Hindawi

Journal of Pregnancy
Volume 2019, Article ID 4176303, 8 pages
https://doi.org/10.1155/2019/4176303

Research Article
Patient Attitudes toward Gestational Weight Gain and Exercise
during Pregnancy

M. L. Lott,1,2 M. L. Power ,3,4 E. G. Reed,4 J. Schulkin,5 and A. D. Mackeen2

1
Maternal-Fetal Medicine, Advocate Lutheran General Hospital, St. Charles, IL, USA
2
Division of Maternal-Fetal Medicine, Women’s and Children’s Institute, Geisinger, Danville, PA, USA
3
American College of Obstetricians and Gynecologists, Washington, DC, USA
4
Smithsonian National Zoological Park and Conservation Biology Institute, Washington, DC, USA
5
University of Washington School of Medicine, Seattle, WA, USA

Correspondence should be addressed to M. L. Power; [email protected]

Received 30 April 2019; Accepted 30 July 2019; Published 17 September 2019

Academic Editor: Luca Marozio

Copyright © 2019 M. L. Lott et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Body mass index (BMI) and gestational weight gain (GWG) are important factors for neonatal and maternal health. Exercise helps
women moderate their BMI and GWG, and provides health benefits to mother and child. This survey study assessed patients’
perceptions of counseling they received during pregnancy, their sources of information about GWG, and their attitudes toward
exercise during pregnancy. We distributed an anonymous survey to 200 pregnant women over the age of 18 at a tertiary care center in
Danville, Pennsylvania. Survey questions included demographics, discussions with medical providers regarding GWG and exercise,
and their exercise habits before and during pregnancy. 182 women (91%) responded. Most reported their provider discussed weight
and diet (78.8%), expected GWG (81.6%), and exercise during pregnancy (79.8%); however, 28% of obese women and 25% of women
who did not plan to exercise during pregnancy reported not receiving exercise counseling. Approximately 20% of women did not
plan to exercise during pregnancy. Women decreased the number of days per week they exercised (40.6% with 3 or more days
prepregnancy versus 30.7% during pregnancy, 𝑃 = 0.002). Some patients who did not exercise prior to pregnancy (12%) expressed
interest in a personal training session. Among women in the eight month or later, 42.4% were above GWG recommendations.
Our study found barriers to adequate activity during pregnancy; 20% of pregnant women not receiving/remembering counseling
regarding exercise. Interest in personal training from patients that did not exercise suggests they would benefit from increased efforts
to encourage physical activity. Exercise and GWG counseling based in medical science as well as patient psychological needs will
help efforts to reduce GWG and improve pregnancy outcomes.

1. Introduction (IOM) published revised guidance on GWG that accounted

for the mother’s prepregnancy BMI with regard to recom-
Maternal body mass index (BMI) and gestational weight gain mendations for total GWG and weekly weight gain during
(GWG) are important factors for neonatal and maternal the second and third trimesters [6]. In 2013 the American
health. Underweight women who do not gain enough weight College of Obstetricians and Gynecologists (ACOG) endorsed
during pregnancy are at risk of small for gestational age neo- the 2009 IOM GWG recommendations [11].
nates and preterm birth [1–4], birth outcomes associated with Exercise can be an important component of lifestyle
poor health later in life for the neonate. High maternal BMI behaviors that help women moderate their BMI and GWG,
and excessive GWG are independent risk factors for increased and provides additional health benefits to mother and child.
neonatal adiposity [5]. Excessive GWG is also a risk factor in Exercise during pregnancy improves or maintains cardiovas-
all BMI categories for fetal macrosomia, cesarean delivery, cular fitness, reduces the risk of gestational diabetes, hyper-
postpartum weight retention [6], and future obesity of both tensive disorders, macrosomia, and cesarean deliveries
mother and child [7–10]. In 2009, the Institute of Medicine [12, 13], and enhances psychological well-being [14]. Exercise
2 Journal of Pregnancy

during pregnancy does not increase the risk of preterm birth demographic information (age, height, prepregnancy weight,
or shorten gestation [12]. Indeed, in overweight and obese current weight, education level, ethnic background, and insur-
women, exercise during pregnancy is associated with a ance information), prepregnancy perception of obesity and
decreased risk of preterm birth [15]. Neonates of women who diabetes, perceptions of discussions with medical providers
reduced their exercise levels at 20 weeks of gestation were more regarding GWG and the consequences of inappropriate GWG,
likely to have an adiposity above the 90th percentile [16]. and exercise habits both before and during pregnancy. For sur-
Exercise in pregnancy has also been shown to decrease total vey responses regarding types of exercise, the following defi-
labor time [17]. nitions were used: Low-impact cardiovascular activity included
ACOG recommends that all women with uncomplicated walking, elliptical, cycling, or swimming. High-impact cardi-
pregnancies engage in moderate intensity physical activity ovascular activity included running, cross-training, or step
30 min per day most days of the week during pregnancy, in aerobics. Weight training included free weights and weight
the absence of maternal contraindications [18]. However, stud- machines. Surveys also inquired into which sources of preg-
ies have found that only a minority of pregnant women achieve nancy information the patient considered most helpful in
the recommended level of activity, with a consistent decrease understanding GWG. The patients were instructed to complete
over pregnancy [19, 20]. Being inactive has become a leading the survey questions and then seal their responses in the pro-
risk factor for mortality and morbidity inside and outside of vided envelope. The envelopes were collected and sent to the
pregnancy [20]. Research Department at the American College of Obstetricians
ACOG and the American Academy of Pediatricians rec- and Gynecologists for review and analysis. The study was
ommend obstetric providers offer education and counseling approved by the Geisinger Institutional Review Board and
regarding GWG, diet, and exercise as an integral aspect of classified as exempt.
routine prenatal care [21]; however, the effectiveness of current Data were analyzed using a personal computer-based sta-
provider counseling practices is uncertain. A qualitative study tistical package (IBM SPSS 24.0; IBM Corp, Armonk, NY).
of providers found that providers did not place a priority on Descriptive statistics were computed for the measures. Missing
appropriate weight gain, had few resources for patients, and values were excluded when calculating frequencies. Patients’
believed that any advice they gave was unlikely to be followed prepregnancy BMI was calculated from their self-reported
[22]. One year after ACOG endorsed the IOM recommenda- height and prepregnancy weight. Weight gain at the time of
tions for GWG, a survey of practicing ACOG Fellows found the survey was calculated by subtracting their prepregnancy
that almost one-in-five were unaware of the recommendations weight from their self-reported current weight. Continuous
and roughly half were not confident in their ability to influence parameters are presented as mean ± SEM. Chi-square was used
GWG [23]. In a later study, although most providers believed to test associations between categorical variables. Significance
that excessive GWG was a major health concern in their prac- was set at 𝑃 < 0.05.
tice, 40% were not confident in their ability to affect their
patients’ GWG [24]. From the patient perspective, two recent
studies found that about one-third of the enrolled pregnant 3. Results
women did not recall receiving advice regarding GWG
[25, 26]. Overweight and obese women were either more likely Demographic information for the 182 women (91%) that com-
not to recall receiving guidance or more likely to have received pleted and returned the survey are given in Table 1. The patient
advice not consistent with the IOM guidelines [25, 26]. population studied had an average age of 29.2 years
The purpose of this survey study is to assess the perception (SEM = 0.4 years), with a mean prepregnancy BMI of
of patients regarding the counseling they received during preg- 29.6 ± 0.6 kg/m2. A majority were either overweight or obese
nancy for GWG and exercise, their sources of information (Table 1). Almost all (93.9%) the respondents were white.
about GWG, and to identify patient attitudes toward exercise Almost all were either married (62.1%) or living with a partner
during pregnancy as compared to their prepregnancy ideals (29.1%). Most had private health insurance (60.8%). The
and activity level. Specifically, we are interested in the willing- patients were, on average, in their seventh month of pregnancy
ness of patients to consider further education regarding exer- (range of second month to tenth month). Almost forty percent
cise during pregnancy including personal training sessions. (39.7%) reported their provider was a medical doctor, with
We examine the self-reported activity exercise level from 23.5% reporting a nurse midwife, and 8.4% reporting a nurse
before and during pregnancy and reasons for any change, such practitioner as a provider (11.7% responded they were not
as unwillingness to participate in activities, fear of exercise sure who their provider was). Thirty of the women reported
during pregnancy, uncertainty regarding the safety of exercise having two or more providers (16.8%).
during pregnancy or direct instruction by an OB provider that Most women reported that their health care provider had
they are restricted from exercise during pregnancy. discussed their weight and diet (78.8%), the expected amount
of weight they should gain (81.6%), exercise and physical
activity during pregnancy (79.8%), and the importance of
2. Materials and Methods controlling their blood sugar during pregnancy (70.4%).
Fewer, but still a majority of women reported being told about
An anonymous survey was distributed to 200 pregnant women possible harms to their baby (67.0%), possible harms to them-
over the age of 18 receiving prenatal care at a tertiary care selves (65.4%), and possible problems with delivery (64.6%)
center in Danville, Pennsylvania. Survey questions included from excessive GWG. A discussion of possible harms to their
Journal of Pregnancy 3

Table 1:  Demographic information for the 182 women that Sixty-six patients were in their eighth month or later of
completed the survey. pregnancy. This group’s demographics were no different than
the overall study population’s demographics (primary pro-
Demographic 𝑁(%)
vider, race, insurance, education, or relationship status).
Education 𝑛 = 182 Within this subset, 42.4% of women were above recommen-
Less than high school diploma 2 (1.1) dations for GWG, based on their self-reported height and
High school diploma 46 (25.1) prepregnancy and current weights. Overweight women were
Some college 40 (21.9) the most likely to have excessive GWG (72.7% versus 26.1%
College graduate 67 (36.6) and 43.8% for normal weight and obese women, respectively,
Graduate/Professional degree 27 (14.8) 𝑃 = 0.040). There was no difference in the recall of counseling
Race 𝑛 = 181 by providers by either BMI or GWG category. Similarly, there
White 170 (93.9) was no difference in BMI or GWG category based on primary
Black or African American 3 (1.7) provider, race, relationship, or education (data not shown).
Asian/Hawaiian/Pacific Islander 2 (1.1) Compared to patients with Medicaid or no insurance, patients
Latina 0 (0) with private insurance were less likely to have GWG below
American Indian or Alaska Native 0 (0) recommendations (12.5% versus 46.7%) and more likely to
Other 0 (0) have GWG within or above recommendations (40.0% versus
Two or more selected 6 (3.3)
13.3%, 47.5% versus 40.0%, 𝑃 = 0.015).
Prepregnancy, only about one in five of the women (19.8%)
Relationship status 𝑛 = 182
reported not regularly engaging in exercise. About two-thirds
Married 113 (62.1)
(66.5%) reported engaging in low-impact cardio exercise pre-
Not married but living together 53 (29.1) pregnancy, with fewer engaging in high-impact cardio (17.0%)
In relationship, not living together 8 (4.4) or weight training (17.6%). The most common response was
Not in a relationship 8 (4.4) engaging in low-impact cardio only (62.4%); very few reported
Insurance 𝑛 = 181 engaging in all three exercise types (4.6%). Prepregnancy,
None 9 (5.0) obese women were more likely than overweight or normal
Private health insurance 110 (60.8) weight women to engage in low-impact cardio (79.7% versus
Medicaid/Medicare 35 (19.3) 60.4%, 𝑃 = 0.008) and less likely to engage in high-impact
Military health care 4 (2.2) cardio (4.1% versus 30.8%, 𝑃 < 0.001) or strength training
Other source 19 (10.5) (9.5% versus 27.5%, 𝑃 = 0.003) (Table 2). Also prepregnancy,
Two or more selected 4 (2.2) patients with Medicaid or no insurance were less likely to
Patient’s obstetric care provider 𝑛 = 179 engage in high-impact cardio than patients with private insur-
Medical Doctor 71 (39.7) ance (0.0% versus 24.8%, 𝑃 < 0.001), and less likely to engage
Nurse Practitioner 15 (8.4) in weight training (7.5% versus 23.8%, 𝑃 = 0.019).
Certified Nurse Midwife 42 (23.5) During pregnancy, the proportion of women engaging in
Not sure 21 (11.7) low-impact cardio increased (79.1%), with 70.4% of the
Multiple providers 30 (16.8)
women reporting low-impact cardio as their only exercise. The
proportion engaging in high-impact cardio (4.4%) and weight
Patient’s BMI category 𝑛 = 182
training (9.9%) decreased substantially (Table 2). In general,
Underweight 2 (1.1)
the women decreased the number of days per week they exer-
Normal weight 62 (34.1)
cised (40.6% reported exercising 3 or more days prepregnancy
Overweight 34 (18.7) versus 30.8% during pregnancy, Table 2, 𝑃 = 0.002). During
Obese 78 (42.9) pregnancy, there was no difference in the proportion of women
Unknown 6 (3.3) engaging in low-impact cardio by BMI category, however,
obese women were still significantly less likely to engage in
baby from too little GWG was reported by 58.7%. A majority high-impact cardio or strength training (Table 2).
of women considered their obstetrician (76.4%) or another Among the aforementioned 66 women in their eighth
health care provider (62.6%) a good source of information month or later in pregnancy, 20.9% reported not exercising
regarding GWG. Neither the patient’s prepregnancy BMI nor prepregnancy and 29.9% did not plan to exercise during preg-
the month of pregnancy was associated with whether she nancy. Before pregnancy 38.8% of these 66 patients exercised
recalled being counseled by her provider on these topics, and 3 or more days per week, but during pregnancy this figure
there was no difference in the patients’ recall of advice/coun- reduced to 23.9%. Exercise status before pregnancy and plans
seling based on type of provider. Insurance status made no to exercise during pregnancy made no difference to whether
difference in recall of counseling for all questions except the their GWG was within or above recommendations.
amount of weight the patient should expect to gain during Of the patients that did not plan to exercise during preg-
pregnancy. Respondents with private insurance were more nancy, reasons reported for not exercising included: being
likely to recall counseling on GWG expectations than respond- unsure if they were allowed to exercise (8%), being afraid to
ents with Medicaid or no insurance (86.4% versus 69.8%, exercise during pregnancy (8%), not liking to exercise (29%),
𝑃 = 0.017). being specifically instructed to not exercise by their provider
4 Journal of Pregnancy

Table 2: Counseling and patient exercise habits prepregnancy and providers, providing an opportunity for health interventions
during pregnancy by BMI. that may not have otherwise occurred. This includes oppor-
tunities for counseling regarding healthy activity and lifestyle
Over-
Normal Obese changes to optimize maternal health and pregnancy outcomes.
All weight
BMI
BMI
BMI Pregnancy can be considered as a “teachable moment” that
may further mold a woman’s dietary and lifestyle choices
𝑁(%) 𝑁(%) 𝑁(%) 𝑁(%)
beyond the puerperium into lifelong improvements in overall
Received coun- health and fitness [27].
142 50 28 57
seling regarding
(78.0%) (83.3%) (84.8%) (74.0%) Obesity remains a growing public health concern,
exercise
particularly among pregnant women. A majority of our study
Desired to meet
49 11 11 26 population were overweight or obese by self-report.
with personal
(26.9%) (18.0%) (35.5%) (34.2%) Inappropriate GWG also continues to be a serious public
trainer
health concern [28], and a large proportion of the women in
Prepregnancy
this study had excessive GWG despite a majority self-reporting
Exercised before 144 49 27 60
(79.9%) (80.3%) (79.4%) (77.9%)
receiving counseling and information from their health care
pregnancy
provider. This result is consistent with a 10-year retrospective
Exercised 3+ days
74 30 14 25 study of GWG in this population using medical records that
per week before
(40.6%) (49.2%) (41.2%) (32.5%) found that a majority of women gained above recommenda-
pregnancy
Engaged in tions, with no change in the pattern over the 10 years [29].
121 35 20 59 Previous published findings indicate the tools available to
low-impact
(66.5%) (59.3%) (62.5%) (79.7%) providers are not sufficient to effect positive change in GWG
cardiovascular
Engaged in outcome [26, 30]. Obstetric providers need increased training
31 18 10 3
high-impact to effectively and efficiently deliver counseling regarding the
(17.0%) (30.5%) (31.3%) (4.1%)
cardiovascular health benefits of appropriate GWG, healthy activity, and dura-
Engaged in weight 32 16 9 7 tion and intensity of exercise. Once consistency of provider
training (17.6%) (27.1%) (28.1%) (9.5%) counseling is demonstrated, we can then focus on the tools
Pregnancy available to patients to allow them successful achievement of
Plan to exercise 144 48 24 62 GWG and fitness goals. Delgado et al. reported differences in
during pregnancy (79.1%) (77.4%) (72.7%) (80.5%) physician versus patient perceptions of counseling, as well as
Plan to exercise 3+ 56 23 8 21 utility of various methods of patient education including post-
days per week (30.8%) (37.1%) (24.2%) (27.3%) ers, hand-outs, and phone applications [31]. Seventy seven
Will engage in percent of patients found information regarding local fitness
144 50 25 62
low-impact resources useful as compared to half of providers perceiving
(79.1%) (80.6%) (75.8%) (81.6%)
cardiovascular them as helpful[31]. Provider counseling must be grounded
Will engage in in both medical science and patient preferences and
8 6 2 0
high-impact behavior.
(4.4%) (9.7%) (6.1%) (0.0%)
cardiovascular
Overweight and obesity-specific counseling and
Will engage in 18 10 5 3
recommendations may be a helpful manner by which at-risk
weight training (9.9%) (16.1%) (15.2%) (3.9%)
populations can begin to improve intrapartum, pregnancy
and neonatal outcomes, as well as long term maternal health.
(2%), and 56% gave other reasons for not exercising such as Patients in all BMI categories were equally as likely to have
illness, injuries, lack of time in the day, heat, or cold. Nineteen received GWG and exercise counseling, but still overweight
percent of patients reported they were not counseled regarding patients were most likely to exceed GWG recommendations.
exercise in pregnancy, with 32.4% of patients that did not exer- Obstetric providers can prescribe exercise in overweight and
cise prior to pregnancy reporting they did not receive coun- obese patients through an effective approach tailored toward
seling. Twenty six percent of obese women and 21.2% of previously sedentary women to slowly and safely reintroduce
women who did not plan to exercise during pregnancy physical activity into their everyday lives [32]. Our survey
reported they did not receive counseling. About 32% of showed one in five respondents were not exercising before
patients who exercised and 12.9% of those who did not exer- pregnancy and that 32% of this group did not receive exercise
cise prepregnancy expressed interest in meeting with a per- counseling. This may represent a lost opportunity to encour-
sonal trainer for an exercise counseling session. Of those age life-long healthy behaviors as well as potentially moder-
interested in personal training, 29.4% reported not receiving ate GWG.
any exercise counseling from a provider. Our results are consistent with findings from previous
studies assessing patient perception of exercise and barriers
to physical activity in pregnancy. Petrov Fieril et al. conducted
4. Discussion face-to-face interviews of 17 pregnant patients in order to
describe experiences of exercise while pregnant [33]. Fourteen
Pregnancy is a time in which women that may not otherwise of the 17 exercised regularly before pregnancy, performing
seek medical care have regular contact with health care highly repetitive resistance training in a group setting on a
Journal of Pregnancy 5

regular basis. The positive impacts of exercise were commonly considered for all women in pregnancy in whom exercise is
discussed, as were some limitations to active participation such not contraindicated.
as concern regarding the effect on the fetus, physical limita- Pregnancy is an optimal time for behavioral interventions
tions, and an overall lack of knowledge regarding physical guided by policy, because of the regular contact with health
activity in the gravid state [33]. Similarly, our patients also care providers women receive during pregnancy. However,
reported a lack of knowledge of acceptable exercise during IOM recommendations themselves are not enough to affect
pregnancy, as well as psychological concerns, including fear GWG practices [38], and internationally many countries have
and dislike of exercise. no policies in place for excessive GWG [39]. Our study impli-
A majority of respondents planned to exercise during cates that current GWG and exercise counseling practices are
pregnancy, most of whom planned to engage in low-impact not sufficient, as a majority of patients reported receiving coun-
cardio activity, which has been shown to reduce GWG and seling on both, yet were still above IOM GWG recommenda-
gestational diabetes [13, 34]. However, 20% of patients did tions. Health care providers often overestimate the percentage
not plan to exercise; 29% of those reported it was because of of their patients with GWG within recommendations, and
a dislike of exercise, pointing to a need for further study and sometimes underestimate the percentage of their patients with
incorporation of emotional drivers of exercise intent into GWG above recommendations [24]. Additionally, health care
interventions. Gustafsson et al. evaluated the impact of exer- providers understand the benefits of exercise during pregnancy
cise on the quality of life of patients that were randomized to but are less well versed in the appropriate ACOG recommen-
participate in thrice weekly moderate intensity exercise [35]. dations for exercise [40]. Provider counseling methods should
The number of women not meeting the ACOG standards for be revised to more prominently include patient preferences,
exercise in pregnancy is consistent with our findings. as personal intent is critical to achieving exercise participation
Interestingly, the overall Psychological General Well-being results, and therefore aid in appropriate GWG [36].
Index (PGWBI) scores were not different between groups and Counseling must also be behavioral change focused, as
exercise did not appear to positively impact psychological behavioral strategies play an important role in successful GWG
wellbeing or self-perceived health [35]. Rauff and Downs interventions [41]. Women who are more knowledgeable
found in their prospective study that the primary predictor about their BMI category and GWG recommendations pre-
for exercise in pregnant women was intention, and that over- pregnancy are more likely to gain within GWG recommenda-
weight and obese participants had lower attitudes and inten- tions [42, 43]. Similarly, women must be knowledgeable about
tion toward exercise compared to normal weight participants appropriate exercise options during pregnancy in order to
[36]. The study’s similar population demographics to ours meet ACOG activity recommendations [18]. A small but note-
and location in Central Pennsylvania are likely indicative that worthy group of our respondents reported confusion over
exercise intention is an influence in our population’s what exercise practices were safe to pursue during pregnancy,
responses. which is consistent with previous studies of demographically
In a systematic review and meta-analysis, Choi et al. found similar populations [44]. Practitioners should use counseling
supervised physical activity showed less GWG than controls, practices that outline personal GWG goals and safe options
while unsupervised physical activity demonstrated a nonsig- for exercise in a format, such as pamphlets/brochures, pre-
nificant increase in GWG as compared to controls [37]. The ferred by patients [31]. Exercise regimes individualized for
studies that included unsupervised physical activity did offer each patient would be the optimal practice, as unsupervised
counseling regarding recommended physical activity during and general exercise plans are less effective in helping achieve
pregnancy but did not prescribe patient-specific regimens, appropriate GWG [37]. Equally important but beyond the
which indicates that a more intensive and individualized scope of our study, policies and counseling practices should
approach to exercise in pregnancy, rather than generalized rec- address women’s health preconception, specifically achieving
ommendations, may be a crucial aspect of reducing GWG [37]. a normal BMI, as ill-health preconception leads to increased
It is concerning that among our respondents in their eighth complications when pregnancy does occur [45].
month of pregnancy or later, exercise status before and during This study has several limitations. Due to the anonymous
pregnancy had no influence on GWG; however, many factors nature of the survey, both height and weight were patient
not included in our survey, such as diet, could have influenced reported information, thus making confirmation of BMI and
GWG outcomes. Although exercise did not help moderate weight gain uncertain. Exercise patterns were all self-reported
GWG for these women, they could have experienced many and we cannot distinguish between actual exercise patterns as
other benefits of exercise during pregnancy such as reduced they occurred from reported plans to exercise. For example,
risk of preterm birth [15] and decreased labor time [17]. we assumed that the 66 patients who were in their eighth
Our results reflect a willingness to counsel with a physical month or later of pregnancy were reporting their actual exer-
trainer during pregnancy, as well as a reluctance to start an cise behavior, as it would be unreasonable to assume that if
exercise intervention due to fear or lack of understanding of they had not been exercising prior that they would begin at
appropriate activity during pregnancy. The direct supervision the end of pregnancy. Another limitation is that our patient
and feedback provided by a physical trainer can offer a patient population is predominantly Caucasian in a rural area, which
reassurance and motivation as well as an individualized fitness leads to the inability to generalize our results to other popu-
routine that can be tailored to the changing gravid abdomen lations. We did not include a referral to a physical trainer to
and exercise tolerance to improve pregnancy outcomes and our patients as part of our study, although the anonymity of
decrease GWG. A referral to a physical trainer should be the survey study would not have allowed evaluation of patient
6 Journal of Pregnancy

compliance or the effect of training. The rural location of the UA6MC19010 and UA6MC31609: Pregnancy-Related Care
study hospital and limited access to health clubs and personal Research Network. This information or content and conclu-
trainers or other fitness experts are an inherent limitation to sions are those of the author and should not be construed as
our population, which may also have impacted patient the official position or policy of, nor should any endorsements
reported exercise habits during pregnancy. Limited access to be inferred by HRSA, HHS or the U.S. Government.
fitness facilities and personnel due to location, as well as cost
inhibitors to fitness are concerns for health during pregnancy.
In our study, women with private insurance were more active References
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