Instructions; please write these two sections for the study (between one and half to two pages)
Gaps in the Literature, Significance of the Proposed Study
Intrapersonal and Interpersonal Factors Associated with Physical Activity Before and During Pregnancy Among Women in Alabama: Analysis of the 2016-2019 PRAMS Data
Background and Literature Review
Physical Activity and Inactivity in the US
Physical activity (PA) at all stages of life maintains and improves overall health, lowers the risk of chronic disease, and extends life expectancy, and is especially important during pregnancy to improve the health of the mother and fetus (American College of Obstetricians and Gynecologists, 2015). According to the 2018 Physical Activity Guidelines for Americans, adults should engage in at least 150 minutes (2 hours and 30 minutes) to 300 minutes (5 hours) of moderate-intensity aerobic PA per week, or 75 minutes (1 hour and 15 minutes) to 150 minutes (2 hours and 30 minutes) of vigorous-intensity aerobic PA per week, or an equivalent combination of moderate- and vigorous-intensity aerobic PA per week, however at this time only 28% of Americans are meeting these recommendations (Abildso, et al, 2023).
Any bodily movement caused by the contraction of skeletal muscles is referred to as PA like walking, running, aerobic, and stretching exercise (American College of Sports Medicine, 2019). PA may be accumulated in a variety of modes and intensities. According to the Centers for Disease Control and Prevention (CDC) and U.S. Department of Health and Human Services, low-intensity PA is defined as any activity level greater than 1.5, but less than 3.0 METs like stretching, light walking, and lifting hand weights. Moderate intensity PA includes activities accumulating 3.0 to 6.0 METs and keep an individual moving rapidly or vigorously enough to burn off three to six times as much energy per minute as sitting quietly, including activities such as water aerobics, walking briskly, yoga, and singles tennis. Vigorous intensity PA includes activities that get an individual moving quickly or strenuously enough to burn off more than six times as much energy per minute as sitting quietly or equating to more than 6.0 METs like jogging, running, race walking, aerobic dancing, and jumping rope (CDC, 2022).
In 2020, 24.2% of people aged 18 and older met the 2018 Physical Activity Guidelines for Americans for both aerobic and muscle strengthening activities (CDC, 2022). In addition, only 28.3% of men and 20.4% of women met the aerobic and muscle-strengthening activity guidelines in 2020 (CDC, 2022). The numbers do seem to be improving, as there has been an increase in Americans adhering to the guidelines from 2020, where 24.2% met guidelines in 2020, and 28% met guidelines in 2023 (Abildso, et al, 2023). These figures apply to the current PA recommendations which include meeting combined aerobic and muscle-strengthening guidelines. However, there is still a significant proportion of the adult population in the US that does not meet PA recommendations or do engage in any PA (i.e., physical inactivity).
Adult physical inactivity is defined as not engaging in any PA outside of work in the previous month, such as running, walking for exercise, or gardening (CDC, 2022). Physical inactivity is rapidly being recognized as a serious public health problem because it is associated with an increase in the risk for chronic diseases like heart disease, stroke, diabetes, hypertension, obesity, anxiety, and depression (Reiner et al., 2013; WHO, 2020). Also, physical inactivity is associated with specific types of cancers like breast, colon, and bladder cancer (WHO, 2020). According to research reports that address data from 2020, the prevalence of physical inactivity in the US varies by region as well as by age, race, gender, and household income (Abildso, 2023).
According to CDC reports from January 2022 (CDC, 2022), adults in the US aged 65 years and older have a high rate of physical inactivity compared to adults aged 18 to 44 years old (33.6% to 19.2%, respectively). This same report found that in relation to race/ethnicity, individuals that identify as Hispanic have the highest rate of physical inactivity in the US (30.6%), followed by people who identify as American Indian and Alaskan Native (29.9%), Black (28.2%), White (20.9%), and Asian (20.4%). The prevalence of people who have not done any PA in the last 30 days other than their job is higher in women when compared to men, 25.4% versus 21.5%, respectively. Regarding household income, people with a household income less than $25,000 per year reported high physical inactivity levels (38.8%) compared to people with incomes between $25,000 to 49,000 (28%) and those with an annual income of $75,000 or more (12.9%). Furthermore, the South had the highest rate of physical inactivity (27.5%), followed by the Midwest (25.2%), Northeast (24.7%), and West (21.0%; CDC, 2022). Notably, a prevalence of 30% or more physical inactivity was found in 7 states (West Virginia, Oklahoma, Louisiana, Alabama, Kentucky, Arkansas, and Mississippi), as well as Puerto Rico (CDC, 2022).
PA During Pregnancy
Pregnant women are encouraged to engage in PA during pregnancy and postpartum. The American College of Obstetrics and Gynecology (ACOG) recommends that women having uncomplicated pregnancies should be encouraged to participate in aerobic and strength-conditioning exercises before, during, and after pregnancy. The ACOG also recommends that pregnant women engage in at least 150 minutes (2 hours and 30 minutes) of moderate-intensity aerobic activity per week. Aerobic activities should preferably be spaced out during the week. Prior to starting PA, pregnant women should be evaluated by a healthcare provider to determine their ability to safely engage in PA and women should adjust the intensity of their workouts to a moderate level as opposed to the higher intensity that women who are not pregnant or postpartum may choose (Olson, et al, 2023).
Some health conditions may make PA contraindicated during pregnancy, including heart disease, lung disease, pregnancy with multiples, preeclampsia or pregnancy induced hypertension, abnormal bleeding, and severe anemia (CDC, 2022). Moreover, pregnant women should take precautions during PA, like drinking enough water to avoid dehydration and getting overheated, especially during the first trimester. It is also recommended that Pregnant women avoid standing still or lying flat because these positions may cause blood pressure to drop too low during activity (CDC, 2022). Although engaging in regular PA is recommended during pregnancy and postpartum, it is estimated that 77% of pregnant women do not engage in sufficient PA during pregnancy (Nakamura et al., 2019).
Despite recommendations for PA during pregnancy, studies show that a significantly low number of women engage in sufficient PA during pregnancy. Data from the National Health and Nutrition Examination Survey (NHANES) collected between 2007 to 2014, indicate that the prevalence of pregnant women meeting the ACOG PA guidelines (i.e., 30 minutes of moderate PA for at least five days a week) was only 12.7% (Hesketh & Evenson, 2016). Data collected from the CDC’s Pregnancy Risk Assessment Monitoring System (PRAMS) in Colorado between 2012 and 2015 also show that during the last three months of pregnancy only 10.2% of pregnant women met the ACOG recommended PA guidelines (CDC, 2020). This epidemiological data suggest that PA levels are low among pregnant women in the US and few pregnant women meet the ACOG recommendations for PA during pregnancy (CDC, 2022).
Physical inactivity during pregnancy is associated with multiple health problems like hypertension, obesity, gestational diabetes, cardiovascular disease, and lung disease (CDC, 2019). For example, from 1993-2014 hypertensive disorders in pregnancy due to lack of exercise have increased in the US from 528.9 to 912.4 cases out of 10,000 pregnant women (CDC, 2019). Consequently, PA can also help minimize excessive weight gain and gestational diabetes during pregnancy and help reduce symptoms of postpartum depression during the postpartum period including the entire first year after delivery (CDC, 2022). Therefore, it is crucial to encourage PA during pregnancy and postpartum period.
There are numerous advantages to exercising during pregnancy such as decreasing the risk of gestational diabetes, excessive weight gain, gestational hypertension, need for cesarean section, and postpartum depression. For example, a meta-analysis of 16 randomized controlled trials found that exercise during pregnancy decreased the likelihood of gestational diabetes by 30% (RR 0.70, 95% CI 0.55-0.89; Sanabria-Martínez et al., 2015). Another systemic review and meta-analysis that explored the association between PA in pregnancy and gestational diabetes showed that engaging in PA before or during pregnancy was associated with decreased risk of gestational diabetes (Ming et al., 2018; Tobias et al., 2010).
Previous research has also shown that being physically active during pregnancy is linked to a decreased likelihood of gestational hypertension (2.5% vs. 4.6%; Magro-Malosso et al., 2017). The same meta-analysis also showed that the incidence of having a caesarian section decreased by 16% among women who engaged in PA (Magro-Malosso et al., 2017). Regarding gestational weight gain, a meta-analysis including 23 randomized controlled trials of 4,462 pregnant women found that engaging in PA three times per week for 30 to 45 minutes per session was associated with lower gestational weight gain in pregnant women (Wang et al., 2019).
Previous studies have also shown that PA during pregnancy may decrease risk of depressive symptoms by elevating brain neurotransmitters (Lin & Kuo, 2013). PA can regulate hormone production, including growth hormone and insulin, which are important to improve quality of sleep, mood, and cognitive function (Al-Qahtani et al., 2018). A systemic review and meta-analysis found a significant decrease in postpartum depression in pregnant women who engaged in regular PA (i.e., 30 to 150 minutes or more per week) during pregnancy compared to those who did not (Nakamura et al., 2019). Guida et al. (2012) conducted a cross-sectional analysis using the 2007-2008 PRAMS data from Colorado and North Carolina to examine the association between pregnancy PA and postnatal depression. The study indicated that women who did not engage in antenatal PA were 1.34 times more likely than those who exercised five or more days per week to meet the criteria for postpartum depression (Guida et al., 2012). These results suggest that not engaging in PA during pregnancy may be associated with a higher incidence of postpartum depression.
Literature Review
Pregnancy-Related Outcomes
Lack of PA during pregnancy is sometimes associated with adverse outcomes. For example, in a systematic review, Fazzi et al. (2017) found that physical inactivity during pregnancy is associated with gestational weight gain and gestational diabetes. In another study, Meander et al. (2021) found that physical inactivity in pregnancy was associated with preeclampsia, pregnancy-induced hypertension, higher blood loss during childbirth (i.e., more than 500 milliliters), and increased risk of Cesarian section. Moreover, as a protective factor, PA is associated with a decreased risk of postpartum depression (Poyatos-León et al., 2017). According to Stanford Children’s Health (2022). A sedentary lifestyle during pregnancy may also cause the fetus to be larger for gestational age (LGA), which is caused by a high quantity of glucose in the maternal blood. LGA is associated with a longer delivery time, risk of injury to the baby during childbirth, and difficulties giving birth for the mother (Ferrari & Joisten, 2021).
PA and Gestational Diabetes
Gestational diabetes mellites (GMD) is one of the most significant pregnancy-related health conditions and a major public health issue (Goyal et al., 2020). GDM is a form of diabetes that can develop during pregnancy in women who have never had diabetes (CDC, 2021). GDM affects between 2% and 10% of pregnancies in the US each year (CDC, 2021). Ming et al. (2018) conducted a systemic review and meta-analysis to determine the effect of PA during pregnancy on GDM occurrence. The analysis found that PA during pregnancy decreases the chance of GDM occurrence. Another systemic review by Tobias et al. (2010) reviewed studies that explored the association between PA in pregnancy and GDM and showed that PA before or during pregnancy was associated with decreased risk of GDM.
PA and Hypertensive Disorders
Hypertensive disorders in pregnancy include gestational hypertension and preeclampsia (ACOG, 2013). Gestational hypertension is defined as an increase in blood pressure to greater than or equal to 140/90 mmHg in previously non-hypertensive women after 20 weeks of gestation (CDC, 2019). Preeclampsia is defined as gestational hypertension along with the beginning of at least one of the following conditions after 20 weeks of pregnancy: proteinuria (i.e., high protein level in the urine 0.3 g or more in a 24-hour urine collection, or 1+ or greater on a urine dipstick test), acute renal injury in the mother, liver failure, neurological symptoms, hematological problems, or uteroplacental dysfunction, such as fetal growth limitation (Brown et al., 2018). A population based, case-control study conducted by Spracklen et al. (2016) to assess the effect of PA on decreasing the risk of preeclampsia and gestational hypertension found that the risk of preeclampsia can potentially be decreased with an increase in the leisure time PA. Also, there was a significant reduction in preeclampsia risk for every 10-minute per week rise in leisure time PA (CDC, 2017). Another study that looked at the influence of leisure time PA on the risk of preeclampsia found that the risk of preeclampsia was lower in women who engaged in leisure time PA on a regular basis (Saftlas et al., 2004).
PA and Gestational Weight Gain
Weight gain throughout pregnancy is critical for the health of pregnant women as well as the baby (CDC, 2021). The amount of weight gain during pregnancy depends on the body mass index (BMI) of the mother before pregnancy (CDC, 2021). According to the 2009 Institute of Medicine (IOM) guidelines, if pregnant women have a normal preconception BMI (i.e., BMI between 18.5 and 24.9), the expected weight gain during pregnancy should be between 25 to 35 pounds (Martinez-Hortelano, et al, 2020). Whereas the expected approximate weight gain for women who are overweight with a pre-pregnancy BMI between 25.0 to 29.9 is 15 to 25 pounds. Furthermore, women who have a pre-pregnancy BMI of 30 or higher (i.e., obesity) are recommended to gain no more than 20 pounds (CDC, 2021). According to recent research, about one-third (32%) of pregnant women in the US acquired the recommended weight during pregnancy, while a greater number of women (48%) gained more weight than recommended (CDC, 2021).
In a meta-analysis that examined the association between PA and gestational weight gain, Wang et al. (2019) found that PA during pregnancy is associated with a significant reduction in gestational weight gain especially for women engaging in PA for 30 to 45 minutes more than three times per week. Also, in a randomized controlled trial to determine the effect of an exercise intervention on gestational weight gain among pregnant women, more pregnant women gained excessive weight in the control group when compared to the exercise intervention group, showcasing the benefits of PA during pregnancy to help control weight gain (30.2% to 20.5%, respectively; Barakat et al., 2019).
Postpartum Outcomes
A healthy lifestyle that includes PA has numerous positive effects on the mother and child during and after pregnancy. Physical inactivity during pregnancy is associated with various outcomes postpartum, including the potential development of type 2 diabetes, low metabolic rate, and ability to maintain a healthy weight (Leite et al., 2017). PA during pregnancy has also been shown to reduce the risk and symptoms of postpartum depression (CDC, 2021).
PA and Postpartum Depression
After the child's birth, postnatal depression is the most common mental illness that women report to their health care provider at a rate of 1 in 8 women who recently gave birth (Gonzalez et al., 2017; CDC Vital Signs, 2020). Studies show that PA can decrease depressive symptoms by elevating brain neurotransmitters (Lin & Kuo, 2013). Also, PA can regulate hormone productions like growth hormone and insulin, which are important in improving quality of sleep, mood, and cognitive function (Al-Qahtani et al., 2018). A systemic review and meta-analysis conducted to see if PA can help reduce postpartum depression found a significant decrease in PPD in pregnant women who engaged in regular PA (i.e., 30 to 150 minutes or more per week) during pregnancy compared to those who had not (Nakamura et al., 2019). Guida et al. (2012) conducted a cross-sectional analysis using the 2007-2008 PRAMS data from Colorado and North Carolina to examine the association between pregnancy PA and postnatal depression. The study indicated that women who did not engage in antenatal PA were 1.34 times more likely than those who exercised five or more days per week to meet the criteria for postpartum depression. These results suggest that not engaging in PA during pregnancy may be linked to a higher incidence of postpartum depression.
Postpartum Weight Retention and PA
Postpartum weight retention is the difference between a woman's weight after birth and her pre-pregnancy weight (Oken et al., 2007). Studies show that postpartum women cannot return to their previous weight before pregnancy due to lack of time, exhaustion, or depressive symptoms, resulting in weight retention postpartum (Dipietro et al., 2019). In a cohort of 1,617 Vietnamese mothers, Ha et al. (2020) investigated the potential relationship between engaging in routine PA at three months, six months, and 12 months postpartum and postpartum weight retention. At six and 12 months postpartum, 35.6% and 25.6% of women, respectively, maintained 5 kg. or more weight over their pre-pregnancy weight. At 12 months postpartum, the prevalence of overweight/obesity was significantly greater than it was prior to pregnancy (21.7% versus 11%). These results tie directly into findings that have shown that a lack of PA during pregnancy links to weight gain as well as the inability to lose weight post-partum (Flannery, et al, 2019).
Oken et al. (2007) reported on a cohort of 902 women in the US that walked at least 30 minutes every day to determine the relationship between various weight management behaviors and maintaining weight postpartum. The odds ratio for maintaining at least 5 kg. was 1.24 each daily hour of television watching, 0.66 per daily hour of walking, and 1.33 for every 0.5% increase in daily calorie intake from trans-fat. Women who watched less than two hours of television, exercised for at least 30 minutes, and ingested less trans-fat had an odds ratio of 0.23 for retaining at least 5 kg. According to the findings from the study, engagement in PA after childbirth is linked with decreased postpartum weight retention (Oken et al., 2007).
Postpartum Diabetes and PA
PA has several benefits for the mother prior to, during, and after pregnancy, as PA may minimize the incidence of gestational diabetes mellitus, weight gain, and lower spine discomfort and prevent diabetes postpartum. (Flannery, et al, 209). Li et al. (2020) conducted two meta-analyses to determine the impact of lifestyle changes on the likelihood of postpartum diabetes in women with gestational diabetes mellitus throughout pregnancy and after childbirth. During pregnancy, lifestyle interventions were ineffective in reducing the risk of postpartum diabetes. However, lifestyle interventions beginning within three years postpartum were extremely successful at lowering the incidence of postpartum diabetes (RR = 0.57; Li et al., 2020).
Retnakaran et al. (2009) investigated the structural patterns of activity of 238 White women (58 with GDM and 180 without GDM) in the year before and after pregnancy. Prior to being diagnosed with GDM, women reported less prenatal sport and recreational activity than their counterparts who did not have GDM. Over the first year postpartum, women with GDM increased their leisure-time activity considerably, but the non-GDM group did not. Women with GDM raised their recreational activity effectively throughout the first year postpartum, indicating a degree of lifestyle modification after this diagnosis.
Impact on the Child
Physical inactivity among pregnant women may negatively impact physiological and mental capacities of the child in utero and after birth (Bauer, et al, 2020). For instance, a sedentary lifestyle among pregnant women is associated with having an infant who is larger than normal for their gestational age (LGA) which can also apply to the fetus. According to Stanford Children’s Health (2022), physical inactivity causes high blood glucose levels in the pregnant woman’s blood, which is transferred to the fetus. This causes the fetus to grow at a faster rate than normal; thereby, making the fetus classified as LGA. The effects of LGA include a high likelihood of injuries to the fetus during childbirth and damage to the nervous system, especially in the brachial plexus of the arms. Physical inactivity during pregnancy also increases the risk of giving birth to children with metabolic and motor issues as found in the Liete et al. study which pulled records from national databases (Liete et al., 2017). In their study of the effects of physical inactivity, Liete et al. (2017) found that babies born to physically inactive women are more likely to be overweight at birth (Kintiraki & Goulis, 2018). Additionally, these babies are likely to suffer from cardiovascular disorders and diabetes mellitus earlier than those born to women that engage in PA during their pregnancy (Moholdt, et al., 2020). The study also found that babies with LGA had slower motor and cognitive abilities than those born by women who were physically active (Liete et al., 2017).
Influences on PA during Pregnancy
It is important to understand in detail the factors that determine the influence on a mother’s PA during pregnancy in order to better inform the development of strategies to increase PA among pregnant women. Recent literature points to the importance of not only intrapersonal factors but also individuals such as friends, family, and medical professionals as having an impact on the level of PA among pregnant women.
Intrapersonal Level Influences
Intrapersonal level influences on pregnant women’s engagement in PA refer to personal factors that either promote or inhibit engagement in PA. Various intrapersonal factors influence PA during pregnancy, like maternal age, race/ethnicity, educational level, health insurance, and income level. The literature shows maternal age is inversely related to PA activity level among pregnant women (Dumith et al., 2012). Dumith et al. (2012) found that the level of PA in pregnancy is higher in pregnant women between the ages 20 to 29, and the rate decreases after age 30 (Dumith et al., 2012). Another study conducted by Evensnon et al. (2009) shows that PA level is higher in young women between ages 18 to 25, and the level gradually decreases with age. Finally, a systemic review to understand the determinants of pregnant women’s PA indicated that women under the age of 24 were approximately two times more likely than women over the age of 25 to be meeting ACOG guidelines (Peterson et al., 2005; Zhang J & Savitz D, 1996).
Another major factor determining PA in pregnancy is educational level. According to studies, pregnant women with higher education levels (i.e., college education) have a higher level of PA throughout pregnancy (Evenson et al., 2009). In addition, another study analyzing PRAMS data from 2012 to 2015 to determine PA behavior before and during pregnancy in Colorado found that pregnant women with an education level greater than a high school diploma were more physically active than women with less than a high school diploma (Ussery et al., 2020). Furthermore, race/ethnicity has been supported as a sociodemographic factor influencing PA in pregnancy. Studies have shown that non-Hispanic White women are more likely to engage in PA during pregnancy compared to other racial/ethnic groups including non-Hispanic Black and Hispanic women in the US (Santo et al., 2017; Ussery et al., 2020).
In addition to the previously mentioned factors, health insurance status can impact PA levels in pregnancy. For example, women with private insurance adhered more to PA during pregnancy than women who had governmental (i.e., Medicaid) or any other insurance type (Ussery et al., 2020). For household income as a factor influencing PA in pregnancy, studies show that pregnant women with higher household incomes are more likely to adhere to the ACOG PA guidelines than low-income women. Peterson et al. (2005) found that pregnant women with an annual household income of $75,000 and more were five times more likely to adhere to the PA guidelines than women with low annual household income (i.e., $20,000 and less) (Peterson et al., 2005). Another study examining the impact of household income on PA level in pregnancy indicated that women with a yearly household income of more than $70,000 were 3.3 times more likely to be active than women with an income of less than $30,000 (Ning et al., 2003).
Interpersonal Level Influences
Interpersonal-level factors that influence pregnant women’s engagement in PA include the provision of social support and other influences from influential others (i.e., spouse/partner, family, healthcare providers, friends). According to Doran and Davis (2011), pregnant women in various studies have identified social support for exercise, having an exercise partner, and having adequate childcare as facilitators of PA. Women have reported that their partner, as well as other close relatives, had the greatest influence on their post-pregnancy exercise behavior. PA involvement, family support, and having a location to exercise were rated as the most critical factors during and after pregnancy.
Support and information from healthcare providers may also impact PA levels among pregnant women by providing access to information, encouragement by healthcare providers, counseling, and follow-ups with healthcare providers (Sánchez-Polán, Nagpal & Barakat, 2023). Healthcare providers may play a significant role in encouraging PA, which is strengthened if they better understand the variables that impact PA throughout pregnancy and postpartum (Doran and Davis, 2011; Makama, Awoke, Skouteris, Moran & Lim, 2021). However, in a study by Doran and Davis (2011), almost 72% of pregnant women reported not receiving recommendations from a health care professional to increase frequent, moderate-intensity PA during or after pregnancy.
Healthcare providers, in particular, have a deep impact on PA in pregnant women as they have the authority and the ability to affect behaviors. These impacts can come in various manners, including the ability of healthcare providers to provide guidance, education, and advice to pregnant women with customized attention to specific needs, limitations, and health concerns that women may have. In this manner, healthcare providers can also create customized plans for exercise so that pregnant women have something to follow that addresses gestational age, any pre-existing medical conditions, and overall health status. This leads to how a medical provider can adjust a pregnant woman’s exercise routine to ensure that it continues to stay safe for them and their baby as they progress through the stages of their pregnancy (Santo et al., 2017).
It is also more than just the physical aspects of PA that a healthcare provider can assist with because PA changes may also require psychological support to help ensure proper mental health. In this regard, a healthcare provider can also provide mental health support that can encourage maintaining PA during pregnancy. While all of these are realities of the healthcare provider-pregnant woman connection related to PA, the real problem is that insufficient support is given to this. Researchers have shown that the advice given by healthcare providers is motivating and can help pregnant women want to exercise. However, there is a disconnect between the evidence for the benefits of PA and the fact that healthcare providers are not effectively providing information on PA to pregnant women (Okafor & Goon, 2021).
The ACOG recommends that healthcare providers emphasize the need for and importance of PA in pregnant women. These recommendations also consider safety and focus on minimizing risk, trauma, and any activities that could result in injury, such as ones that can result in falling or trauma to the abdomen. In these recommendations from the ACOG, there are also clear directives for healthcare providers to ensure individualized assessment and planning for pregnant women to ensure that they get the exact PA recommendations that are best for them. Healthcare providers are additionally charged with monitoring and providing dynamic advice on PA to pregnant women. This shows that, ultimately, the ACOG advises providers to counsel, guide, and support pregnant women on PA throughout all stages of their pregnancy.
When pregnant women cannot get advice on PA from medical providers or midwives, they often defer to seeking answers from their friends and family, as well as other sources like the Internet or magazines (Flannery et al., 2018). For various reasons, friends are a source of advice, and 27% of pregnant women get some form of advice on PA from their friends (Flannery et al., 2018). Studies have also pointed out that pregnant women are highly influenced by social influences, with incredibly significant influence coming from family and friends who can initiate PA behavior in them (Flannery et al., 2018). There are many ways in which friends and family help this process, including providing emotional support, helping to suggest specific forms of PA to pregnant women, and assisting with technical parts of PA behavior like getting the right clothes to become PA (Flannery et al., 2018).
Gaps in the Literature
Significance of the Proposed Study
