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WHO Guidelines on Physical Activity and Sedentary Behaviour. Geneva: World Health Organization; 2020.

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WHO Guidelines on Physical Activity and Sedentary Behaviour.

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D1EVIDENCE ON PHYSICAL ACTIVITY FOR PREGNANT AND POSTPARTUM WOMEN

Guiding Questions

D1.

What is the association between physical activity and health-related outcomes?

  1. Is there a dose response association (volume, duration, frequency, intensity)?
  2. Does the association vary by type or domain or timing (pre-pregnancy, antenatal or postnatal) of physical activity?

Inclusion Criteria

Population: Pregnant women and postpartum mothers

Exposure: Greater volume, duration, frequency or intensity of physical activity

Comparison: No physical activity or lesser volume, duration, frequency, or intensity of physical activity

OutcomesImportance
Excessive weight gainCritical
Gestational diabetes mellitusCritical
Gestational hypertension/pre-eclampsiaCritical
Mental health (e.g., anxiety symptoms, depressive symptoms, post-partum depression)Critical
Fetal outcomes (e.g., preterm birth, birthweight)Critical
Adverse outcomes (e.g., miscarriage, stillbirth)Critical
Delivery complicationsImportant

Evidence identified

The GRADE Evidence Profiles (EPs) developed for the Canadian Guideline for Physical Activity Throughout Pregnancy (1) were used as a basis for this update, given the rigor in methods and recency in included evidence. The original EPs can be found in the supplemental materials of seven systematic reviews prepared to inform the guideline (2–8). Five additional reviews were conducted to inform the Canadian Guideline but are not included here given the outcomes addressed(i.e., urinary incontinence (9), glucose response (10), fetal heart rate and umbilical and uterine blood flow (11), low back pain, pelvic girdle and lumbopelvic pain (12)) and type of exercise (i.e., supine exercise (13)).

Given the recency of the systematic reviews that were conducted to inform the Canadian Guideline, we compared the included studies within each of those systematic reviews with that of any new systematic reviews. In cases where the bodies of evidence were entirely overlapping, we only included the Canadian review (exclusions are noted in Table D1.1).

Seven reviews that informed the development of the Canadian guideline were included (2–8). Ten additional reviews (published in 2018 or 2019) were identified by the WHO team that examined the association between physical activity and health-related outcomes among pregnant or postpartum women (14–23). Four of these reviews were excluded because they were duplicative and less comprehensive than the reviews that were published to inform the Canadian Guideline (15, 18, 22, 23). One additional review was excluded because it was a review of reviews which included outdated literature (17) and another publication was excluded because it was an RCT that updated the point estimate from a 2011 review with their study results (21). Table D1.1 presents the 6 reviews that were excluded and their reason for exclusion. Table D1.2 presents the 4 reviews that were included and the outcomes they each reported.

Table D1.3 presents the ratings for each included review according to all the AMSTAR 2 main domains. None of the systematic reviews were rated as having high credibility based on the AMSTAR 2 instrument. Three were rated as having moderate credibility and 1 was rated as having low credibility.

Table D1.1Excluded Systematic Reviews, with Reasons for Exclusion

Author, YearReason for ExclusionRationale
Bennett 2018 (15)RedundancyAll included evidence is included in reviews by Davenport (5)
Farpour-Lambert 2018 (17)DesignReview of reviews
Guo 2018 (18)RedundancyAll included evidence is included in the review by Davenport (5)
Nobles 2018 (21)DesignNot a systematic review
Syngelaki 2019 (22)RedundancyAll included evidence is included in reviews by Ruchat (8) and Davenport (5)
Yu 2018 (23)RedundancyAll included evidence is included in reviews by Davenport (5)

Table D1.2Included Systematic Reviews

Author, YearExcessive weight gainGDMGestational HYP/preeclampsiaMental health outcomesFetal outcomes (e.g., preterm birth, birth-weight)AEs (e.g., miscarriage, stillbirth)Delivery complicationsLast Search Date# of Included StudiesAMSTAR 2
Beetham 2019 (14)✕✕Nov-201815Moderate
Du 2018 (16)✕✕✕✕✕Apr-201813Low
Mijatovic-Vukas 2018 (19)✕Feb-201717Moderate
Nakamura 2019 (20)✕Oct-201721Moderate

Abbreviations: AE = adverse event; GDM = gestational diabetes mellitus; HYP = hypertension

Table D1.3Credibility Ratings (AMSTAR 2)

Author, YearPICO1Apriori Methods2Study Design Selection3Lit Search Strategy4Study Selection5Data Extraction6Excluded Studies7Included Studies8RoB Assessment9Funding Sources10Statistical Methods11Impact of RoB12RoB Results13Hetero-geneity14Publication Bias15COI16Overall Rating17
Beetham 2019 (14)YYYPYYYNYYNYYNNNYModerate
Du 2018 (16)YPYNPYYYNYYNYNNYNNLow
Mijatovic-Vukas 2018 (19)YYYPYYYNYYNYNYYYYModerate
Nakamura 2019 (20)YPYNPYYYNPYPYNYNYYYYModerate

Abbreviations: COI = conflict of interest; N = no; PICO = population, intervention, comparator, outcome; PY = partial yes; RoB = risk of bias; Y = yes

1

Did the research questions and inclusion criteria for the review include the components of PICO?

2

Did the report of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations from the protocol?

3

Did the review authors explain their selection of the study designs for inclusion in the review?

4

Did the review authors use a comprehensive literature search strategy?

5

Did the review authors perform study selection in duplicate?

6

Did the review authors perform data extraction in duplicate?

7

Did the review authors provide a list of excluded studies and justify the exclusions?

8

Did the review authors describe the included studies in adequate detail?

9

Did the review authors use a satisfactory technique for assessing the risk of bias (RoB) in individual studies that were included in the review?

10

Did the review authors report on the sources of funding for the studies included in the review?

11

If meta-analysis was performed did the review authors use appropriate methods for statistical combination of results?

12

If meta-analysis was performed, did the review authors assess the potential impact of RoB in individual studies on the results of the meta-analysis or other evidence synthesis?

13

Did the review authors account for RoB in individual studies when interpreting/ discussing the results of the review?

14

Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?

15

If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?

16

Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?

17

Shea et al. 2017. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. (24)

D.1. Physical Activity

Table D.1.a. Excessive weight gain and physical activity, pregnant and postpartum women (PDF, 94K)

Black font is from original GRADE Evidence Profile from the systematic review (Ruchat 2018 (8)) to support the 2019 Canadian Guideline for Physical Activity Throughout Pregnancy. Red font denotes additions based on WHO update using review of existing systematic reviews. Two systematic reviews were identified that addressed the relationship between physical activity and excessive weight gain (14, 16).

Table D.1.b. Gestational diabetes mellitus and physical activity, pregnant and postpartum women (PDF, 77K)

Black font is from original GRADE Evidence Profile from the systematic review (Davenport 2018 (5)) to support the 2019 Canadian Guideline for Physical Activity Throughout Pregnancy. Red font denotes additions based on WHO update using review of existing systematic reviews. Two systematic reviews were identified that addressed the relationship between physical activity and gestational diabetes (16, 19).

Table D.1.c. Gestational hypertension/pre-eclampsia and physical activity, pregnant and postpartum women (PDF, 94K)

Black font is from original GRADE Evidence Profile from the systematic review (Davenport 2018 (5)) to support the 2019 Canadian Guideline for Physical Activity Throughout Pregnancy. Red font denotes additions based on WHO update using review of existing systematic reviews. One systematic review was included that addressed the relationship between physical activity and gestational hypertension and pre-eclampsia (16).

Table D.1.d. Mental health outcomes and physical activity, pregnant and postpartum women (PDF, 131K)

Black font is from original GRADE Evidence Profile from the systematic review (Davenport 2018 (3)) to support the 2019 Canadian Guideline for Physical Activity Throughout Pregnancy. Red font denotes additions based on WHO update using review of existing systematic reviews. One systematic review was identified that addressed the relationship between physical activity and postpartum depression (20).

Table D.1.e. Fetal health outcomes and physical activity, pregnant and postpartum women (PDF, 104K)

Black font is from original GRADE Evidence Profiles from two systematic reviews (Davenport 2018 (4) and Davenport 2019 (7)) to support the 2019 Canadian Guideline for Physical Activity Throughout Pregnancy. Red font denotes additions based on WHO update using review of existing systematic reviews. Two systematic reviews were identified that addressed the relationship between physical activity and fetal health outcomes (14, 16).

Table D.1.f. Adverse effects and physical activity, pregnant and postpartum women (PDF, 82K)

Black font is from original GRADE Evidence Profile from the systematic review (Davenport 2019 (2)) to support the 2019 Canadian Guideline for Physical Activity Throughout Pregnancy. No new systematic reviews were identified that addressed the relationship between physical activity and delivery complications.

Table D.1.g. Delivery complications and physical activity, pregnant and postpartum women (PDF, 81K)

Black font is from original GRADE Evidence Profile from the systematic review (Davenport 2019 (6)) to support the 2019 Canadian Guideline for Physical Activity Throughout Pregnancy. One systematic review was included that addressed the relationship between physical activity and risk of caesarean delivery (16).

References

1.
Mottola MF, Davenport MH, Ruchat SM, Davies GA, Poitras VJ, Gray CE, et al. 2019 Canadian guideline for physical activity throughout pregnancy. British journal of sports medicine. 2018;52(21):1339–46. [PubMed: 30337460]
2.
Davenport MH, Kathol AJ, Mottola MF, Skow RJ, Meah VL, Poitras VJ, et al. Prenatal exercise is not associated with fetal mortality: a systematic review and meta-analysis. Br J Sports Med. 2019;53(2):108–15. [PubMed: 30337346]
3.
Davenport MH, McCurdy AP, Mottola MF, Skow RJ, Meah VL, Poitras VJ, et al. Impact of prenatal exercise on both prenatal and postnatal anxiety and depressive symptoms: a systematic review and meta-analysis. Br J Sports Med. 2018;52(21):1376–85. [PubMed: 30337464]
4.
Davenport MH, Meah VL, Ruchat SM, Davies GA, Skow RJ, Barrowman N, et al. Impact of prenatal exercise on neonatal and childhood outcomes: a systematic review and meta-analysis. Br J Sports Med. 2018;52(21):1386–96. [PubMed: 30337465]
5.
Davenport MH, Ruchat SM, Poitras VJ, Jaramillo Garcia A, Gray CE, Barrowman N, et al. Prenatal exercise for the prevention of gestational diabetes mellitus and hypertensive disorders of pregnancy: a systematic review and meta-analysis. Br J Sports Med. 2018;52(21):1367–75. [PubMed: 30337463]
6.
Davenport MH, Ruchat SM, Sobierajski F, Poitras VJ, Gray CE, Yoo C, et al. Impact of prenatal exercise on maternal harms, labour and delivery outcomes: a systematic review and meta-analysis. Br J Sports Med. 2019;53(2):99–107. [PubMed: 30337349]
7.
Davenport MH, Yoo C, Mottola MF, Poitras VJ, Jaramillo Garcia A, Gray CE, et al. Effects of prenatal exercise on incidence of congenital anomalies and hyperthermia: a systematic review and meta-analysis. Br J Sports Med. 2019;53(2):116–23. [PubMed: 30337347]
8.
Ruchat SM, Mottola MF, Skow RJ, Nagpal TS, Meah VL, James M, et al. Effectiveness of exercise interventions in the prevention of excessive gestational weight gain and postpartum weight retention: a systematic review and meta-analysis. Br J Sports Med. 2018;52(21):1347–56. [PubMed: 30337461]
9.
Davenport MH, Nagpal TS, Mottola MF, Skow RJ, Riske L, Poitras VJ, et al. Prenatal exercise (including but not limited to pelvic floor muscle training) and urinary incontinence during and following pregnancy: a systematic review and meta-analysis. Br J Sports Med. 2018;52(21):1397–404. [PubMed: 30337466]
10.
Davenport MH, Sobierajski F, Mottola MF, Skow RJ, Meah VL, Poitras VJ, et al. Glucose responses to acute and chronic exercise during pregnancy: a systematic review and meta-analysis. Br J Sports Med. 2018;52(21):1357–66. [PubMed: 30337462]
11.
Skow RJ, Davenport MH, Mottola MF, Davies GA, Poitras VJ, Gray CE, et al. Effects of prenatal exercise on fetal heart rate, umbilical and uterine blood flow: a systematic review and meta-analysis. Br J Sports Med. 2019;53(2):124–33. [PubMed: 30337345]
12.
Davenport MH, Marchand AA, Mottola MF, Poitras VJ, Gray CE, Jaramillo Garcia A, et al. Exercise for the prevention and treatment of low back, pelvic girdle and lumbopelvic pain during pregnancy: a systematic review and meta-analysis. Br J Sports Med. 2019;53(2):90–8. [PubMed: 30337344]
13.
Mottola MF, Nagpal TS, Bgeginski R, Davenport MH, Poitras VJ, Gray CE, et al. Is supine exercise associated with adverse maternal and fetal outcomes? A systematic review. British journal of sports medicine. 2019;53(2):82–9. [PubMed: 30337348]
14.
Beetham KS, Giles C, Noetel M, Clifton V, Jones JC, Naughton G. The effects of vigorous intensity exercise in the third trimester of pregnancy: a systematic review and meta-analysis. BMC pregnancy and childbirth. 2019/08/09 ed2019. p. 281. [PMC free article: PMC6686535] [PubMed: 31391016]
15.
Bennett CJ, Walker RE, Blumfield ML, Gwini SM, Ma J, Wang F, et al. Interventions designed to reduce excessive gestational weight gain can reduce the incidence of gestational diabetes mellitus: A systematic review and meta-analysis of randomised controlled trials. Diabetes research and clinical practice. 2018;141:69–79. [PubMed: 29698713]
16.
Du MC, Ouyang YQ, Nie XF, Huang Y, Redding SR. Effects of physical exercise during pregnancy on maternal and infant outcomes in overweight and obese pregnant women: A meta-analysis. Birth (Berkeley, Calif). 2019;46(2):211–21. [PubMed: 30240042]
17.
Farpour-Lambert NJ, Ells LJ, Martinez de Tejada B, Scott C. Obesity and Weight Gain in Pregnancy and Postpartum: an Evidence Review of Lifestyle Interventions to Inform Maternal and Child Health Policies. Frontiers in endocrinology. 2018;9:546. [PMC free article: PMC6168639] [PubMed: 30319539]
18.
Guo XY, Shu J, Fu XH, Chen XP, Zhang L, Ji MX, et al. Improving the effectiveness of lifestyle interventions for gestational diabetes prevention: a meta-analysis and meta-regression. BJOG : an international journal of obstetrics and gynaecology. 2019;126(3):311–20. [PubMed: 30216635]
19.
Mijatovic-Vukas J, Capling L, Cheng S, Stamatakis E, Louie J, Cheung NW, et al. Associations of Diet and Physical Activity with Risk for Gestational Diabetes Mellitus: A Systematic Review and Meta-Analysis. Nutrients. 2018;10(6). [PMC free article: PMC6024719] [PubMed: 29849003]
20.
Nakamura A, van der Waerden J, Melchior M, Bolze C, El-Khoury F, Pryor L. Physical activity during pregnancy and postpartum depression: Systematic review and meta-analysis. Journal of affective disorders. 2019;246:29–41. [PubMed: 30576955]
21.
Nobles C, Marcus BH, Stanek EJ, 3rd, Braun B, Whitcomb BW, Manson JE, et al. The Effect of an Exercise Intervention on Gestational Weight Gain: The Behaviors Affecting Baby and You (B.A.B.Y.) Study: A Randomized Controlled Trial. American journal of health promotion : AJHP. 2018;32(3):736–44. [PubMed: 28950725]
22.
Syngelaki A, Sequeira Campos M, Roberge S, Andrade W, Nicolaides KH. Diet and exercise for preeclampsia prevention in overweight and obese pregnant women: systematic review and meta-analysis. The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstet. 2019;32(20):3495–501. [PubMed: 29792061]
23.
Yu Y, Xie R, Shen C, Shu L. Effect of exercise during pregnancy to prevent gestational diabetes mellitus: a systematic review and meta-analysis. The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstet. 2018;31(12):1632–7. [PubMed: 28409688]
24.
Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J, et al. AMSTAR 2: A critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. 2017;358:j4008. [PMC free article: PMC5833365] [PubMed: 28935701]
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