Researching Pregnancy Part 4

However, in this instance the person perceived to be vulnerable is more likely to be the baby; the targeting of the mother stems from their custodians.h.i.+p of their baby's health.

During the period of our study (Pattison and Bhagrath, 2003) there were two main food scares directed at pregnant women. One concerned coffee, which was linked to stillbirth and early infant death in an epidemiological study published in the British Medical Journal (Wisborg et al., 2003).

This nding was taken up by various newspapers and other media in the UK. The second concerned tuna sh, and followed on from previous studies on the mercury content of oily sea sh such as marlin and shark. These other sh do not form a major part of British women's diets. However, when it was found that tuna may also contain high levels of mercury, this information was quickly spread in the media and incorporated into The Food Standard Agency guidelines. Of the women we interviewed only about a third had heard either or both the coffee and tuna stories. However, 72 per cent of those who had heard responded by eliminating or drastically reducing their intake of the food, but the others did not change their consumption at all. This emphasises one of the harmful effects of food scares. While reducing coffee intake is unlikely to harm women, it may make them feel uncomfortable. However, tuna is generally regarded as a healthy food, so the elimination of it is not likely to improve women's diets.

In a survey commissioned by SMA (a baby milk producer) in 2003, 558 mothers with children aged between 12 months and two years in the UK and the Republic of Ireland were questioned about their diet during 91 pregnancy and what they believed about foods that const.i.tuted a healthy diet. The results showed that while they were aware of food scares, they did not always know or understand the research ndings which formed their basis. Some foods were regarded as unsafe through a generalisation from another food. So 60 per cent of women believed that cottage cheese, which is a safe, low-fat source of protein, was unsafe because they failed to make a distinction between this and soft cheeses which may carry listeria. However, in other cases women failed to generalise from one food to others which were similarly hazardous. For example, most avoided or reduced their intake of coffee, because of the risk of caffeine, yet 70 per cent believed that diet cola drinks, which also contain caffeine, were safe.

In one of our studies we also found that women reduced their intake of coffee in an attempt to avoid caffeine, but increased their intake of other caffeine-containing drinks such as tea and cola drinks (Gross and Pattison, 1995).

Research that underpins dietary advice is often presented in a way which makes it very difcult to interpret. Take the following extract from the Babyworld website: Research published in 1999 suggested that high doses of vitamin C and vitamin E may help reduce the incidence of pre-eclampsia in women at high risk of developing the illness. Although this seems encouraging news, most experts remain unconvinced. First, the study was very small (only 160 women completed the study) so the results may not be accurate (a larger trial is being planned).

Secondly, there is some doubt over the safety of the ma.s.sive doses required of the two vitamins.

(Hulme Hunter, 2005) Women who are concerned about pre-eclampsia are advised to talk this study over with their obstetrician. However, the study is unattributed and is so heavily criticised that it would be difcult to imagine any woman feeling comfortable raising these ndings if she does not have knowledge of scientic procedures, or access to medical journals to look up the study. It seems that an attempt not to blind readers with science has led to an oversimplied version, which will only have the effect of making women feel worried.

However, attempting to produce all the caveats and exceptions to advice given is also confusing and likely to make readers worried. Take, for example, the following extract from the BBC website: Research indicates that mothers who eat sh once a week are less likely to give birth prematurely. Oily sh eaten in pregnancy also helps with children's eyesight. However, when you're pregnant 92 have no more than two portions of oily sh a week. Oily sh includes fresh tuna (not canned tuna, which does not count as oily sh), mackerel, sardines and trout. Avoid eating shark, swordsh and marlin and limit the amount of tuna to no more than two tuna steaks a week (weighing about 140g cooked or 170g raw) or four medium-size cans of tuna a week (with a drained weight of about 140g per can). This is because of the levels of mercury in these sh.

At high levels, mercury can harm a baby's developing nervous system.

(Welford, 2005) Again the research is unattributed, and even undated, making it very difcult to trace, and there is not enough information to evaluate it. What const.i.tutes oily sh here is unclear; the pa.s.sage seems to suggest both that women should and should not eat tuna, fresh or canned. In an attempt to be accurate and all encompa.s.sing, the advice becomes controlling.

While information from research that is incorporated into professional leaets and websites may be balanced, much of what appears in the media is not. For example, the research paper referred to above on coffee actually indicated that this was not really a problem for women who were drinking less than eight cups of coffee a day (Wisborg et al., 2003). Similarly, a later report by Bech et al. (2005) suggested that the risk of foetal death was only signicantly higher if women drank more than four cups of coffee a day.

However, as we have shown in Chapter 2, people tend to cla.s.sify things as either safe or unsafe, so the media portrays foods in this way and the likelihood is that, if women act on food scares at all, they will avoid the apparently hazardous foods completely. The distinction between safe and unsafe foods also tends to vary across cultures and be embedded in more general eating habits. So people from European countries tend to regard wine as safe in moderation, whereas it is denitely on the list of things to avoid completely in the US, even though the research evidence on which advice is based is the same.

A nal aspect of food scares to consider is that they nearly always come too late for pregnant women to act on them. Finding out that tuna contains mercury when you are several weeks into pregnancy, and you have already consumed large quant.i.ties of this formerly healthy food, is only likely to induce guilt and anxiety. Neither of these emotions are likely to increase the health of women or their babies. The BUPA website even gives a list of foods that women should have avoided before pregnancy: There are also certain foods that women should avoid pre-pregnancy. These include: liver and large quant.i.ties of vitamin A in supplements, unpasteurized dairy products, 93. raw eggs, pateas, soft cheese.

(BUPA, 2005).

There is little evidence to support this draconian advice and since so many pregnancies are not planned with the precision required by this, many women will not have been able to act on it anyway.

Concluding remarks Research on diet and dietary change during pregnancy is unusual in several respects. One important characteristic is the amount of research which has been carried out in countries other than those in the developed world. While little of this work could be said to be cross-cultural, it does at least give us some insight into how pregnancy is experienced by the women outside the mainstream focus. The differences and similarities between women of different cultures are illuminating in that they show how important it is to consider the context and cultural underpinnings of women's lives.

We have reiterated several times in this chapter that women's eating behaviour during pregnancy is studied out of the context of their everyday lives and history. In particular, little account is taken of dietary restraint and dieting behaviour before pregnancy. Yet at the same time the exception to this is a fascination with the dietary habits of what to most researchers is 'the other', notably pica.

A further unusual feature of research on diet is the direct impact that research has on sanctioning women's behaviour during pregnancy. Epidemiological studies which show some a.s.sociation between what women have eaten during pregnancy and subsequent pregnancy outcomes make almost daily appearances in the media. The risks a.s.sociated with food types are amplied through newspapers, magazines and television, and, perhaps most pervasively, through the internet. Often these studies are later refuted, dealing as they often do with statistically very small increases in risk. However, few women in the developed world can be unaware of the food scares and risk messages directed at them. Yet, what use they make of this information, or the effect of receiving risk messages, often too late to act, on psychological health still goes largely unexplored.

6.KEEPING ACTIVE.

Daily activity and exercise in pregnancy.

I've slowed down. Its common sense really isn't it?

(Gross and Clarke, 2004b: 167).

The 2003 guidelines published by the American College of Obstetricians and Gynecologists (ACOG) on Exercise in Pregnancy and the Postnatal Period state that: 'pregnant women with uncomplicated pregnancies should be encouraged to continue and engage in physical activities . . . exercise has minimal risks and conrmed benets for most women' (ACOG, 2003, cited in Artal and O'Toole, 2003: 8).

This advice, which comes from an established medical authority, is derived from a plethora of research on the potential effects of strenuous exercise on pregnancy outcome and maternal wellbeing. It is such guidelines as these which inform professional advice around the world. The expectations behind such guidelines are that with appropriate medical input, women's health and that of their baby the pregnancy outcome can be a.s.sured. But how relevant is this advice beyond extreme cases, either of high-risk pregnancies, since the guidelines provide many details of contraindications for continuing with exercise, or of a very few high-level athletes. What is the link between such advice and most women's experience?

The research on physical exercise has taken place within a context where the various discourses of pregnancy, both lay and medical, have presented it as a time of moderation and the emphasis has been on the giving up of activities that might put the baby at risk. As we discussed in Chapter 4, there is plenty of advice on how to behave during pregnancy in order to ensure the safety of the pregnancy and to maintain maternal health. By contrast with some of the domains of research we have already discussed (for example paid work, diet), research on physical exercise in pregnancy has instead provided conrmation that physical stresses arising from recreational exercise do not appear to increase the incidence of poor outcomes and in fact may signicantly reduce the risks. The current advice 95 from ACOG and similar authorities is thus a commonsense position that we should be able to endorse and to act upon.

However, rst, these current guidelines represent quite a s.h.i.+ft in the medical literature from previous recommendations of moderation to the present maintenance recommendations, and these still require consultation with professionals. Second, the focus of the guidelines is more on exercise than physical activity more generally and the apparently straightforward statement of encouragement is less easy to translate when all forms of activity are considered. Clearly, women habitually partic.i.p.ate in a combination of occupational, domestic and recreational activities and their experience of pregnancy is effectively a process of negotiating being pregnant within the multiple demands of their daily lives. In this context, therefore, physical exercise programmes may be a very small part of their physical activity. How women with ordinary lives respond to advice to sustain physical activity at the same time as moderating other of their behaviours is more complex than the guidelines alone might suggest.

In this chapter, we look at some of the research evidence that has informed, and continues to inform and update, such guidelines and advice on exercise and activity with a view to identifying the kinds of activity referred to and the nature of the advice that they have produced. Then, through material from our own work on women's activity during pregnancy, we explore how women manage the competing expectations of their behaviour in pregnancy.

Exercise activity and outcomes: infant and mother When investigating the topic of physical activity in pregnancy, there is a wide-ranging literature reporting research on exercise, including work on animals, undertaken from a primarily biomedical perspective, which makes some reference to psychological effects. The research seeks to examine the physiological response of the body in order to identify where risks may or may not occur and the extent to which changes taking place in pregnancy may extend or reduce such risks. For example, a book edited by Artal and his colleagues on Exercise in Pregnancy (Artal et al., 1991) draws on a range of existing expertise to address not only the physiological adaptations to pregnancy, but also the physiology of exercise during pregnancy and, signicantly, the practical applications of this research in terms of advice. The appendix to the book contains what were the current ACOG guidelines at the time the rst edition of the book was produced (1986), which were more cautious in their advice than those cited above. The editors indicate that one of the reasons for caution in both the earlier guidelines and their own conclusions, that they 'no longer have to claim that there is lack of data to allow sage, moderate exercise prescription in pregnancy' (Artal et al., 1991: ix, emphasis added), is the lack of statistical 96 power in some of the studies on strenuous exercise in particular. We shall examine further the concept of permission for women to exercise represented in this statement, once we have looked at the nature of the evidence to which they refer. The historical development of the exercise guidelines is interesting in itself, reecting as it does the available evidence base; the 1994 revision of the ACOG guidelines (ACOG, 1994), though still cautious, by incorporating phrases such as 'should be able to' was more relaxed in tone and even somewhat prescriptive about the value of exercise.

Typically, in research terms, exercise has been used to refer to structured programmes or practices of physical activity, such as those of compet.i.tive and recreational athletes and partic.i.p.ants in organised sporting activities, which can include gym attendance. The increased attention to the value of exercise is reected both in health promotion literature which appears in a variety of media and in the research that has gone on to examine its impact. The benets of physical activity and its relation to physical and psychological health have been increasingly emphasised for all groups (Hagger and Chatzisarantis, 2005). Even in 1991, Artal and Gardin were able to state, albeit rather patronisingly, that 'the exercise spirit has enraptured women of all ages, including women in their childbearing years' (Artal and Gardin, 1991: 1).

The discussion now turns to research on the extent to which physical activity may impact on pregnancy and pregnancy outcome and examines whether or not the traditional consensus of discouraging physical activity can be scientically supported. Coming from very different perspectives, physiologists like Artal, sociologists (e.g. Barker, 1998) and literary a.n.a.lysts (e.g. Hanson, 2004) take the position that, throughout history, recommendations for physical activity in pregnancy have typically been based more on social and cultural expectations than they have on any denitive evidence. Nonetheless, there has been an acc.u.mulation of literature that suggests there may once have been a genuine theoretical basis for reducing exertion.

The central concern is the body and the physiological response to pregnancy since it is clearly the case, as Sternfeld (1997: 34) indicates, that: 'Pregnancy stresses the body more than any other physiological event in a healthy woman's life and requires considerable cardiovascular, metabolic, hormonal, respiratory and musculo-skeletal adaptations'.

The adaptations occur whether or not women are partic.i.p.ating in exercise regimes; the issue is whether the addition of exercise pushes the systems beyond their capacity and thus causes harm, either directly to the foetus or via the impact on maternal functioning. Thus, the medical and safety issues regarding physical activity in pregnancy have been based upon the concern that certain aspects of cardiovascular, metabolic, thermal and mechanical stress could act to threaten outcome.

97.The essential and routine changes in the human circulatory system are quite dramatic in nature and may manifest in many of the unpleasant symptoms of pregnancy including dizziness, nausea and waves of sudden fatigue, but they are not necessarily damaging. As the vascular network expands, increased dilation particularly occurs in the blood vessels supply-ing the skin, kidneys and reproductive tissues. In many ways, the circulatory adaptations induced by pregnancy appear to complement those produced by regular weight-bearing activity in the non-pregnant state; studies of the circulatory effects of regular exercise have demonstrated that vigorous training will increase blood volume and increase the maximum cardiac output that an individual can achieve. It will also increase the density and growth of blood vessels and improve an individual's ability to dissipate heat. Moreover, research evidence suggests that when an adequate exercise regime is maintained during pregnancy, the results of the interaction between these two sources of cardiovascular adaptation are at least additive (Clapp, 1998). Benets for the prospective mother have also been postulated and include what are regarded as signs of tness in nonpregnant individuals: reduced heart rate and reduced blood pressure (Simpson, 1993).

Despite the positive effects of the physiological vascular changes, there nonetheless remained some concerns regarding the capabilities of the human cardiovascular system to meet the dual demands of exercise and pregnancy. As with the investigations of the impact of paid work in pregnancy on outcomes, it could be convincingly argued that this concern and the ensuing research was particularly eurocentric (or Western-centric); many women in the developing world almost certainly continue to undertake strenuous activities that give rise to the same physiological changes as exercise and have little opportunity to choose to moderate such activity.

The main rationale for considering physical stress as a risk factor for poor pregnancy outcome lies in the a.s.sumption that heavy physical effort during pregnancy may divert blood ow from the uterus and, by doing so, reduce oxygen and nutrient delivery to the foetus, or that increase in muscle action will divert effort to the skeletal muscles (McMurray et al., 1993; Stein et al., 1986). Compounding this response further is the proposition that foetal oxygen requirements may increase with strenuous physical work, primarily as a consequence of concurrent increases in temperature and metabolic activity (Lotgering et al., 1985). If this were the case then any reduction in uterine blood ow initiated by physical exertion might be a.s.sociated with a more severe foetal hypoxia than a similar reduction occurring at rest (Bell and O'Neill, 1994), raising alarm bells for the pursuance of maternal exercise at high levels.

However, rea.s.suringly, investigations suggest that the biological system appears to be robust, since several mechanisms have been identied which may act to ensure that foetal oxygen consumption is not easily 98 compromised and the cardiovascular adaptations that occur during pregnancy appear sufcient to maintain adequate blood ow and oxygen delivery to both the exercising muscles and the developing foetus (Clapp, 1980; Rauramo and Forss, 1988). Recent research by Larsson and Lindqvuist (2005) suggests that low-impact aerobics has little or no effect on maternal hyperthermia. From this perspective at least, therefore, it seems that physical activity in pregnancy need not be discouraged. The evidence would, therefore, seem to be at odds with the advice appearing at the time. The basis for such guidelines, to stringently limit exercise during pregnancy, must therefore have arisen from other evidence. This evidence was likely to be that derived from the results of clinical investigations which concentrated directly on the strength of a.s.sociation between activity partic.i.p.ation and pregnancy outcome. In this research, the variables that were considered are those that suggested the greatest foetal risk or poorer foetal outcome and include the standard obstetric parameters of foetal growth, length of gestation and type of delivery. Maternal wellbeing has been addressed, though this received less attention in the rst instance.

In one of the earliest epidemiological studies of recreational activities, Clapp and d.i.c.kstein (1984) observed an adverse pregnancy outcome among women continuing vigorous exercising late into their pregnancy.

Comparisons were made between pregnant women who maintained their exercise until late into the third trimester and those who either reduced their activity or remained sedentary. Women who continued to exercise at an intensity greater than 50 per cent of their age-predicted maximum heart rate for 30 minutes or more, three times a week, were found to exhibit signicantly less pregnancy weight gain and a shorter pregnancy.

The same women also demonstrated a higher incidence of small for gestational age (SGA) babies and a mean birthweight 500g less than either women who were sedentary or women who had stopped exercising prior to the 28th week of their pregnancy. In a similar manner, Clapp and Capeless (1990) later reported that babies born to women who continued to exercise at or above 50 per cent of their pre-pregnancy level were found to weigh an average of 310g less than those who did not. These authors concluded that approximately 70 per cent of the observed variance in infant birthweight could be directly attributed to differences in infant body fat. Typically, infant body fat develops in the last trimester, thus exercise at this time would have appeared to reduce both maternal and infant body fat.

Nonetheless, this work is by no means conclusive since subsequent and already existing research studies found no effects. Rose et al. (1991) did not nd the same rates of lowered birthweight in the babies of women undertaking vigorous physical activity and other studies have reported that physical stress arising from recreational exercise activity does not increase the incidence of either SGA infants or premature labour, and may even 99 decrease the incidence of both (Berkowitz et al., 1983; Klebanoff et al., 1990; Rabkin et al., 1990). Furthermore, case studies of athletes found that they delivered normal birthweight infants despite running regularly throughout their pregnancies (Korc.o.k, 1981). These studies are complemented by laboratory studies which found a similar absence of relations.h.i.+p between work effort or tness on birthweight (Dibblee and Graham, 1983; Wong and McKenzie, 1987).

While the results of such biologically focused research may be criticised for their small sample sizes and insufcient statistical power to detect a true a.s.sociation, as Artal and his colleagues (1991) conclude, nevertheless, the available larger studies have only served to substantiate their ndings.

Hall and Kaufmann (1987) recruited 845 pregnant women, each given the option of partic.i.p.ating in an individually prescribed prenatal exercise programme. Foetal heart rates were monitored throughout the exercise sessions and no abnormalities were observed. Partic.i.p.ants were later categorised on the basis of the total number of exercise sessions they completed during their pregnancy and no adverse effect of exercise programme on gestational age or birthweight was reported. In fact, the authors observed a trend for birthweight to be higher in the exercise group.

Moreover, greater amounts of exercise were revealed to be a.s.sociated with a reduced incidence of caesarean section, higher infant Apgar scores (a composite rating of colour, breathing, heart rate, movements and reexes normally a.s.signed one and ve minutes after birth) and shorter hospitalisation. In this instance, therefore, higher levels of physical activity actually appeared to be of benet. Research has conrmed that labour and delivery appear to be shorter in women who exercise regularly (Clapp, 1990), although the contradictory nature of these ndings also shows that in a cohort of runners there was a higher likelihood of caesarean delivery (Dale et al., 1982). However, in an Australian study of perinatal outcome in a low-risk obstetric population, referred to in Chapter 4, Magann and colleagues (2002) contribute to the confusion by nding that exercise in working women was a.s.sociated with smaller babies, increased incidence of induction of labour and longer labours.

Nevertheless, the c.u.mulative result of this research provides little indication of a negative relations.h.i.+p between higher levels of physical activity and adverse pregnancy outcome. Most studies demonstrate neutral if not favourable a.s.sociations between maternal tness and length or type of delivery and although there are clearly studies which do give cause for concerns about pregnancy outcome it may be that the differences are small despite their statistical signicance. Of course, if there are other risk factors present, a small difference arising from exercise may be compounded and the medical concerns would be legitimate as there could be serious reper-cussions for both mother and baby. But, what about the possible impact on maternal health and wellbeing?

100.As the ndings from the studies indicate, physical exercise may well be benecial in terms of labour and delivery. More than this, it may also be of direct physiological benet, in terms of aerobic capacity (Sternfeld, 1997).

Support for this view has been provided both by compet.i.tive athletes, who anecdotally reported improved performance following delivery (Sady and Carpenter, 1989), and by case studies of recreational athletes (Hutchinson, 1981). Additionally, physical activity during pregnancy has also been linked with the promotion of good maternal posture, prevention of excess maternal weight gain and the prevention of lower back pain (Dewey and McRory, 1994) as well as reduced risk of gestational diabetes (Dye et al., 1997). Evidence for the value of exercise for women's physical health in general is reported by Haas et al. (2005) who nd that a lack of exercise is a.s.sociated with poorer health status pre-pregnancy, during pregnancy and after pregnancy.

There is also literature considering the potential impact of exercise on maternal perceptions of their physical and psychological wellbeing during pregnancy. For some time, there have been studies showing that women who exercise during pregnancy typically report fewer pregnancy-a.s.sociated symptoms than those who are sedentary (Hall and Kaufmann, 1987; Sternfeld, 1997; Wallace et al., 1986). This applied to symptoms of nausea, fatigue, leg cramps, ligament pain and lower back pain. In addition, work by Sternfeld et al. (1995) appeared to identify a temporal a.s.sociation between exercise and wellbeing such that increases in symptom reporting were preceded by a decrease in exercise, leading to the conclusion that women were feeling better because they were exercising. This kind of relations.h.i.+p needs to be viewed with caution, rst because of the social pressure to conform to the positive messages about exercise and second since it could be used to put women in a position where exercise was in fact prescribed as a solution to some of the physical symptoms of pregnancy. Nevertheless, such ndings would have been instrumental in the revisions of the ACOG guidelines.

As far as psychological wellbeing is concerned, research conducted within the general population over the past 20 years has also pointed to the benets of exercise and physical activity. There is an extensive literature on this topic, much of which also attempts to take account of reservations about confounding variables. For example, people do not choose to exercise at random. There may be signicant other differences between active and inactive people that are responsible for differences in mental health (as measured in the biologically oriented exercise studies) and that are more relevant than activity in terms of outcomes and benets. Furthermore, people may have differential expectations of intervention exercise programmes, which may in themselves have an effect on psychological wellbeing.

Nevertheless, this work demonstrates unequivocally that physical activity and psychological health appear to be related in a bi-directional 101 manner. There have been several reviews and meta-a.n.a.lyses (e.g. Long and van Stavel, 1995; North et al., 1990) which show that exercise reduces anxiety and depression and increases self-concept, self-esteem, aspects of cognitive functioning and mood. Longitudinal studies have been carried out investigating the effects of exercise training on psychological wellbeing with a range of populations, including students, groups of older people, people with psychiatric or medical disorders and members of specic groups like the police or the military. Virtually none of these have shown aerobic exercise to have a deleterious effect on psychological health and studies involving comparisons of intervention and control groups demonstrate that the active group show greater psychological improvement even when the control group undertakes another group activity apart from exercise (Steptoe, 1992). The overwhelming conclusion is that physical exercise can exert a positive effect on psychological wellbeing over and above that which might be attributed to other factors.

The ndings of studies investigating the impact of exercise on maternal wellbeing in pregnancy produce the same conclusions: in 1981 Sibley and colleagues found that women who partic.i.p.ated in swimming activity during the second trimester of pregnancy did not improve their tness but did have improved appet.i.te and a more restful sleep pattern; Wallace et al.

(1986) found higher levels of self-esteem and Dewey and McCrory (1994) reported fewer depressive symptoms in women who exercised. These ndings are endorsed by recent studies and reviews, for example Da Costa et al. (2003) and Morris and Johnson (2005), which have shown that exercise in pregnancy improves maternal wellbeing.

The initial focus of medical concern about the potential risks of exercise in pregnancy was driven by the historic need to reduce infant mortality and was centred around the need to reduce or moderate physical activity.

The positive benets of exercise, which have been demonstrated through these mainly physiological studies over time, have undoubtedly contributed to the change in the tenor of advice from ofcial sources such as the contemporary advice on exercise in pregnancy issued by the ACOG. As the 1994 guidelines suggested, women have now been granted permission, on the basis of what might be considered as suitably founded research, to continue with moderate, and even some strenuous, exercise in pregnancy, with the caveat that the pregnancy itself is designated as medically low risk. In fact, there is almost a suggestion that women should now partic.i.p.ate in exercise in order to ensure a healthy outcome for themselves and their baby. This may be a reection of what is acknowledged to be a highly body-conscious society as much as a concern for women's health and wellbeing. (See also below 'Body image as a barrier'.) As with diet, women's behaviour in pregnancy would seem to be determined by the exhortations of ofcial admonitions rather than solely by personal choice.

102.

Daily activities, health and outcomes Current gures on partic.i.p.ation in physical exercise, based on the UK General Household Survey, suggest that nearly 60 per cent of adults take part in sport or physical activity on a regular basis and around a quarter of the population report partic.i.p.ating in an active sport at least three times a week, the most popular activity being walking (Sport England, 2006).

However, the gures are lower than this for women, for those from minority ethnic groups and those with limited incomes. The gures suggest that around 50 per cent of women partic.i.p.ate in at least one type of active sport once a month. This does not necessarily equate to regular partic.i.p.ation in strenuous exercise activity. As for women during pregnancy, the gures do not relate. In fact, it is probably the case that for most women who become pregnant, physical activity is likely to centre around the regular routines of their daily lives, together with recreational activities involving some physical exertion such as swimming, dancing, weekly aerobics cla.s.ses, walking, gardening and so on. The competing demands of employment, relations.h.i.+ps and the household mean that these recreational activities may in themselves be limited. What does research have to say about daily activity, which may be less amenable to moderation or change?

Studies of the general population are more limited in this area, apart that is from studies of older people, who are considered to be at risk from inactivity in two ways (Milligan et al., 2004; Shepard and Montelpare, 1988). One of these is that the restriction of physical mobility reduces wellbeing through loss of independence and control. The other is the potential reduction in social partic.i.p.ation as a result of physical inactivity, also leading to reduced psychological wellbeing. Aside from studies of older people, Falloweld (1990) and Maloni (1996) point to the importance of job role in self-esteem in the general population, and of course jobs usually entail some kind of activity outside the home. Thus, the positive benets of routine activity are a.s.sumed to ow from the elements of independence and control. However, these types of studies are looking at either very specic elements of activity, such as physical mobility, or at what might be called components of a person's lifestyle. The signicance of levels of physical activity aside from formal exercise programmes is not as easily discovered in the research, although the increase in rates of obesity in Western cultures has led to concern that people's lives are too inactive for long-term health (Lees and Booth, 2004). Morris and Hardman (1997), for example, suggested that although the pleasurable, therapeutic/health, psychological and social dimensions of walking are evident, they had rarely been studied within the context of an occupational or domestic routine.

Outside specically physical activities, there is some interesting work by Ehlers et al. (1988) and others (Hofer, 1984; Wever, 1985) that emphasises the importance of social activities in stabilising biological rhythms which 103 may affect feelings of depression and reported somatic symptoms. It is possible therefore that the maintenance of a daily routine may serve to sustain social cues and protect against the impact of disruptions to regulating mechanisms, whether these are socially or biologically determined.

There is very little work looking at pregnant groups and daily activity in terms of pregnancy outcome or maternal wellbeing in the way that exercise has been examined. Launer et al. (1990), in a study looking at both employment- and non-employment-related physical activity in Western women, found that women who had three or more children and received no household help were at increased risk of delivering a small for dates baby, although not of having preterm delivery. Woo (1997) attributes the higher rates of small for dates babies in women with other children to the strenuous activities a.s.sociated with caring for young children something it was perhaps not necessary to carry out a study to discover! However, once again the research is not conclusive, with several other studies failing to nd an a.s.sociation between domestic activity and pregnancy outcome (Rabkin et al., 1990; Schramm et al., 1996). The difculty is, as before, of dening what is meant by strenuous activity. The impact of performing household ch.o.r.es may depend on the population being studied. Even the fundamental aspects of daily living may be a risk for some low-income women during pregnancy, for example climbing stairs and walking are particularly demanding. There may also be cultural differences: Hickey and colleagues (1995) report that carrying loads may be a.s.sociated with an elevated risk of premature birth in white women while strenuous home-based ch.o.r.es may heighten the risk in black women.

In terms of psychological wellbeing and activity, what research there is comes from studies of women whose pregnancies are deemed at risk and who are ordered bed rest, something they nd surprisingly unwelcome especially since they feel well (Curtis, 1986; Mackey and Coster-Schultz, 1992). This reduction in psychological wellbeing, which includes anxiety and depression beyond that related directly to the pregnancy risk, is attributed to restriction of activity, as with older people. Monaham and De Joseph (1991) have suggested that this is because of loss of control; bed rest at home still involves the competing demands from relations.h.i.+ps, households and careers which may be hard to manage and meant that women 'cheated' so that they could accomplish what they saw as necessary for the smooth functioning of their home life. Of course, women with low-risk pregnancies will not be required by medical pract.i.tioners to undergo total restriction on their activity, but they may nd that their routine is affected by the various discomforts of pregnancy itself, such as tiredness, nausea and increasing weight. Furthermore, women's own concerns or the reactions of others, arising perhaps from information they have received, may deter them from partic.i.p.ating in certain activities or discourage them from public outings (Unger and Crawford, 1996). Anderson et al. (1994) 104 found that pregnant women who reported more depressed mood also said that they were bored and that they wished they could socialise more.

Notwithstanding the very small amount of research on daily activity, the benets would appear to be very similar to that of exercise, for both the general population and for women during pregnancy. In particular, these refer to the sense of control and self-esteem a.s.sociated with being active and making choices about what activities to pursue, whether in the public or in the private domain. Having reviewed the larger literature on exercise we can clearly see that the emphasis is on taking responsibility for health through appropriate physical activities, something that is extremely familiar in the context of women's experiences during pregnancy in particular. We turn now to some examples of the kinds of advice that women receive, where they nd this advice and how they feel about it. In doing so, we have to consider the various sources of advice and nature of those sources. It is likely that the sources themselves have particular expectations about women's continuing partic.i.p.ation in activity during their pregnancy and that these will impact on women's own responses.

Activity advice Like advice on other areas of pregnancy, we can look at a variety of types of available advice that is available to women. Others have reviewed some of these types of literature in particular (e.g. Barker, 1998; Woollett and Marshall, 1997) and highlighted the typically biomedical discourses they represent. We have also discussed in Chapter 4 how published advice sustains a series of discourses of responsibility. A further discourse is that of moderation and self-management, something integral to the advice we have already mentioned in this chapter. Interestingly, while the ACOG guidelines quoted and discussed in the sections above may inform medical advice or ofcial literature, they are not directly available to women themselves. Advice on exercise activity is commonly included in general health advice during pregnancy, alongside advice on smoking, diet (see Chapter 5), alcohol and so on. Publications on pregnancy and birth may also refer directly to research data on such issues. For example, work by Kelly (2005) indicates that 15 minutes of exercise three times a week is acceptable, and Kardel (2005) suggests that it is acceptable for top athletes to continue vigorous exercise; such general statements may emerge in the print and electronic media. However, Lumbers (2002) points out that there is no simple exercise prescription and that generally the approach to advice is to encourage women to maintain existing exercise regimes but not to take up new ones. Kagan and Kuhn (2004) highlight the benets of moderate exercise, though of course the term moderate is notoriously unhelpful in terms of actual activity and will depend on the current or previous levels of 105 exercise activity. If information on exercise is difcult to interpret, then what about information on daily activity?

As we have pointed out already, there are plenty of sources of material available to women about pregnancy. Any search, real or virtual, will provide a list of hundreds of t.i.tles concerning pregnancy and childcare.

These are written by experts of various kinds: family doctors, obstetricians, celebrity mothers, midwives, childcare experts and so on. Taking only the pregnancy aspect of these publications, all of them provide at least some information and practical advice on the changes accompanying pregnancy, the common symptoms, antenatal testing, health concerns and anxieties, diet, childbirth choices, preparing for baby and so on. There are also monthly magazines available on the newsstands that deal with the same topics. The style of such publications and the prescriptiveness of advice vary according to the author but are universally concerned to give the same message how to ensure a safe and normal pregnancy and pregnancy outcome.

There are also publications specically on tness in pregnancy, many of which are published in America. For example, in Joan Butler's (1996) book Fit and Pregnant: The Pregnant Woman's Guide to Exercise (in its 10th edition), which is described in the publisher's catalogue as aterric book for active women who want to keep up their workouts', readers can learn, among other things, how the baby is affected by the exercise they do, and how to modify their exercise. Joan Butler is a nurse. Another t.i.tle, also written by experts in exercise and maternal health, is Fit Pregnancy for Dummies (Cram and Stouffer Drenth, 2004), which indicates that it helps women to understand how a t pregnancy helps with delivery and postpartum shape-up. There is also specialist material, for example the Runners World Guide to Running and Pregnancy, subt.i.tled How to Stay Fit, Keep Safe and Have a Healthy Baby (Lundgren, 2003). Publicity material for this book makes explicit reference to the differing messages women may encounter on exercise in the phrasenever be puzzled by conicting advice again', something we discuss further below. There is clearly a wide range of potentially helpful material for all kinds of women, which makes reference to the benets of exercise and physical activity as well as to the need to moderate such activity. Such material is fascinating in itself but it is not the subject of this current chapter or book. If the health messages about exercise are to be understood they need to be easily available to everybody.

Aside from these books on pregnancy and childbirth, which women would have to purchase or borrow through the public library system or from friends, women in the UK are routinely given The Pregnancy Book (Department of Health, 2006) via their antenatal clinics. The advice and information it contains cover all aspects of pregnancy, childbirth and the rst few weeks with a new baby. In the rst chapter 'Your health in 106 pregnancy', there is one full page on physical activity, which suggests that the more active women remain the easier it will be to adapt to the physical changes of pregnancy. As far as daily activity is concerned its recommendation is that women should 'keep up [their] normal daily physical activity or exercise' (Department of Health, 2006: 15) whether this is a sport or just walking to the shops, for as long as they feel comfortable. The same section also says that women should not exhaust themselves and that they may need to slow down as pregnancy progresses. With a recommendation to keep active on a daily basis, for example by walking, the text says that any amount of activity is better than nothing. Finally, swimming is recommended as a suitable form of exercise. These recommendations therefore chime with the types of exercise that most women do in fact the accompanying pictures are of women swimming, on a bicycle and gardening and with the research ndings, emphasising again the benets of exercise and activity. It is clearly making reference to the nature of daily lives by including routine activity such as shopping. However, the advice does also represent a message of moderation and slowing down, allowing women to act on such advice if it corresponds with other information they may have been given. On a following page, the emphasis is on exercise in pregnancy. As we indicated earlier, this refers to specic exercises that will benet both labour and postnatal recovery rather than how to continue existing exercise programmes. It therefore describes particular exercises that women might undertake, such as pelvic oor exercises, to generally improve their health.

Another major source of information is via the world wide web. In the UK, the BBC website is both popular and respected (www.bbc.co.uk). As well as providing news and current affairs coverage, the website provides information about the range of much of the BBC's output as well as background material to BBC television programmes and issues that are considered of interest or relevance to the general public. It has a magazine-type format with links to many external sites and also hosts interactive notice boards and discussion groups. One major area of the site is the Health Website, which has a heading of 'Women's health', under which a range of topics are addressed, including 'Parenting' (BBC, 2006). Parenting concerns include, for example, having a baby, which in turn has pages dealing with pregnancy, sleep, skin, hair and clothes as well as coping with advice, exercise and tness, diet and health, and antenatal care. The web pages on this area of the site are written by Heather Welford, a freelance health writer, and offer advice about the process and progress of pregnancy. Like The Pregnancy Book, suggested exercises to enjoy are walking, swimming and toning and stretching cla.s.ses: a further reference to both the actual partic.i.p.ation in activities and thus women's real lives. It would seem, therefore, that advice that is available to women in the UK, at least some of it, does provide limited information about how to continue with 107 an active lifestyle. Whether this advice is perceived as such is open to debate, given the continuing and parallel references to taking it easy. As far as exercise is concerned, available advice is in line with research and guidelines but how does it actually impact on women's lives when they are pregnant?

Changing behaviour?

One of our major concerns in this book has been to reect how the changes a.s.sociated with pregnancy, aside from those physiological changes which are largely outside women's control, are the result of a complex interaction between women's own experiences, their understanding and expectations of their physical state and those of others, both generally and personally in terms of family or work colleagues.

Typically, investigation of women's partic.i.p.ation in exercise and activity outside the physiological has tended to take a health psychology approach, where the emphasis has been on identifying the factors which will determine appropriate changes in health behaviour in line with available evidence for positive outcomes (in terms of maternal and foetal health). The popular models of health behaviour (such as the Health Belief Model or the Theory of Planned Behaviour) incorporate the role of att.i.tudes and beliefs in determining health behaviours. In our view, while such an approach has provided some useful information that we have already referred to on predictors of exercise activity for example, in our view this has not generally taken account of the complexity of women's daily activities and the complexity of the differing and simultaneous demands for changes that occur during pregnancy. Thus, women may be expected to change their behaviour in line with cultural expectations mediated through professional advice, friends and family, as well as to manage the activities of their daily lives and to respond to the changes taking place in their bodies, within a relatively short time period. While the obvious benets of reducing smoking or alcohol or increasing exercise may be solved by one relatively simple process, this is not so for the various different activities that make up women's lives.

In our longitudinal study of daily activity in 57 pregnant women (Rousham et al., 2006) we found that as a whole, and perhaps not surprisingly, women's routine daily activity declined over the period of their pregnancy. This measured and reported change allowed for changes in weight, thus the reduction in activity over the course of pregnancy could not be attributed solely to the weight gains a.s.sociated with the pregnancy.

The reduction in activity occurred signicantly in domestic activity and leisure activity, sometimes including physical exercise activity, and included some elements of occupational activity. We have discussed some of the changes that women made at work in Chapter 4. Of particular interest here 108 is that although several of the women in the study had partic.i.p.ated in regular physical exercise activity prior to pregnancy, most of them had given this up during their pregnancy and their daily lives were therefore relatively inactive. Furthermore, most of them had essentially sedentary jobs. In discussing changes in physical activity, therefore, we are really looking at routine activity that is undertaken in order to perform the basic functions of living, rather than the limiting of physical exercise activity as recommended by the research.

In the context of the current chapter our focus is on how women described and explained their changes in behaviour and on whether the changes reected the advice they had received. We identied several 'barriers' to maintaining their habitual activities. These barriers include the physical symptoms of pregnancy, maternal perceptions of risk, poor maternal body image, reduced motivation, social and cultural discouragement and a lack of appropriate facilities. The relative impact of each of these barriers varied according to the point of pregnancy at which women were interviewed. We shall discuss some of these barriers briey here in the context of physical activity and exercise and then go on to examine what coping strategies they were able to negotiate to overcome these barriers and deal with advice.

The ndings from the study suggest that the perceived responsibilities of pregnancy begin early in pregnancy. Up to 25 weeks, the most common reason women gave for reducing their activity was physical limitations, and this was mostly nausea and vomiting and maternal fatigue; interestingly Downs and Hausenblas (2004) found that women's beliefs about exercise were that it improves mood but that physical limitations restrict exercise. Thus, physical limitations may operate both at the level of beliefs about appropriate behaviours as well as making it actually difcult to persist with physical exercise or activity. If women suffered from physical symptoms, their strategy was to try to use their available energy to sustain their working week, often at the expense of their routine home and leisure activities: 'm less active, I'm too tired. I can't go out at weekends sometimes I struggle to get dressed in the morning I'm so tired'. However, as well as the limitations induced by their physical symptoms, the women had clearly also made a conscious decision to reduce their general activity level. The rationale for both avoiding specic tasks and modifying more general activity was similar: 'm not socialising so much. I've slowed down. It's common sense really, isn't it'.

The physical symptoms of pregnancy, in particular the profound tiredness of early pregnancy, also appear to provide women with a legitimate justication for changing behaviour or at least avoiding activities later in pregnancy. This is facilitated by the identication of tiredness as a symptom of pregnancy and one that can be avoided or reduced by resting, as we highlighted in the section on advice above. Women are therefore able to 109 recruit tiredness as an explanation for their behaviour or lack of behaviour in describing the changes to us and to others, without having recourse to any other justication: a commonly recurring response was that they would have liked to do morebut have been too tired'. It is also irrefutable, since it is the case that simply being pregnant can make women tired, without even the extra weight of effort of exercising. Thus, women are free from blame and permitted to be inactive, at the same time as fullling their responsibility as carer/container in the maternal role.

Moreover, the importance that women in the study attributed to rest during pregnancy was found to be comparable to the importance that they attributed to other well-established health behaviours, such as not smoking or abstaining from alcohol, and to be signicantly higher than the importance accorded to regular exercise or an active lifestyle. Whereas advice to cut down on cigarettes or alcohol (or other substances) highlights the potential and invisible risks of continuing, rest and sleep tend to be seen only as benecial to both mother and baby, whatever else might be happening. Once at home, it is also easy to accomplish, especially in an environment where others are concerned for your wellbeing. As far as the importance of sleep and rest during pregnancy is concerned, this may partially reect an expectation of a disrupted sleep pattern after the birth but also the prevalence of advice on resting, which is endorsed by friends and family. The visibility of some areas of advice and information is high, certainly in the early stages of pregnancy. The lower importance a.s.signed to exercise and activity may be in part a feature of its lower visibility compared to rest or relaxation.

In addition to tiredness and physical limitations, another 'legitimate'

barrier was the direct or indirect risks arising from activity. Women described how they believed that there was an unnecessary degree of risk a.s.sociated with many of the activities that they had routinely undertaken prior to becoming pregnant and the advice on exercise to avoid makes clear that they are right. Direct risks arose from various aspects of occupational, domestic and recreational activity and usually occurred wherever a particular task was a.s.sumed to be too strenuous or too dangerous to perform. Many women, however, left the precise nature of the perceived risk unspecied although almost all of the women in the study believed that an aspect of their former behaviour could directly jeopardise the progress of the pregnancy: haven't done any DIY, I won't lift the heavy toolbox. I just don't want to overdo it'.

It should be mentioned again here that none of the women had jobs that required heavy lifting or that might be considered inherently dangerous in health and safety terms. Signicantly, when asked about strenuous physical activity the women discussed the possibility of it leading to unwanted acci-dents, falls or muscular strain, in relation to their own welfare rather than that of the baby. In the few cases where the baby's health or development 110 was considered to be at risk, the women described themselves as consciously tailoring their activity to place the perceived needs of their unborn child above their own. A partic.i.p.ant, who considered herself previously as an active person, said that she did not 'rush around so much or carry heavy things or go dancing. It's my choice, something growing in me needs as much help as it can get'.

Women also felt that it was necessary to make changes in order to avoid indirect risks. Indirect risks arose from the notion that, while the performance of an activity in itself might not be dangerous, there were a.s.sociated with it other potential hazards that may threaten health. The vast majority of indirect risks arose from recreational pursuits. Within this context, three specic limitations to activity were cited. These occurred in roughly equal proportion and referred to the potential harm that could be caused by activities commonly a.s.sociated with pa.s.sive smoking, overcrowded loca-tions and alcohol consumption. Two of these have risks a.s.sociated with them at any time, while the danger of crowds was something specic to pregnancy. The overriding effect of these concerns was to discourage women from engaging in social activities outside the home and for some this included physical activities. For example, one woman had not only limited her social activities but also had limited her swimming to times when only adults would be present: always have to try to protect myself in crowded rooms, so I don't want to go out. I like swimming but I can only go when it's adults only. I went before and got kicked by the children'. Particularly in later pregnancy when they had often given up work, the women spoke of the isolation that can follow from the limiting of their social activities and not only their own limitations. The pressure from others to reduce activity contributed signicantly to their feelings of bore-dom and social isolation. While women felt they had to full their maternal role, there was also some resistance to this external pressure: 'My friends don't think I should be going out, so they don't bother phoning me.

I haven't seen anyone for ages. I feel like I've given everything up, my job, my life'. Another woman explained how frustrating it could be to be prevented from doing what she wanted at home: 'm not allowed to do things like gardening or housework. My partner stops me so I try to rest more but then I get very frustrated. I know when to stop but he won't believe me. It's so boring just sitting'.

Alongside the perceived risks to health, a further and important issue that the women raised with us was an increased anxiety over their new body shape. This contributed to their feeling unwilling or uncertain about partic.i.p.ating in recreational activity. The issue of body image has not been addressed elsewhere in this chapter and it is perhaps worth exploring it a little further at this point before coming back to the topic of how and what advice the women in our study had received about physical activity during pregnancy.

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Body image as a barrier Even quite early in pregnancy, women often described themselves as 'feeling fat', 'feeling heavy' and 'feeling awkward' and this affected their behaviour: 'm going out less. I feel fat, very body-conscious . . . I feel like people are looking at me a lot. Maybe I'm just paranoid'. This is not unusual in the sense that women's bodies do undergo signicant changes in a short period of time and within a few months they may have changed shape dramatically. Earle (2003) argues that concerns with fatness and physical appearance are signicant factors in women's lives during pregnancy. The experience of embodiment clearly represented by pregnancy can be a frightening one. It is thus not surprising that even in the earliest stages of pregnancy concerns over body image may inuence women's activity levels, in part because of their ambivalence towards the physical changes that accompany pregnancy. It has been suggested that anxiety over physique or bodily appearance may be responsible for a lower rate of partic.i.p.ation in recreational and social activities by women, especially those who perceive themselves to be overweight (Spink, 1992; Wiles, 1994). One of the reasons given for taking exercise is to keep t; another is to improve body image (e.g. Choi, 2000; Grogan, 2000). Women in indus-trialised societies are immersed in issues of weight control and appearance, neither of which may be acceptable to them during pregnancy and there is increasing pressure on women to return quickly to their pre-pregnancy appearance, often prompted by the coverage of celebrity pregnancies (see Chapters 5 and 7). One study of pregnant women found that only a small minority responded positively to their new gure (Zajicek, 1979) and there is earlier research evidence of dissatisfaction with body during later pregnancy in particular (Harris, 1979; McConnell and Datson, 1961; Mercer, 1986). It is also possible that women who are less positive about being pregnant or who are anxious in the rst instance may also respond more negatively to their bodily changes and pregnancy more generally.

However, the response is by no means universal. For some women pregnancy can represent a welcome period during which they feel temporarily free from cultural demands to be slim (Unger and Crawford, 1996; Wiles, 1994). Baker et al. (1999) found that weight and shape satisfaction were higher in pregnancy than at four months post partum.

Similarly, Clark and Ogden (1999) found that the pregnant women in their study of health behaviours were less dissatised with their body shape than non-pregnant women. Boscaglia et al. (2003) reported that women who exercised regularly were happier with their changed body image when they became pregnant. Clearly, women will differ in their responses to exercise or activity during pregnancy itself and to some extent this may be determined by their pre-pregnancy att.i.tudes both to exercise and to their body image (Devine et al., 2000; Downs and Hausenblas, 2003).

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The women's various concerns and experiences, which contributed to what we have described as barriers to activity, may not only affect women's willingness to partic.i.p.ate in the recommended exercise activities but also in routine activities and therefore contribute to the changes in behaviour we identied in the study. The physical symptoms of pregnancy and the concept of risky activities provide women with a form of control over their choices of behaviours. However, concerns over body image may in part reect women's feelings of being out of control, which they do not wish to be visible to others. Although recourse to physical limitations and risk may offer women control over their activity, these concepts also allow others to comment on and determine how women should behave. The balancing and negotiation of their own needs and requirements in respect of activity have to take account of what others may expect.

Taking advice?

In the longitudinal study we asked the women partic.i.p.ating whether they had received any advice regarding their physical activity behaviour in the four weeks prior to each of the ve interview points. Nearly all of the women indicated that they had received advice or information at least once during the course of their pregnancy about exercise and activity more generally. The primary sources of information changed over pregnancy, with books or magazines being the main source at the start and least used towards the end. A consistent source of advice across pregnancy was that from friends and family.

Written sources of advice that were mentioned included a variety of the professional and lay self-care books, pregnancy and parenting magazines and The Pregnancy Book that we referred to above. They also mentioned leaets and newspapers. The inclusion of newspaper items may have provided them with up-to-date information, but as we have already seen in regard to dietary advice, the information can be misleading