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Physical Activity and Health-Related Quality of Life During
Pregnancy: A Secondary Analysis of a Cluster-Randomised Trial
Pa
¨ivi Kolu •Jani Raitanen •Riitta Luoto
Published online: 1 March 2014
ÓSpringer Science+Business Media New York 2014
Abstract The aim of the study was to evaluate the role of
physical activity before and during pregnancy on health-
related quality of life (HRQoL). Data from the cluster-
randomised gestational diabetes mellitus primary preven-
tion trial conducted in maternity clinics were utilised in a
secondary analysis. The cases considered were pregnant
women who reported engaging in at least 150 min of
moderate-intensity leisure-time physical activity per week
(active women) (N=80), and the controls were women
below these recommendations (less active) (N=258). All
participants had at least one risk factor for gestational
diabetes mellitus. Their HRQoL was evaluated via the
validated generic instrument 15D, with HRQoL at the end
of pregnancy examined in relation to changes in physical
activity during pregnancy. Logistic regression models
addressed age, parity, education, and pre-pregnancy body
mass index. At the end of pregnancy, the expected HRQoL
was higher (tobit regression coefficient 0.022, 95 % CI
0.003–0.042) among active women than less active
women. Active women also had greater mobility (OR 1.98,
95 % CI 1.04–3.78), ability to handle their usual activities
(OR 2.22, 95 % CI 1.29–3.81), and vitality (OR 2.08, 95 %
CI 1.22–3.54) than did less active women. Active women
reported higher-quality sleep (OR 2.11, 95 % CI
1.03–4.30) throughout pregnancy as compared to less
active women. Meeting of the physical activity guidelines
before pregnancy was associated with better overall
HRQoL and components thereof related to physical
activity.
Keywords Health-related quality of life Physical
activity Pregnancy GDM
Introduction
An active lifestyle has been shown to have positive and far-
reaching effects on both pregnant women’s and infants’
physical health [1]. In a Norwegian study [2], only 15 % of
women were found to have followed the exercise guide-
lines they were given for pregnancy, which poses a chal-
lenge for promotion of health during pregnancy. According
to global physical activity recommendations for adults, an
uncomplicated pregnancy should still include, at minimum,
150 min of at least moderate-intensity aerobic physical
activity a week, with the suggested approach being sessions
of 10 min’ duration or more, at least three times per week
[1]. Objective measurement of physical activity among
pregnant women shows that its levels increase from the
first to the second trimester, then decrease during the last
trimester [3], yet the level of leisure-time physical activity
as subjectively evaluated was lower among pregnant than
non-pregnant women of the same age [3]. Also, physical
activity levels tend to fall during pregnancy [4–7] or from
the pre-pregnancy baseline [6,8].
Health-related quality of life (HRQoL) can be seen as a
synthesis of health as self-evaluated, which, by the defi-
nition of the Word Health Organization (WHO), has
P. Kolu (&)J. Raitanen R. Luoto
UKK Institute for Health Promotion Research,
Kaupinpuistonkatu 1, 33501 Tampere, Finland
e-mail: paivi.kolu@uta.fi
J. Raitanen
School of Health Sciences, University of Tampere,
33014 Tampere, Finland
R. Luoto
Department of Children, Young People and Families, National
Institute for Health and Welfare, 00271 Helsinki, Finland
123
Matern Child Health J (2014) 18:2098–2105
DOI 10.1007/s10995-014-1457-4
physical, mental, and social components. In previous
studies was found evidence both supporting and against the
hypothesis that physical activity affects quality of life.
Three-month programme of supervised physical activity
during pregnancy improved HRQoL among exercise group
more than among control group [9]. In particular, the
improvements were reported in domains of physical func-
tion, bodily pain and general health [9]. Moreover, at least
moderate physical activity can have positive effects on
depressive symptoms during pregnancy [10–12], another
element of HRQoL.
In contrast, no association has been observed between
overweight and obese pregnant women’s HRQoL and
either water exercise performed three times a week during
gestation [13] or application of a protocol for light to
moderate-intensity physical exercise [14]. Neither has a
connection been seen between HRQoL and physical
activity of the levels stated in recommendations from pre-
pregnancy to the second trimester [6].
Pregnant women’s physical and mental quality of life
may have extensive effects on ability to work, return to the
labour market, and use of health-care services. The infor-
mation on pregnant women’s physical activity and quality
of life is contradictory. Therefore, our study was under-
taken, to provide new information on associations between
pregnancy, physical activity, and quality of life. The aim
was to evaluate the association between physical activity
and health-related quality of life among pregnant women
with a risk of GDM.
Methods
Data from the cluster-randomised gestational diabetes
mellitus (GDM) primary prevention trial (N=399) con-
ducted in Finnish maternity clinics was utilised for this
study. That prevention trial, spanning 2007–2009 (trial
registration: ISRCTN33885819), is described in detail
elsewhere [15]. The cases in the present secondary analysis
were pregnant women who reported at least 150 min of
moderate-intensity leisure-time physical activity per week
(active women) (N=80), with the controls being women
below these recommended levels (less active)(N=258).
The aim of the original randomised controlled study was
to assess the effectiveness of primary prevention of GDM
through intensive dietary and physical activity counselling
among women at risk for GDM [15,16]. The original study
was approved by the medical ethics committees of the
Pirkanmaa hospital district (R06230), and participants’
informed consent was obtained, with a signature. The
research was conducted in accord with prevailing ethical
principles. The study population consisted of women with
at least one of the following GDM risk factors:
BMI C25 kg/m
2
, GDM or a macrosomic newborn
(C4,500 g) in any earlier pregnancy, any sign of glucose-
intolerance, type 1 or 2 diabetes in first- or second-degree
relatives, and age C40 years. The exclusion criteria were a
pathological value in baseline oral glucose-tolerance test
(OGTT) at 8–12 or 26–28 weeks’ gestation (fasting blood
glucose C5.3 mmol/l, 1-h level C10.0 mmol/l, or blood
glucose C8.6 mmol/l at 2 h), type 1 or 2 diabetes before
pregnancy, inadequate proficiency in the Finnish language
for the study, age \18 years, twin pregnancy, and physical
limitations preventing physical activity.
On pregnant women’s first visits to the antenatal clinic,
public health nurses recruited all women willing to par-
ticipate who met the inclusion criteria. The intervention
involved five out of the 11–15 recommended antenatal care
visits [17], which were divided evenly during gestation
from 8 to 12 until 37 weeks. With the intervention group,
the public health nurses focused on intensive one-on-one
dietary and physical activity counselling, which was based
on national physical activity and dietary recommendations,
personalised goals, and regular follow-up on targets but
also on recommendations as to gestational weight gain
[15]. The women at the control maternity clinics received
only routine care and no counselling beyond the usual care;
nor was group exercise arranged. However, routine
maternity care includes some dietary and physical activity
counselling [18,19]. Women who were at least slightly
active physically and had an uncomplicated pregnancy
were encouraged to engage in at least 150 min of moderate
or vigorous leisure-time activity at least 3 days a week [1].
Moreover, women in the intervention group were offered
an opportunity to participate in five separate 2-h physical
activity group sessions, including theory and practice of
various forms of physical activity, under the instruction of
a physiotherapist [15].
Differences in physical activity between the original
intervention and control groups were not found (see
Table 1). We previously reported that intensified physical
activity counselling had no effects on the time spent in
leisure-time physical activity (in general or of any specific
intensity level) during pregnancy in the intervention group
as compared to the usual-care group [7]. However, the
decrease seen in the days per week of general and of at
least moderate-intensity leisure-time physical activity was
smaller in the intervention group than the usual-care group
from baseline to the end of the second trimester [7]. In this
case–control study, the criteria for assignment to the case
group were physical activity in line with recommendations
of at least 150 min’ moderate-intensity leisure-time activ-
ity at least 3 days a week at the end of pregnancy in cases
of uncomplicated pregnancy and of the activity being done
in sessions at least 10 min long [1]. The controls were
women with less physical activity.
Matern Child Health J (2014) 18:2098–2105 2099
123
Information on subjectively evaluated weekly physical
activity and HRQoL in both groups was collected via
questionnaires completed by the women at the beginning of
the pregnancy (at 8–13 weeks’ gestation) and at the end of
pregnancy (at 36–37 weeks’ gestation). Women were to
report on the type of physical activity, its intensity (light,
moderate, or vigorous), and the duration of the session. In
addition, the public health nurse asked enquired as to
adverse events related to physical activity, such as vaginal
bleeding, major contractions, dizziness, headache, chest
pains, and muscle weakness, in every fifth visit [7,15].
The evaluation of quality of life was based on the
15-dimension questionnaire, which is a validated instru-
ment for measurement of health-related quality of life, with
five alternatives possible for each separate dimension
(5 =excellent health status, 4 =very good health status,
3=good health status, 2 =fair health status, and
1=poor health status) [20,21]. The 15D’s dimensions are
mobility, vision, hearing, breathing, sleeping, eating,
speech, excretion, usual activities, mental function, dis-
comfort and its symptoms, depression, distress, vitality,
and sexual activity. In addition to dimensions related to
physical and mental health, an overall HRQoL score can be
expressed, by a single index number, from 0 to 1 (1 for
optimal quality of life, 0 for death) [21].
Analyses were restricted to those women who filled in
the HRQoL questionnaires at both 8–13 and 36–37 weeks’
gestation. Data on scores were expressed with mean and
standard error (SE) values or with frequencies and per-
centages. Differences between the groups were tested with
Mann–Whitney Utesting for continuous variables and by
using of Chi squared tests for categorical variables.
The distribution of values for overall quality of life (i.e.,
of 15D scores) was limited 0–1. More cases were with
scores of 1 than one would expect from looking at the rest
of the distribution. If we use the ordinary least-squares
method (a linear regression model), we obtain biased
estimates. Therefore, tobit regression models were used to
estimate the association between physical groups and 15D
scores at the 8–13 and 36–37-week points. The tobit model
proposed by James Tobin [22], also called a censored
regression model, is designed to estimate linear relation-
ships between variables when there exist either left- or
right-censoring in the dependent variable. Censoring from
above takes place when cases with a value at or above
some threshold all take on the value of that threshold, such
that the true value could be equal to the threshold but might
also be higher. Tobit regression coefficients are interpreted
similarly to ordinary least squares (OLS) regression coef-
ficients, but the linear effect is on the uncensored latent
variable, not the observed outcome. However, we are
interested in the effect of a predictor on actual outcome, so
we used marginal effects to interpret the effect of physical
activity on 15D score.
A logistic regression model was used in addition, to
evaluate the association between the various physical
activity groups and 15D scores (overall and for individual
dimensions) at the end of pregnancy. The answers for five-
option items related to health status were divided into two
categories: excellent health status (a score of 5) and at least
some problems with one’s current health status (scores of
1–4). Over 90 % of the answers were ‘4’s or ‘5’s;
Table 1 Baseline characteristics (mean ±SE or frequency and per-
centage) and distribution of GDM risk factors
Meeting physical activity
recommendations
a
pvalue
Yes No
N 80 258
Age 29.4 ±0.51 29.8 ±0.29 0.43
c
Body mass index
Normal (\25 kg/m
2
) 35 (44.3) 107 (41.5) 0.77
d
Overweight
(25–29.9 kg/m
2
)
28 (35.4) 103 (39.9)
Obese (C30 kg/m
2
) 16 (20.3) 48 (18.6)
Parity
0 40 (50.0) 111 (43.0) 0.27
d
C1 40 (50.0) 147 (57.0)
Education level
Vocational school or less 21 (26.2) 94 (36.6) 0.17
d
Polytechnic level 41 (51.2) 104 (40.5)
Higher education 18 (22.5) 59 (23.0)
Marital status
Married or cohabiting 76 (95.0) 247 (95.7) 0.78
d
Single or divorced 4 (5.0) 11 (4.3)
Smoking
No 60 (75.9) 189 (73.8) 0.71
d
Smoker before and/or
during Pregnancy
19 (24.1) 67 (26.2)
Diagnosed GDM at latest pregnancy
Yes 15 (18.8) 46 (17.9) 0.86
d
No 65 (81.3) 211 (82.1)
Original RCT study group
Intervention group 46 (57.5) 144 (55.8) 0.79
d
Control group 34 (42.5) 114 (44.2)
Sum of GDM risk factors
b
1.33 ±0.06 1.34 ±0.04 0.97
c
a
Minimum of 150 min of at least moderate-intensity aerobic phys-
ical activity per week at the end of pregnancy
b
BMI C25 kg/m
2
, GDM in any earlier pregnancy or any sign of
glucose-intolerance, a macrosomic newborn (C4,500 g) in any earlier
pregnancy, type 1 or 2 diabetes in first- or second-degree relatives, or
age C40 years
c
Mann–Whitney Utest
d
Pearson’s Chi squared test
2100 Matern Child Health J (2014) 18:2098–2105
123
therefore, ordinal regression or multinomial logistic
regression models were not used. Physical activity during
pregnancy and before was divided into four categories: (1)
active both before and during pregnancy, (2) active only
before pregnancy, (3) active only at the end of pregnancy,
and (4) active neither before nor during pregnancy (see
Table 3).
We constructed unadjusted and adjusted regression
models to include possible confounding factors. The con-
founding factors considered were maternal age, parity,
education, and pre-pregnancy body mass index. Both the
adjusted and the unadjusted estimates were reported.
In the cases wherein some 15D data were missing, if six
or fewer dimensions were not covered (seen with six par-
ticipants, 1.8 %, at the 8–13-week visits and three partic-
ipants, 0.9 %, at 36–37 weeks’ gestation), imputations for
missing values were performed via linear-regression-model
technique [21]. The results were considered to be statisti-
cally significant if p\0.05. Analyses were performed with
the software IBM SPSS Statistics (version 20) and STATA
(version 12.0 for Windows).
Results
Approximately every fourth (23.7 %) pregnant women was
sufficiently active (i.e. met the physical activity recom-
mendations) during the last 3-month period of their preg-
nancy. In this study were no differences in age, weight,
parity, education, smoking habits, or sum of GDM risk
factors between these women and the others (see Table 1).
The most commonly seen GDM risk factors were being
overweight (60.8 %) and presence of type 1 or 2 diabetes in
first- or second-degree relatives (54.9 %). No association
was found between the groups in diagnosed GDM in a
previous pregnancy or in the physical activity levels of the
original RCT study groups. Physical activity level had no
impact on use of health-care services: no difference was
found between groups in the mean number of visits to the
public health nurse or physician at the maternity clinic
(15.0 vs. 14.8, p=0.46) or a specialist physician (1.4 vs.
1.7, p=0.31).
At the beginning of pregnancy (i.e., at 8–13 weeks’
gestation), no statistically significant differences were
between groups in overall 15D score (see Table 2) or for
any dimension of HRQoL. At the start of pregnancy,
16.3 % of the women experienced symptoms of depres-
sion, such as sadness, and 14.8 % of participants had
symptoms of distress. The adjusted total 15D index score
was not statistically significantly different at the beginning
of pregnancy between the groups (see Table 2). At the end
of pregnancy, the expected 15D index score—that is, the
predicted overall quality of life—would be 0.022 units
higher among active women than less active women; in this
case, the marginal effect was the same as the adjusted 95 %
tobit regression coefficient, to three decimal places (see
Table 2).
Active women reported greater mobility at the end of
pregnancy than less active women did (odds ratio (OR)
1.98, 95 % CI 1.04–3.78; see Table 2). Active women also
reported better ability to handle their usual activities, such
as work, leisure activities, or study (OR 2.22, 95 % CI
1.29–3.81), and more vitality (OR 2.08, 95 % CI
1.22–3.54) than did less active women. In addition, at the
end of pregnancy active lifestyle tended to have a positive
effect also on quality of sleep (OR 1.64, 95 % CI
0.93–2.90) and was correlated with lower distress (OR
2.00, 95 % CI 0.96–4.18; see Table 2).
A sixth of the women (16.6 %) performed 150 or more
minutes of at least moderate-intensity aerobic physical
activity per week both at the beginning of pregnancy and at
the end of pregnancy (see Table 3). Under a tenth (7.1 %)
increased their physical activity during pregnancy and met
the physical activity recommendations at the end of preg-
nancy but not at the beginning. More than a third (36.1 %)
of the women reduced their physical activity during preg-
nancy. Among the GDM risk group, 40.2 % of the women
reported less physical activity than was recommended,
throughout their pregnancy.
The overall HRQoL index score fell among all women
in the course of pregnancy, but it declined least among
women who were physically active throughout their preg-
nancy (see Table 3). In addition, women who were phys-
ically active for their entire pregnancy had greater mobility
(OR 2.49, 95 % CI 1.08–5.76), slept better (OR 2.11, 95 %
CI 1.03–4.30), and had a higher usual-activities score (OR
2.68, 95 % CI 1.32–5.46) than women who throughout
their pregnancy showed less physical activity than
recommended.
Discussion
Following the physical activity guidelines was associated
with higher overall quality of life at the end of pregnancy
and with higher values for the mobility, usual-activities,
and vitality components among women at risk for GDM.
Accordingly, regular physical activity was associated with
better ability to walk without problems and greater ability
to cope with one’s usual leisure-time activities, work, and
study in the third trimester of pregnancy among women at
risk of GDM. Women who were active already before
pregnancy and were able to sustain this activity had an
especially favourable HRQoL in comparison to less active
women. However, the improvement in HRQoL could have
been the cause of the continuation of physical activity at
Matern Child Health J (2014) 18:2098–2105 2101
123
Table 2 Associations (regression coefficients or odds ratios and 95 % confidence intervals) between physical activity recommendations and health-related quality of life (15D), with means and
standard error of means of 15D total index score and the frequencies and percentages of the 15D dimensions
HRQoL at 8–13 weeks’ gestation HRQoL at 36–37 weeks’ gestation
Meeting physical activity recommendations at the end of pregnancy
a
Meeting physical activity recommendations at the end of pregnancy
a
Yes (n=80) No (n=258) Unadjusted coeff.
(95 % CI)
Adjusted coeff.
(95 % CI)
c
Yes
(n=80)
No (n=258) Unadjusted coeff.
(95 % CI)
Adjusted coeff.
(95 % CI)
c
15D total index score 0.96 (0.005) 0.95 (0.003) 0.005 (-0.009, 0.018) 0.006 (-0.008, 0.019) 0.92 (0.007) 0.90 (0.005) 0.022 (0.002, 0.042) 0.022 (0.003, 0.042)
15D dimensions Yes (%) No (%) Unadjusted OR
(95 % CI)
Adjusted OR
(95 % CI)
Yes (%) No (%) Unadjusted OR
(95 % CI)
Adjusted OR
(95 % CI)
Mobility 79 (98.8) 251 (97.3) 2.20 (0.27, 18.2) 2.16 (0.25, 18.8) 66 (82.5) 180 (69.8) 2.04 (1.08, 3.85) 1.98 (1.04, 3.78)
Breathing 72 (90.0) 237 (91.9) 0.80 (0.34, 1.88) 0.65 (0.27, 1.59) 60 (75.0) 177 (68.6) 1.37 (0.78, 2.43) 1.40 (0.78, 2.53)
Sleeping 48 (60.0) 142 (55.0) 1.23 (0.74, 2.04) 1.23 (0.73, 2.07) 26 (32.5) 58 (22.5) 1.66 (0.96, 2.88) 1.64 (0.93, 2.90)
Excretion 64 (80.0) 202 (78.3) 1.11 (0.59, 2.07) 1.11 (0.59, 2.11) 53 (66.3) 164 (63.6) 1.13 (0.66, 1.91) 1.26 (0.73, 2.17)
Usual activities 73 (91.3) 239 (92.6) 0.83 (0.34, 2.05) 0.93 (0.35, 2.48) 54 (67.5) 131 (50.8) 2.01 (1.19, 3.41) 2.22 (1.29, 3.81)
Mental function 77 (96.3) 241 (93.4) 1.81 (0.52, 6.34) 1.76 (0.49, 6.27) 69 (86.3) 224 (86.8) 0.95 (0.46, 1.98) 0.96 (0.45, 2.03)
Discomfort and
its symptoms
43 (53.8) 142 (55.0) 0.95 (0.57, 1.57) 0.97 (0.58, 1.63) 31 (38.8) 94 (36.4) 1.10 (0.66, 1.85) 1.12 (0.66, 1.89)
Depression 70 (87.5) 213 (82.6) 1.48 (0.71, 3.09) 1.43 (0.68, 3.01) 73 (91.3) 215 (83.3) 2.09 (0.90, 4.84) 1.94 (0.83, 4.56)
Distress 68 (85.0) 220 (85.3) 0.98 (0.48, 1.98) 1.02 (0.50, 2.10) 70 (87.5) 202 (78.3) 1.94 (0.94, 4.01) 2.00 (0.96, 4.18)
Vitality 36 (45.0) 107 (41.5) 1.15 (0.70, 1.91) 1.25 (0.74, 2.11) 37 (46.3) 78 (30.2) 1.99 (1.19, 3.32) 2.08 (1.22, 3.54)
Sexual activity 68 (85.0) 232 (89.9) 0.64 (0.30, 1.33) 0.73 (0.34, 1.57) 44 (55.0) 132 (51.2) 1.17 (0.71, 1.93) 1.23 (0.73, 2.06)
a
At minimum, 150 min of at least moderate-intensity aerobic physical activity per week at the end of pregnancy
b
Vision, hearing, eating, and speech components are not shown, because they remained the same during pregnancy
c
Adjusted for age, parity, education, and pre-pregnancy body mass index
2102 Matern Child Health J (2014) 18:2098–2105
123
Table 3 Associations (regression coefficients or odds ratios and 95 % confidence intervals) by change of physical activity (PA) level and health related quality of life (15D) score and score
components during pregnancy, with means and standard error of means of 15D total index score and the frequencies and percentages of the 15D dimensions
PA–
a
(n=136) PA ?-
b
(n=122)
PA-?
c
(n=24)
PA ??
d
(n=56) PA ?-Coeff. (95 % CI) PA-?Coeff. (95 % CI) PA ?? Coeff. (95 % CI)
15D total index score
e
-0.054 (0.006) -0.050 (0.005) -0.037 (0.012) -0.037 (0.006) 0.004 (-0.011, 0.019) 0.017 (-0.008, 0.043) 0.018 (-0.001, 0.036)
15D dimensions
f
PA– (%) PA ?-(%) PA-?(%) PA ?? (%) PA ?-OR (95 % CI) PA-?OR (95 % CI) PA ?? OR (95 % CI)
Mobility 97 (71.3) 87 (71.3) 18 (75.0) 48 (85.7) 1.03 (0.60, 1.77) 1.27 (0.47, 3.45) 2.49 (1.08, 5.76)
Breathing 95 (69.9) 88 (72.1) 17 (70.8) 46 (82.1) 1.12 (0.65, 1.93) 1.05 (0.40, 2.71) 1.99 (0.92, 4.33)
Sleeping 78 (57.4) 63 (51.6) 10 (41.7) 38 (67.9) 0.93 (0.54, 1.60) 0.54 (0.20, 1.43) 2.11 (1.03, 4.30)
Excretion 107 (78.7) 98 (80.3) 18 (75.0) 44 (78.6) 1.03 (0.55, 1.92) 0.68 (0.24, 1.98) 1.04 (0.48, 2.26)
Usual activities 76 (55.9) 65 (53.3) 14 (58.3) 43 (76.8) 0.92 (0.56, 1.50) 1.08 (0.44, 2.62) 2.68 (1.32, 5.46)
Mental function 125 (91.9) 108 (88.5) 21 (87.5) 50 (89.3) 0.68 (0.29, 1.56) 0.60 (0.15, 2.35) 0.77 (0.27, 2.21)
Discomfort and
its symptoms
91 (66.9) 87 (71.3) 19 (79.2) 38 (67.9) 1.31 (0.72, 2.40) 1.93 (0.60, 6.18) 1.08 (0.50, 2.30)
Depression 123 (90.4) 112 (91.8) 22 (91.7) 53 (94.6) 1.18 (0.50, 2.80) 1.16 (0.25, 5.52) 1.85 (0.50, 6.81)
Distress 114 (83.8) 108 (88.5) 23 (95.8) 51 (91.1) 1.46 (0.71, 3.01) 3.90 (0.50, 30.7) 2.05 (0.73, 5.74)
Vitality 104 (76.5) 89 (73.0) 21 (87.5) 40 (71.4) 1.14 (0.61, 2.15) 1.62 (0.40, 6.54) 1.22 (0.56, 2.68)
Sexual activity 76 (55.9) 69 (56.6) 17 (70.8) 33 (58.9) 1.05 (0.64, 1.73) 1.91 (0.74, 4.92) 1.12 (0.59, 2.11)
a
Physically inactive throughout pregnancy
b
Physically active at the beginning of pregnancy (before 8–13 weeks’ gestation) but inactive at the end of pregnancy (at 36–37 weeks’ gestation)
c
Physically inactive at the beginning of pregnancy (before 8–13 weeks’ gestation) but active at the end of pregnancy (at 36–37 weeks’ gestation)
d
Physically active throughout pregnancy
e
From linear regression model
f
From logistic regression model
Matern Child Health J (2014) 18:2098–2105 2103
123
the end of pregnancy, leading to higher perceived quality
of life in the third trimester.
Overall HRQoL showed a trend of decline during
pregnancy, but among women with a risk of GDM main-
taining a physically active lifestyle for one’s entire preg-
nancy is a way to diminish the decrease in HRQoL. In
addition, regular physical activity during pregnancy has
advantages for mobility, sleep quality, and one’s usual
activities, which are significant components for a mother’s
overall well-being. According to our study, physical
activity at the end of pregnancy was essential from the
perspective of quality of life, with the advantages being
clearer among women who met the physical activity cri-
teria throughout their pregnancy, not only at the end of
pregnancy.
Our findings were similar to those of a previous trial that
showed pregnant women’s 3-month subjectively measured
aerobic exercise to be linked to improved overall HRQoL
and physical component summary value, along with higher
physical function and general health scores than the control
group showed [9]. In our study, meeting the recommen-
dations for weekly physical activity had only a weak cor-
relation with depression, although several studies have
found an association between regular physical activity and
lower amount of depression during pregnancy [4,11,12].
Some previous studies have concluded that antenatal mood
changes, anxiety, and fatigue, often correlated with
depression, are quite common during pregnancy [4,23].
However, the prevalence of depression in the GDM risk
group in our study was in parallel with the findings of other
studies implemented in industrial countries [24].
Among women at risk for GDM, screening for it may
have a negative influence on perceived health [25]. Diag-
nosed GDM was connected with a higher depression score
[26] and a lower value for the general health component of
HRQoL in the third trimester but, unexpectedly, a better
physical component than seen in healthy pregnant women
[27], which may be because GDM patients compare their
physical health to that of other GDM women, not healthy
pregnant women. On the other hand, according to Daniells
et al. [28] and Katon et al. [29], diagnosed GDM had no
influence on anxiety or depression, although healthy
pregnant women were reported to have increased depres-
sion or anxiety during pregnancy [30] and a lower value for
the physical component of HRQoL [31].
Pregnancy brings with it many changes in health that
may decrease quality of life and perceived health and that
could reduce capacity to be physically active. Even though
the 15D instrument revealed some differences between
groups, a more pregnancy-sensitive way of measuring
quality of life could have been used than the 15D ques-
tionnaire, especially since several components, such as
hearing, eating, and speech, remained the same during
pregnancy.
A limitation of the study was that its findings cannot be
generalised to all pregnant women, on account of the risk-
group approach. Another limitation is related to the sub-
jective reporting of physical activity, which may underes-
timate or exaggerate the amount of physical activity. The
results were still consistent with those of previous studies
employing subjective collection of data on physical activ-
ity. Participants were combined between the intervention
and control group, which may have biased the results,
because no differences in physical activity were found
between the groups and the data were adjusted for the
group variable. The counselling sessions with the inter-
vention group may have influenced perceptions of quality
of life, although original RCT study group was used as a
confounding factor in the analyses.
The strength of the study stems from its measurement of
physical activity and HRQoL both at the beginning and at
the end of pregnancy. Previous studies reporting changes in
lifestyle during pregnancy are not available that take an
HRQoL perspective. The multidimensional nature of
HRQoL points to a need for more studies evaluating
motivation-related factors and perceived problems in
physical activity during pregnancy. Objective measurement
of physical activity would improve the precision of the
results. In addition, the physical activity measurement
should encompass all activities. Further studies of physical
activity and HRQoL during pregnancy would provide
useful information for determination of more effective
ways of promoting health. Improvements in overall
HRQoL and physical-activity-related components may also
have far-reaching effects in terms of re-entering the labour
market and may bring cost savings from a societal per-
spective and decrease the use of health-care services.
In conclusion, meeting of the physical activity guide-
lines was associated with higher overall quality of life at
the end of pregnancy. Regular physical activity at a mod-
erate or greater level should start before pregnancy if the
woman is to gain optimal health-related quality of life until
the end of pregnancy.
Acknowledgments Financial support was received from the Juho
Vainio Foundation, the Yrjo
¨Jahnsson Foundation, and Doctoral
Programs in Public Health (DPPH), along with medical research
funding from Tampere University Hospital (as competitive research
funding from the Pirkanmaa hospital district), the Academy of Fin-
land, and Finland’s Ministry of Education and Ministry of Social
Affairs and Health. The authors would like to thank Minna Aittasalo
for planning and preparing all physical activity counselling materials,
for training the nurses in counselling, and for designing the thematic
meetings on physical activity and the associated materials. In addi-
tion, we wish to thank Tarja Kinnunen for planning all dietary
counselling materials and for providing training for the nurses.
2104 Matern Child Health J (2014) 18:2098–2105
123
Conflict of interest The authors declare that there are no conflicts
of interest.
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