases however, knowledge did not lead to recommended behaviors. Furthermore, lower levels of knowledge and compliance to recommended behaviors during pregnancy were found in younger women, minority women, and women with lower incomes and less education. Therefore, younger and minority populations in lower socioeconomic areas might benefit most from effective health education and promotion providing accurate information from a reliable source.

Jones, Housman & McAleese

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