Physical activity and its correlates among pregnant women from the French national cohort ELFE

doi:10.21203/rs.3.rs-4976137/v1

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Physical activity and its correlates among pregnant women from the French national cohort ELFE

https://doi.org/10.21203/rs.3.rs-4976137/v1

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Background

Most pregnant women do not reach the minimum recommended level of 150 min/week of moderate physical activity (MPA). Most previous studies of correlates focused on leisure time physical activity (LTPA) ignoring other domains of MPA (occupational, household/childcare, transportation). This article aims to estimate the proportion of French pregnant women meeting physical activity (PA) guidelines, and identify sociodemographic, and maternal health and behavioural correlates, whenever only LTPA or overall MPA is considered.

Methods

A total of 14,484 pregnant women included in 2011 in the French national ELFE birth cohort reported their PA during the last trimester of their pregnancy using the Pregnancy Physical Activity Questionnaire. Women spending ≥450 MET-min/week in MPA (i.e., ≥150 min/week in activities at ≥3 METs) were considered reaching recommended PA levels. Sociodemographic and maternal health and behavioural correlates associated, respectively, with meeting PA guidelines for LTPA and having a high overall MPA (defined as an overall MPA ≥70^th percentile) were assessed by multivariable logistic regressions.

Results

Most of the pregnant women reported engaging in LTPA during the last three months of pregnancy (92.3%), with walking as main activity; however, about 28.0% of women met guidelines for LTPA. Adding other MPA (transportation, household/caregiving, occupational) drastically increased this estimate (up to 85.6%). Primiparity, higher education and income levels, and a higher number of prenatal classes attended were positively associated with meeting guidelines for LTPA, but negatively with having high overall MPA levels. Younger age was positively associated with high MPA whereas not working during the last trimester of pregnancy was negatively associated with high MPA. Pre-pregnancy overweight/obesity were negatively associated with meeting guidelines for LTPA. Being single was positively associated with both outcomes.

Conclusions

Most sociodemographic and maternal correlates examined had differing associations with engaging in sufficient LTPA or high overall MPA. In particular, associations with indicators of social vulnerability were in opposite directions. These results call for continuing efforts to promote PA during pregnancy while inviting to specify which activities (type/context) provide optimum health benefits.

Trial registration

Not applicable.

physical activity

sedentary behaviours

pregnancy

physical activity guidelines

public health recommendations

domain of activity

risk factors

Physical activity (PA) during pregnancy has multiple benefits on maternal health, obstetric and birth outcomes (e.g., reduced risk of excessive gestational weight gain, gestational diabetes mellitus, gestational hypertension, preeclampsia, and postpartum depression) and presents no risk for the newborn.^1–7 For these reasons, pregnant women experiencing a healthy pregnancy are encouraged to engage in regular PA throughout their gestation.^8–12 More specifically, the World Health Organisation (WHO) 2020 guidelines recommend that pregnant women without medical contraindication engage in at least 150 min per week of moderate-intensity PA (MPA) spread throughout the week for substantial health benefit.¹³ These recommendations are consistent with PA guidelines recently issued by professional societies and health organisations from several countries,^8,9,11,14 although some inconsistencies and imprecision regarding the definition of a ‘moderate physical activity’ could be noted with some guidelines recommending specifically exercise and other leisure-domain PA while others (like the WHO guidelines) do not specify any PA domain.⁸ Moreover, as for the general adult population, the WHO 2020 guidelines and other recent guidelines also encourage pregnant women to limit the time spent being sedentary (sitting time) and replace it by PA at any level of intensity, although insufficient data exist to quantify a precise upper sedentary time threshold.^12–15

Despite the strong evidence base showing the benefits of PA during pregnancy and the existence of guidelines, research conducted mainly in North America, the United Kingdom, Northern Europe, and Asia indicate that most pregnant women do not reach the minimum recommended level of 150 minutes of MPA per week.^16–22 Of note, however, most of the studies are based on relatively small or non-representative samples,^16,17,20 and there is no national estimate of PA guideline compliance to inform health professionals in most countries, including in France where only scarce data are available.^14,23 A large number of studies have examined maternal sociodemographic and health-related correlates of PA during pregnancy as a first step to better understand the factors that influence women’s PA behaviour and guide PA promotion efforts.^24–26 However, few consistent correlates have been identified (most notably, higher levels of education and income, primiparity, being of European ancestry, and being physically active prior to pregnancy). An increasing number of qualitative and quantitative studies have also examined women’s perceived barriers to PA participation during pregnancy.²⁶ These studies identified mostly intrapersonal barriers (e.g., pregnancy-related symptoms and limitations, mother-child safety concerns, lack of motivation, lack of time) and interpersonal barriers (e.g., lack of social support, lack of advice and information), which suggests important themes to be addressed by health care professionals to help pregnant women increase their level of PA. However, efforts to increase PA through education and motivational behaviour change techniques, prenatal counselling, or supervised exercise programs have produced mixed results and showed only moderate increase in PA.²⁷

Previous studies that examined the proportion of pregnant women meeting guidelines or the correlates/determinants of PA have predominantly focused on leisure-time PA (LTPA).²⁴ Only a few PA questionnaires cover all domains of PA (e.g., household/childcare, occupational, sports/exercise, transportation) and have been specifically conceived or adapted for and validated in pregnant women.^28–30 The limited number of studies that used such questionnaires showed that pregnant women spend considerable time and energy in activities related to household, job and family care, which may significantly contribute to overall MPA.^{20,21,31–33} Hence, gaining insight into the correlates of overall MPA during pregnancy appears important, especially since pregnant women are generally advised to be active in everyday life activities. However, a few studies conducted in specific populations of pregnant women (Hispanic US / Singaporean women) suggest that sociodemographic, cultural, health and behavioural correlates of PA vary by domain of PA and by types (e.g., walking) of MPA.^34,35 Moreover, several reviews of the literature that examined socioeconomic differentials in PA among the general adult population concluded that the classically reported positive association between socio-economic status and PA pertains essentially to LTPA;^36,37 when PA undertaken in other domains (e.g., occupation, transportation) are added to the mix, the association with “total PA” is much less clear (majority of null results), but men and women were generally not examined separately and household/caregiving activities were not taken into account. Examining differences in the set of correlates associated with LTPA and overall MPA within the same population of pregnant women may indicate new directions for future research aimed at better understanding factors that influence PA during pregnancy and provide some guidance for the development of more targeted interventions that may improve the reach and effectiveness of existing PA promotion interventions. However, there is a lack of population-based studies that simultaneously measured PA using a validated PA questionnaire covering all PA domains along with various potential correlates of PA in large and socially diversified samples of pregnant women. Moreover, although there is accumulating evidence regarding the detrimental effects of sedentary behaviour during pregnancy,^14,38 there is still limited descriptive data from large population-based studies regarding the time pregnant women spend in different types and domains of sedentary behaviour (e.g., leisure-related screen use, sitting at work, motorized transportation) that could inform future guidelines and preventive interventions development.¹⁵

Given the above considerations, the aims of the present study are to i) describe PA practices and sedentary behaviour in a large representative sample of French pregnant women (> 14,000); ii) estimate the prevalence of adherence to PA guidelines among French pregnant women experiencing a healthy pregnancy according to whether only LTPA is considered or other moderately-intense activities performed in other life domains are also taken into consideration; and iii) identify the set of correlates (sociodemographic factors and maternal health and behavioural characteristics) associated, respectively, with meeting the PA guidelines for LTPA and having a high level of MPA (across all domains).

Study Design and Participants

This study used data from the ELFE (Étude Longitudinale Française depuis l’Enfance) study, which is a nationally representative French birth cohort launched in 349 randomly selected maternity units from metropolitan France in 2011.^39,40 Children and their mothers were enrolled at birth, from the 320 maternity units that agreed to participate, throughout four periods over the year. Exclusion criteria were: stillbirth, birth < 33 weeks of gestation, mother < 18 years old, multiple births > 2, or plan to move out of mainland France in the following three years. Mothers also had to be capable of giving informed consent in either French, English, Arabic, or Turkish. The acceptance rate was 51%, for a total of 18,040 recruited mothers. Maternity data were collected through both a standardized questionnaire administered face-to-face by trained interviewers and medical files, during the post-birth maternity time. Mothers were also asked to complete a self-administered questionnaire on “lifestyle habits” including an assessment of PA based on the Pregnancy Physical Activity Questionnaire (PPAQ).³⁵ Out of the 17,912 participating women, 15,475 (86.4%) completed the PPAQ, of whom 14,484 were considered to have a valid total PA score and were included in the present study (Fig. 1).

Measure of PA and sedentary behaviour

The PPAQ, a semi-quantitative questionnaire designed specifically for pregnant women and validated in this population,^29,35 was used to measure PA and sedentary behaviour during the last three months of pregnancy. Respondents were asked to report the time spent participating in 32 different activities pertaining to the following domains: household/caregiving (13 questions), leisure-time sedentary behaviour (3 questions), transportation (3 questions), LTPA (8 questions, including 1 open-ended question to declare up to 3 non-prespecified activities), and occupation (5 questions). Time spent in each activity was multiplied by its corresponding intensity,³⁵ using pregnancy-specific estimates for walking and light- to moderate-intensity household tasks,⁴¹ and compendium-based metabolic equivalent of task (MET) values for the other activities.⁴² These activity-specific estimates of energy expenditure (in MET-min/week) can then be summed over all activities or grouped by domains or levels of intensity to derive a total PA score as well as various sub-scores of PA (in MET-min/week). The intensity levels were defined as follows: sedentary (MET ≤ 1.5), light (1.5 < MET < 3.0), moderate (3.0 ≤ MET ≤ 6.0) or vigorous (MET > 6.0).⁴³ We also calculated the overall time spent sitting by combining activities associated with a MET value corresponding to sedentary behaviour (≤ 1.5 MET) – that is, “watching television or a video” (1.0 MET), “sitting and reading, discussing, or on phone [not for work]” (1.1 MET), and “driving or being transported by bus, car, etc.” (1.5 MET) – with two other activities associated with a MET value (provided by PPAQ’s authors) corresponding to light-intensity activities – that is, “sitting and using a computer or writing [not for work]” (1.8 MET) and “sitting at work or in class” (1.6 MET).

At the time of the study, French clinical and public health guidelines recommended pregnant women with uncomplicated pregnancies to engage in regular moderately-intense PA, and infographics referring to the American College of Obstetricians and Gynaecologist (ACOG)⁴⁴ guidelines had been developed for professionals and provided examples of types of PA in which pregnant women could be encouraged to engage in (e.g., walking for exercise, swimming, prenatal gymnastics).^45,46 Thus, we operationalized the threshold of attainment of PA guidelines as follows: 450 MET-min/week of MPA, that is 150 minutes multiplied by 3 METs (the lowest boundary value defining MPA), which may correspond, for instance, to 30 min/day of walking for exercise (MET = 3.2) for 5 days a week. A few women in the study sample (n = 121/14,484, 0.84%) reported engaging in sports of vigorous-intensity (e.g., jogging, cardio workout, trail running, etc.) during the last three months of their pregnancy. These women were included in the estimate of the prevalence of women meeting guidelines.

Potential correlates

Information on potential correlates was obtained by questionnaire during the maternity stay and by phone interview at 2 months postpartum. Sociodemographic correlates included maternal age (< 30; 30–35; >35 years old), parity (primiparous; multiparous), parental cohabiting status (lives as a couple; single), maternal educational level (adapted from the International Standard Classification of Education 2011 levels, ≤lower secondary; upper secondary; short tertiary; ≥bachelor),⁴⁷ household income per consumption unit (< 1,000 €; 1,000-1499 €; 1,500-1,999 €; ≥2,000 €/month),⁴⁸ maternal country of birth (born in France; outside France), worked (for wages, as a volunteer or a student) during the last three months of pregnancy (yes; no). Maternal health and behavioural characteristics included pre-pregnancy BMI (underweight, < 18.5 kg/m²; normal range, 18.5–24.9 kg/m²; overweight, 25-29.9 kg/m²; obesity, ≥ 30 kg/m²),⁴⁹ number of prenatal classes attended (0; 1–6; ≥7 classes – which corresponds to the French recommendations),⁵⁰ score of adherence to the French dietary guidelines (in tertiles),^51,52 smoking status (non-smoker; smoker before pregnancy; smoker during pregnancy), alcohol consumption during pregnancy (non-consumer; only before knowing being pregnant; consumer).

Statistical analyses

We first described the sociodemographic, health and behavioural characteristics of the 14,484 pregnant women included in the study sample as well as their PA practices and sedentary behaviour during the last three months of their pregnancy. Adherence to PA recommendations was first calculated for LTPA. We then explored how adding successively active transportation (here, walking) and then other moderate-intensity daily life activities (household/caregiving and occupation-related activities) influenced the estimated prevalence of women reaching the minimum recommended level of 150 min/week of MPA. Adherence to PA recommendations was also calculated after excluding 1,709 women with absolute contraindications to PA for whom practicing exercise during pregnancy is not recommended (Fig. 1), as defined by the American College of Obstetricians and Gynaecologists.⁴⁴ Remaining with pregnant women without contraindication to exercise during late pregnancy (N = 12,775), we measured the association of the sociodemographic, health and behavioural characteristics with the probability of, respectively, meeting PA guidelines for LTPA or having a high MPA (across all domains) using multivariable logistic regression models: (1) first, adjusted for season of birth only (knowing that the reference period for the PPAQ is the last three months of gestation and that seasonality has been shown to significantly influence the level of PA⁵³); and (2) additionally and mutually adjusted for all sociodemographic factors. For these analyses, the “high MPA” subgroup is comprised of the 30% of women who had the highest MPA scores (a subgroup of similar size to the group of women meeting guidelines for LTPA, as reported below in the Results section).

As described elsewhere,^39,54 a sampling weight, considering the sampling plan and refusals at both maternity unit and individual levels, has been developed to correct for non-representativeness in ELFE and provide national statistics (https://www.elfe-france.fr/fichier/rte/178/Coté%20recherche/weighting-inclusion.pdf). In brief, it accounts for the inclusion sampling and selection bias attributable to non-consent,⁵⁵ and includes marginal calibration using statistical data from the state register’s and the 2010 French National Perinatal survey on the following variables: age, marital and migration status, level of education, parity and region of residence.⁵⁶ Descriptive data and estimates of compliance with PA guidelines are presented after using weights for sampling correction. Missing data on correlates (up to 10.4% for the variable ‘household income’) were imputed using multiple imputation by chained equations (20 imputed datasets).⁵⁷ Data were assumed to be missing at random after taking into consideration observed correlates. Logistic regression models used sampling weights and multiple imputations.

We conducted sensitivity analyses without sampling weighting and on complete case sample. All analyses were carried out using the statistical software Stata version 15.1 (StataCorp, College Station, TX, USA). Statistical significance was defined as a two-sided p-value < 0.05.

Sociodemographic, health and behavioural characteristics of the 14,484 pregnant women included in the study are summarized in Table 1. Around 45% of the women were younger than 30 years old and primiparous, most of them were living in couple and were born in France, approximately one third had a high educational level with a bachelor or more. The majority had a pre-pregnancy BMI in normal range (65%) and one quarter attended at least 7 prenatal classes; 20% smoked during pregnancy and 19% continued to drink alcohol after knowing being pregnant Of note, the use of sampling correction slightly increased the weight of socially disadvantaged women.

Table 1

Characteristics of pregnant women included in the study (N = 14,484) (without and with sampling correction).
	Without sampling correction		With sampling correction
	N	(%)	N^a	(%)
General characteristics
Season concerned by the PPAQ, missing = 0 (0.0%)
Winter	2,305	(15.9)	3,496	(24.1)
Spring	3,664	(25.3)	3,807	(26.3)
Summer	4,117	(28.4)	3,729	(25.7)
Autumn	4,398	(30.4)	3,453	(23.8)
Sociodemographic characteristics
Maternal age, missing = 43 (0.3%)
< 30 years	6,469	(44.8)	6,769	(46.9)
30–35 years	5,185	(35.9)	4,912	(34.0)
> 35 years	2,787	(19.3)	2,760	(19.1)
Maternal parity, missing = 165 (1.1%)
Primiparous	6,489	(45.3)	6,176	(43.1)
Multiparous	7,830	(54.7)	8,143	(56.9)
Parental cohabiting status, missing = 108 (0.8%)
Couple	13,736	(95.5)	13,523	(94.1)
Single	640	(4.5)	853	(5.9)
Maternal educational level, missing = 37 (0.3%)
≤Lower secondary	2,424	(16.8)	3,467	(24.0)
Upper secondary	2,945	(20.4)	2,822	(19.5)
Short tertiary	4,059	(28.1)	3,840	(26.6)
≥Bachelor	5,019	(34.7)	4,317	(29.9)
Household income per consumption unit, missing = 1,506 (10.4%)
< 1000€/month	2,207	(17.0)	2,795	(21.5)
1000–1499€/month	4,087	(31.5)	4,070	(31.4)
1500–1999€/month	3,722	(28.7)	3,501	(27.0)
≥ 2000€/month	2,962	(22.8)	2,613	(20.1)
Maternal country of birth, missing = 121 (0.8%)
France	12,939	(90.1)	12,484	(86.9)
Born outside France	1,424	(9.9)	1,879	(13.1)
Worked during the three last months of pregnancy^b, missing = 0 (0.0%)
No	6,210	(42.9)	6,803	(47.0)
Yes	8,274	(57.1)	7,681	(53.0)
Maternal health and behavioural characteristics
Maternal pre-pregnancy BMI, missing = 165 (1.1%)
Underweight	1,115	(7.8)	1,132	(7.9)
Normal range	9,321	(65.1)	9,122	(63.7)
Overweight	2,462	(17.2)	2,530	(17.7)
Obesity	1,421	(9.9)	1,535	(10.7)
Attended prenatal classes, missing = 426 (2.9%)
0 class	6,055	(43.1)	6,751	(48.0)
1–6 classes	4,174	(29.7)	3,994	(28.4)
≥ 7 classes^c	3,829	(27.2)	3,313	(23.6)
Adherence to the French dietary guidelines (tertiles)^d, missing = 272 (1.9%)
Lower third	4,928	(34.7)	5,118	(36.0)
Middle third	4,687	(33.0)	4,676	(32.9)
Upper third	4,597	(32.3)	4,418	(31.1)
Maternal smoking status, missing = 99 (0.7%)
Non-smoker	8,109	(56.4)	8,055	(56.0)
Smoker before pregnancy	3,400	(23.6)	3,189	(22.2)
Smoker during pregnancy	2,876	(20.0)	3,141	(21.8)
Maternal alcohol consumption during pregnancy, missing = 111 (0.8%)
Non-drinker	10,846	(75.5)	10,926	(76.0)
Only before knowing being pregnant	819	(5.7)	813	(5.7)
Drinker (occasional/regular)^e	2,451/257	(17.1)/(1.8)	2,370/265	(16.5)/(1.8)
Abbreviations: PPAQ, Pregnancy Physical Activity Questionnaire. BMI, body mass index. ^aN are rounded to a whole number with the use of weight for sampling correction. ^bYes included working for wages, as a volunteer or a student, all part- or full-time. ^cFrench recommendations. [REF] ^dDefined using the French Programme National Nutrition Santé (PNNS) score. [REF] ^eOccasional and regular consumer defined as “once a month or less” and “more than once a month”, respectively.

PA and sedentary behaviour during late pregnancy

Descriptive data regarding the PA and sedentary behaviour of the 14,484 sample women are presented in Table 2. Household/caregiving PA contributed the most (47.0%) and LTPA the least (3.4%) to the total energy expenditure. Light and moderate PA contributed to 54.9% and 20.9% of total PA, respectively; in comparison, vigorous PA contributed to less than 1%. Most pregnant women (92.3%) reported engaging in some LTPA during the last three months of pregnancy, the majority of which were of moderate intensity. The activities reported were: slow walking (reported by 87% of women), moderate, fast or uphill walking (53%), swimming (30%), dancing (16%), antenatal gymnastic (13%), running/jogging (1%), other sport activities (4%) (results not shown). Moderately intense activities undertaken in the household domain (child and adult care, essentially) presented the largest share (51.5%) of total MPA, while moderately intense LTPA contributed 23.2%. Half women spent at least 2 hours per day [interquartile range (IQR): 0.5-4.0] watching television or videos and 4 hours per day [IQR: 2.2-6.0] in sedentary behaviour (defined as ≤ 1.5 MET) which includes home-based leisure-time activities while sitting and motorized transportation. When considering all sitting activities whatever the domain (i.e., leisure-time, transportation, occupation), the median time spent sitting increased to 6.5 hours per day [IQR: 4.0-9.5]. Descriptive results using the unweighted sample were very close (Supplemental Table 1).

Table 2

Description of the PA and sedentary behaviour during late pregnancy based on PPAQ data (N = 14,484).a
Total PA (in MET-min/week)
By domain of activity	Med	[IQR]		(% contribution)^b
Household/caregiving	4345.3	[2567.9; 6915.7]		(47.0%)
Occupation	2880.0	[1981.4; 3592.8]^c		(14.0%)
Transportation	802.2	[441.0; 1470.0]		(10.5%)
LTPA	192.0	[66.2; 472.8]		(3.4%)
Leisure-time sedentary behaviour^c	2142.0	[1197.0; 3276.0]		(25.1%)
By intensity level	Med	[IQR]		(% contribution)^b
Sedentary (≤ 1.5 MET)^d	1915.2	[1222.2; 3024.0]		(23.8%)
Light (1.5–3 METs)	5481.0	[3861.5; 7419.0]		(54.9%)
Moderate (3–6 METs)	1722.0	[722.5; 3534.2]		(20.9%)
Vigorous (> 6 METs)	0.0	[0.0; 46.8]		(0.4%)
Total	9820.7	[7200.1; 13213.2]		-
Moderate PA (in MET-min/week)
By domain of activity	Med	[IQR]		(% contribution)^b
Household/caregiving	831.6	[161.3; 2100.0]		(51.5%)
Occupation	151.2	[0.0; 653.4]^c		(11.7%)
Transportation	201.6	[0.0; 201.6]		(13.7%)
LTPA	192.0	[66.2; 469.2]		(23.2%)
Total	1752.1	[738.2; 3617.8]		-
Time spent in PA and sedentary behaviour
Women reporting engaging in LTPA, n (%)			13,362		(92.3)
Time (min/week) spent in LTPA (all levels of intensity), Med [IQR]^e			51.6		[7.2; 120.0]
Time (min/week) spent in moderate-intensity LTPA, Med [IQR]			51.6		[7.2; 120.0]
Time (min/week) spent in moderate-intensity PA (all domains), Med [IQR]			501.6		[210.0; 1023.6]
Time (h/day) spent watching television or a video, Med [IQR]			2.0		[0.5; 4.0]
Time (h/day) spent in sedentary behaviour (≤ 1.5 MET), Med [IQR]^d			4.0		[2.2; 6.0]
Time (h/day) spent being seated (all domains), Med [IQR]^f			6.5		[4.0; 9.5]
Abbreviations: PA, physical activity. MET, metabolic equivalent of task. Med, median. IQR, interquartile range. LTPA, leisure-time physical activity. SB, sedentary behaviour. ^aValues are rounded to one decimal and calculated with the use of weight for sampling correction. ^bContribution to the total PA/MPA level (average of individual percentages). ^cValues calculated excluding women not working during the last three months of pregnancy. ^dIncludes the following activities: watching television or a video (1.0 MET); sitting and reading, discussing, or on phone [not for work] (1.1 MET); driving or being transported by bus, car, etc. (1.5 MET). ^eUsing pregnancy-specific estimates of PA intensity, all LTPA proposed in the Pregnancy Physical Activity Questionnaire (PPAQ) are considered to be of moderate or vigorous intensity (≥ 3 METs). Only few other LTPA that have been reported in response to the open-question (free text) were from light intensity (e.g., stretching, light yoga practice, pregnancy ball exercises). ^fIncludes all the above activities classified as sedentary (≤ 1.5 MET) plus the following two sitting activities of very light intensity: being seated to use a computer or writing [at home, not for work] (1.8 MET) and being seated [at work] (1.6 MET).

Proportion of pregnant women meeting PA guidelines

Out of the 12,775 pregnant women without contraindication, less than one third (28.0%) comply to PA guidelines for LTPA (i.e., reached the target level of at least 450 MET-min per week of moderate-intensity LTPA) (Table 3). By adding active transportation (here, walking) to the calculation, the compliance to PA guidelines increases up to 45.5%; a figure that raises up to 85.6% when moderately-intense PA undertaken in all domains are considered. Not excluding pregnant women with probable medical contraindication results in slightly lower prevalence estimates (between − 1.1 and − 1.6%).

Table 3
Proportion of French pregnant women meeting the PA guidelines (i.e., ≥ 450 MET-min/week of moderate-intensity PA) depending on the PA domain(s) considered.a
Among all women (N = 14,484)
Moderate-intensity in LTPA only, n (%)	3,895	(26.9)
Moderate-intensity in LTPA or transport, n (%)	6,356	(43.9)
Moderate-intensity in all PA domains, n (%)	12,167	(84.0)
Among women without medical contraindications to exercise during pregnancy (N = 12,775)^b
Moderate-intensity in LTPA only, n (%)	3,574	(28.0)
Moderate-intensity in LTPA or transport, n (%)	5,812	(45.5)
Moderate-intensity in all PA domains, n (%)	10,934	(85.6)
Abbreviations: PA, physical activity. SB, sedentary behaviour. LTPA, leisure-time physical activity. Med, median. IQR, interquartile range. MET, metabolic equivalent of task. ^aN are rounded to a whole number with the use of weight for sampling correction. ^bStatistics weighted over the 12,775 women without medical contraindications to exercise during pregnancy. Based on medical records, we excluded women with absolute medical contraindications to practice exercise during pregnancy, as reported by the American College of Obstetricians and Gynaecologists [ACOG, 2002], and known by French healthcare professionals at the time of the study [HAS, 2008]; i.e., twin pregnancy (n = 231), threatened preterm labour (n = 1,021), vaginal bleeding (i.e., placenta previa, placental abruption, etc.) during the two last trimesters (n = 134), gestational hypertension diagnosed before eight months of pregnancy (n = 164), in line with the PPAQ covering the last three months of pregnancy. We also excluded women with more than seven days of hospitalisation during pregnancy (n = 168), considering these women with complex health situation not representing common pregnancy.

Correlates of meeting PA guidelines for LTPA and of having a high MPA level

Results of the multivariable logistic models estimating odds ratio (OR) and their 95% confidence intervals (95% CI) adjusted for sociodemographic characteristics are presented in Table 4. Primiparous women, with higher levels of educational and household income were more likely to meet PA guidelines for LTPA, but less likely to have a high overall MPA level. Being single was associated positively with both outcomes, whereas younger maternal age and working during the last three months of pregnancy were associated with having a high MPA level only. Maternal birth in France and working during the last three months of pregnancy were not associated with meeting the PA guidelines after adjustment for sociodemographic characteristics.

Table 4

Correlates associated with meeting the PA guidelines for LTPA or having a high overall MPA level (N = 12,775) (OR and 95% CI from weighted logistic regression models).a
	Meeting the PA guidelines for LTPA				Having a high overall MPA level
	Adjusted for seasonality only		Additionally adjusted for sociodemographic factors		Adjusted for seasonality only		Additionally adjusted for sociodemographic factors
	OR	(95% CI)	OR	(95% CI)	OR	(95% CI)	OR	(95% CI)
Sociodemographic characteristics
Maternal age [ref: 30–35 years]
< 30 years	1.04	(0.94, 1.16)	1.09	(0.97, 1.22)	1.16	(1.05, 1.29)	1.46	(1.29, 1.65)
> 35 years	0.88	(0.78, 1.01)	0.90	(0.79, 1.02)	0.87	(0.76, 0.99)	0.75	(0.65, 0.86)
Maternal parity [ref: Multiparous]
Primiparous	1.35	(1.23, 1.49)	1.19	(1.08, 1.32)	0.37	(0.33, 0.40)	0.30	(0.27, 0.34)
Parental cohabiting status [ref: Couple]
Single	1.36	(1.07, 1.73)	1.61	(1.25, 2.08)	1.68	(1.33, 2.12)	1.49	(1.16, 1.92)
Maternal educational level [ref: ≥Bachelor]
≤Lower secondary	0.68	(0.59, 0.79)	0.78	(0.66, 0.92)	2.15	(1.88, 2.47)	1.66	(1.40, 1.96)
Upper secondary	0.74	(0.65, 0.84)	0.83	(0.72, 0.96)	1.80	(1.58, 2.05)	1.55	(1.33, 1.81)
Short tertiary	0.81	(0.72, 0.90)	0.85	(0.76, 0.96)	1.27	(1.13, 1.42)	1.20	(1.05, 1.36)
Household income per consumption unit [ref: ≥2000€/month]
< 1000€/month	0.63	(0.54, 0.74)	0.69	(0.56, 0.84)	2.05	(1.75, 2.39)	1.27	(1.04, 1.55)
1000–1499€/month	0.65	(0.57, 0.73)	0.72	(0.62, 0.84)	1.57	(1.38, 1.79)	1.12	(0.96, 1.32)
1500–1999€/month	0.80	(0.71, 0.90)	0.83	(0.72, 0.95)	1.10	(0.96, 1.26)	0.96	(0.83, 1.12)
Maternal country of birth [ref: France]
Born outside France	0.80	(0.67, 0.94)	0.85	(0.72, 1.02)	1.00	(0.85, 1.18)	0.98	(0.82, 1.17)
Worked during the last three months of pregnancy [ref: Yes]^b
No	0.82	(0.75, 0.91)	0.91	(0.82, 1.01)	0.71	(0.65, 0.79)	0.52	(0.47, 0.58)
Maternal health and behavioural characteristics
Maternal pre-pregnancy BMI [ref: Normal range]
Underweight	0.90	(0.75, 1.07)	0.90	(0.76, 1.08)	1.09	(0.91, 1.31)	1.04	(0.85, 1.26)
Overweight	0.71	(0.63, 0.81)	0.77	(0.67, 0.88)	1.02	(0.90, 1.16)	0.89	(0.77, 1.02)
Obesity	0.74	(0.62, 0.87)	0.83	(0.70, 0.99)	1.31	(1.11, 1.53)	1.02	(0.86, 1.21)
Attended prenatal classes [ref: ≥7 classes^c]
0 class	0.54	(0.48, 0.60)	0.59	(0.52, 0.67)	2.51	(2.24, 2.82)	1.28	(1.11, 1.47)
1–6 classes	0.82	(0.73, 0.92)	0.84	(0.74, 0.94)	1.38	(1.21, 1.56)	1.13	(0.99, 1.29)
Adherence to the French dietary guidelines [ref: Upper third]^d
Lower third	0.62	(0.55, 0.69)	0.61	(0.54, 0.69)	0.93	(0.83, 1.04)	0.77	(0.68, 0.87)
Middle third	0.83	(0.74, 0.93)	0.84	(0.75, 0.94)	1.00	(0.89, 1.12)	0.91	(0.80, 1.03)
Maternal smoking status [ref: Non-smoker]
Smoker before pregnancy	1.08	(0.96, 1.20)	1.05	(0.94, 1.18)	0.98	(0.88, 1.10)	1.02	(0.90, 1.14)
Smoker during pregnancy	0.90	(0.79, 1.02)	0.95	(0.83, 1.09)	1.35	(1.19, 1.52)	1.11	(0.97, 1.27)
Maternal alcohol consumption during pregnancy [ref: Non-drinker]
Only before knowing being pregnant	1.27	(1.05, 1.54)	1.14	(0.94, 1.39)	0.86	(0.70, 1.06)	1.06	(0.86, 1.31)
Drinker^e	1.21	(1.08, 1.36)	1.18	(1.05, 1.33)	0.95	(0.84, 1.07)	1.00	(0.88, 1.13)
Abbreviations: PA, physical activity. LTPA, leisure-time physical activity. MPA, moderate-intensity physical activity. OR, odds ratio. CI, confidence interval. Ref, reference category. BMI, body mass index. ^aValues are OR and their 95% CI from logistic regression models (1) adjusted for season of birth only; (2) additionally and mutually adjusted for all sociodemographic factors; all with the use of weight for sampling correction. ^bYes included working for wages, as a volunteer or a student, all part- or full-time. ^cFrench recommendations. [REF] ^dTertiles defined using the French Programme National Nutrition Santé (PNNS) score. [REF] ^eDue to the small number of women categorised as regular consumer (“more than once a month”) and the public health message to avoid drinking alcohol during pregnancy, they were regrouped with occasional consumer (“once a month or less”) into a modality of “drinker”.

Looking at maternal health and behavioural characteristic, women who were overweight or obese before pregnancy, attended none or less than 7 prenatal classes, and had a lower adherence to the French dietary guidelines were less likely to meet PA guidelines for LTPA in adjusted analyses. Not attending prenatal preparation classes or having a greater adherence to the French dietary guidelines were associated with having a high MPA level. Obesity prior to pregnancy and smoking during pregnancy were not associated with having a high MPA level after adjustment for sociodemographic characteristics. Alcohol consumption during pregnancy remained significantly associated with meeting PA guidelines for LTPA in the fully adjusted model.

Sensitivity analyses using the unweighted and complete case samples gave broadly similar results and did not affect study conclusions about the key correlates for both outcomes (Supplemental Tables 2 & 3).

Our first aim was to describe PA practices and sedentary behaviour in various life domains in a large and socially diverse sample of French pregnant women, and to provide a national estimate of the proportion of French women reaching the recommended target level of at least 150 min per week of MPA. We found that household/caregiving PA made the greatest contribution (up to 56%) to the total energy expenditure of pregnant women in late pregnancy, whereas LTPA contributed only to 3 to 4%. Similar results have been found in previous studies that assessed PA using the PPAQ, regardless of the pregnancy period (i.e., trimester) analysed.^21,33 Most French pregnant women engaged in some LTPA during the last three months of pregnancy, with walking being the most frequently reported activity, a common finding in studies that examined PA practices during pregnancy.³⁴ Our results also revealed that while LTPA accounted for almost a quarter of overall MPA, activities in the household domain (child and adult care, essentially) represented more than half of it. As a result, the estimated proportion of women meeting PA guidelines varied a lot depending on which moderately intense activities were taken into consideration. We found that only 28% of French pregnant women without contraindication to the practice of PA engaged in at least 150 minutes per week of moderate-intensity LTPA. Adding moderately-intense PA undertaken in other domains (household/caregiving, occupation and transportation) multiplies by three this estimate, with over 85% of women reaching the target level of MPA, which raises question regarding the appropriateness of the 150 min/week threshold for self-reported overall MPA. In the literature, the prevalence of meeting the PA guidelines varies greatly, but estimates are usually below 50%.^16–20,58 These variations may be explained by differences in population and PA measuring tool used, but the way guidelines are interpreted and the precise criteria used to define compliance also have major influence on the estimates.^20,59 Using data from the 2007–2014 NHANES survey for instance,²⁰ it has been estimated that around 23% of U.S. pregnant women engaged in at least 150 minutes of moderate-intensity LTPA during a week (in line with ACOG guidelines). Adding active transportation (walking essentially), the estimate rose to around 40%, which is similar to our findings. However, adding the criteria “on most (5) days”, significantly decreased the proportion of U.S. pregnant women meeting guidelines down to around 13% (whether or not active transport was considered). We were not able to assess whether LTPA practice was regular or not, since the PPAQ asks women to estimate the average time they spent doing exercise/sports over a week. However, most other moderate PA considered are common daily activities, in particular activities in the household domain (child and adult care, essentially) which contribute the largest share of total MPA (women are indeed ask to report the average time per day they spend doing these activities).

Regarding sedentary behaviour, we found that half women spent at least 6.5 hours per day sitting, including 2 hours per day watching television or videos. Here too, it is difficult to compare these results with the literature due to the heterogeneity of tools and threshold definition used. These results are lower than those reported in the studies included in a recent systematic review on sedentary behaviours during pregnancy.³⁸ The one study based on self-reported data reported a mean sitting time of 8.6 hours per day (including 2.4 hours watching television) among Singaporean pregnant women,⁶⁰ while the other studies that used objective measures (e.g., accelerometer-based) reported values between 7.1 and 18.3 hours per day spent in sedentary behaviour. Current “dual” PA/sedentary behaviour guidelines recommend pregnant women to limit the amount of time spent in sedentary behaviour and replace it with PA of any intensity.^12,13,15 Although evidence regarding the detrimental effect of sedentary behaviour during pregnancy is accumulating,³⁸ the above recommendations are essentially extrapolated from evidence in the general population of adults. The current evidence base is insufficient, however, to specify a maximal daily time threshold above which significant adverse health effects are expected.¹⁵

Associated correlates

Single women were more likely to both meet PA guidelines for LTPA and have a high overall MPA level. Younger women and those working during the last three months of pregnancy were more likely to have a high MPA level. Such associations have already been reported in previous studies, although results were mainly inconclusive and studies focused essentially on LTPA.²⁴ We found that primiparity, high maternal educational level and household income were positively associated with LTPA, as already reported in previous reviews.^24,26 However, they were negatively associated with a high MPA level. These results are in line with a recent review questioning the differences in PA across socioeconomic groups,³⁷ and concluding that the positive association between socioeconomic status and PA frequently found in the literature was mainly a relationship between socioeconomic status and LTPA. The results highlight the importance of measuring the different domains of PA. Being aware of these sociodemographic correlates is of upmost importance to target pregnant women less likely to meet PA guidelines for LTPA for whom public health interventions and politics should be prioritized.

Maternal health and behavioural characteristics were more consistently associated with meeting the PA guidelines for LTPA, whereas associations with having a high MPA level were less clear and most of them did not remain significant after adjustment for sociodemographic characteristics. Pregnant women living with overweight or obesity before pregnancy, those doing none or less prenatal preparation classes and those with a low level of adherence to the French dietary guidelines were less likely to meet the PA guidelines for LTPA. In the literature, studies that examined the association between pre-pregnancy weight or BMI and LTPA during pregnancy were generally inconclusive.²⁴ The association between prenatal classes attended and the meeting of PA guidelines may reflect both the daily time available of these women and their greater health literacy. The association between following both PA and dietary guidelines remind us the potential benefits of combined diet and exercise interventions during pregnancy to promote maternal and foetal health.³ Similarly to six out of the seven studies included in the review by Gaston and Cramp,²⁴ which examined the relationship between smoking status and exercise during pregnancy, we did not find any significant association with meeting the PA guidelines for LTPA.

Implications for research and policy

Our study together with others show that activities undertaken in life domain other than leisure-time, in particular household/childcare, significantly contribute to both total and moderate PA throughout pregnancy. Hence, an important issue to consider is whether moderately intense daily life activities provide similar health benefits for mothers and their babies than exercise or recreational PA. Indeed, most of the evidence regarding the health benefits and safety of PA during pregnancy comes from interventional studies that evaluated specific exercise programs corresponding to a standard dose of 150 min per week of moderate-intensity aerobic activities, and on observational studies that focused essentially on LTPA, in contrast to overall MPA.^8,9,11,23 In fact, some observational studies reported no or even adverse associations between occupational and household PA during pregnancy and various pregnancy outcomes (e.g., premature birth, low weight for gestational age) or maternal mental health during pregnancy and the postpartum period. For instance, the systematic review and meta-analysis from Aune et al.⁶¹ on PA and the risk of gestational diabetes mellitus found an association between LTPA and a reduction in the relative risk of gestational diabetes mellitus but no significant association with occupational and household PA during pregnancy. Other studies also suggest that the domain (e.g., household) or context in which the PA takes place could influence the association between PA and mental health during pregnancy or the risk of postpartum depression.^7,62 Further research are needed on the health impact of various volumes and intensity of PA that are performed within different domains to inform the development of future guidelines.^1,63

The review of Fazzi et al.³⁸ highlighted the significant time spent in sedentary behaviour during pregnancy. Our results based on a large and diversified sample confirm that pregnant women spend an important part of the day in sedentary (sitting) activities, whether at home (e.g., watching TV or videos) or in other contexts (at work, in transport). Thus, research exploring sedentary behaviour patterns during pregnancy and their potential impact on maternal and foetal health should continue to grow so that more precise recommendations can be made to pregnant women regarding sedentary behaviours.^15,38,63 Interventions aimed at reducing sedentary behaviour may be a complementary way worth exploring to improve maternal health during pregnancy as well as pregnancy outcomes.

Strengths and limitations of the study

The main strengths of this study are its large, nationally representative sample of > 14,000 pregnant women,³⁹ the standardized collection of sociodemographic, health and behavioural characteristics, and the measurement of PA using a validated and widely used tool.^28,35 Although the PPAQ is a self-reported tool which might be subject to recall bias in comparison to objective measurements such as accelerometer,^17,29,35,64 the PPAQ is one of the few validated questionnaires designed specifically to assess PA among pregnant women. In a recent systematic review comparing the measurement properties of all self-administered questionnaires assessing PA in pregnancy, the authors considered that the French version of the PPAQ had both sufficient reliability and construct validity, and recommended it to assess PA in pregnancy.²⁸ In addition, this tool makes it possible to analyse different domains of PA, what we found to vary considerably the estimation of prevalence of women meeting the PA guidelines, as well as the associated correlates. Unfortunately, we did not have information on the evolution of PA before and throughout pregnancy, while the level of PA has been shown to reduce for the start and during pregnancy.^{17,18,24,32–34} However, the estimation of the proportion of women meeting the minimum threshold does not seem to vary widely between trimester,^{20,33,58,59,65} and the PA guidelines are valid for all the pregnancy period.^8–11,23 Furthermore, the PPAQ asks a weekly duration for the different activities and does not take into consideration the frequency of practice (e.g., 5 times 30 minutes per week) which is a key element of most guidelines,^8–11,23 and usually leads to a lower proportion of women meeting the PA guidelines.²⁰ Although recruitment already date from 2011, the main French population survey with information on PA did not report major changes on PA level in the last decades.^66,67 On the other hand, an additional strength was the possibility to identify women with an absolute medical contraindication to PA for whom practicing exercise during pregnancy is not recommended,^8,10,44,50 and thus having results taking into consideration the clinical context. Last, we used a sampling weight to account for selection bias,^39,55 making our findings generalizable to the French population of pregnant women.

Although most pregnant women reported engaging in LTPA during the last three months of pregnancy, only 28.0% met the PA guidelines of at least 150 minutes per week of moderate-intensity LTPA, illustrating the importance of promoting LTPA and limit SB during pregnancy. Correlates associated with meeting the PA guidelines for LTPA differ to those associated with having a high overall MPA level. These results provide a basis for improving the identification of women less likely to meet PA guidelines but also suggest that PA domains should always be distinguished when studying PA during pregnancy. Last, they call for the clarification of the PA guidelines regarding the balance between all activities.

ACOG, American College of Obstetricians and Gynaecologist

BMI, Body mass index

CI, Confidence interval

ELFE, Etude Longitudinale Française depuis l’Enfance

ISCED, International Standard Classification of Education

IQR, Interquartile range

LTPA, Leisure-time physical activity

MET, Metabolic equivalent of task

MPA, Moderate-intensity physical activity

NHANES, National Health and Nutrition Examination Survey

OR, Odds ratio

PA, Physical activity

PNNS, Programme National Nutrition Santé

PPAQ, Pregnancy Physical Activity Questionnaire

SD, Standard deviation

WHO, World Health Organisation

Ethical approval and consent to participate

The ELFE study received ethical approvals for data collection in maternity units and for each data collection wave during follow-up from the national advisory committee on information processing in health research (CCTIRS: Comité Consultatif sur le Traitement des Informations pour la Recherche et la Santé), the national data protection authority (CNIL: Commission Nationale Informatique et Liberté), and the committee for protection of persons engaged in research (CPP: Comité de Protection des Personnes). The ELFE study was also approved by the national committee for statistical information (CNIS: Conseil National de l’Information Statistique).

Consent for publication

Not applicable.

All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Availability of data and materials

The ELFE has an open-data policy after an 18-month exclusivity period for the ELFE-associated research teams following each release of new data. Study protocols, questionnaires and the data catalogue can be found online. Data access requests can also be submitted via the data access platform for approval by the ELFE data-access committee. All proposals must comply with the ELFE data-access policy that can be downloaded from the data-access platform.

Competing interests

J.Y.B. is a member of the Editorial Board of International Journal of Behavioral Nutrition and Physical Activity. J.Y.B. was not involved in the journal’s peer review process of, or decisions related to, this manuscript.

A.M.A., M-A.C., B.H., and P.D-M. have no conflicts of interest relevant to this article to disclose.

Funding

The ELFE cohort is a joint project between the French Institute for Demographic Studies (INED) and the National Institute of Health and Medical Research (INSERM), in partnership with the French blood transfusion service (Etablissement Français du Sang, EFS), Santé publique France, the National Institute for Statistics and Economic Studies (INSEE), the Direction Générale de la Santé (DGS, part of the Ministry of Health and Social Affairs), the Direction Générale de la Prévention des Risques (DGPR, Ministry for the Environment), the Direction de la Recherche, des Etudes, de l’Evaluation et des Statistiques (DREES, Ministry of Health and Social Affairs), the Département des Etudes, de la Prospective et des Statistiques (DEPS, Ministry of Culture), and the Caisse Nationale des Allocations Familiales (CNAF), with the support of the Ministry of Higher Education and Research and the Institut national de la Jeunesse et de l’Education Populaire (INJEP). The ELFE cohort receives a government grant managed by the National Research Agency under the “Investissements d’avenir” programme (ANR-11-EQPX-0038, ANR-19-COHO-0001).

The funders/sponsors did not participate in the work.

A.M.A., M-A.C., B.H., J.Y.B., and P.D-M. have no financial disclosures.

Authors' contributions

A.M.A. carried out the statistical analyses, drafted the initial manuscript, and revised the manuscript.

J.Y.B. and P.D-M. conceptualized and designed the present study, supervised the statistical analyses, and reviewed the manuscript.

M-A.C. and B.H. participated in data collection and curation and critically reviewed the manuscript for important intellectual content.

M-A.C., B.H., and P.D-M. designed the cohort.

Acknowledgements:

We are grateful to: (i) the former members of the ELFE unit, without whom the project would never have started: Henri Léridon, initiator and former PI of the project, Stéphanie Vandentorren, Claudine Pirus and Ando Rakotonirina; (ii) for their expertise and assistance, members of the unit for support functions, notably: Catherine Guevel, Sophie de Visme, Laure Gravier, Meryem Zoubiri, Hélène Juillard, Cédric Ricourt and Adriana Candea; (iii) all the researchers who contribute to the projects as members of the ELFE thematic groups and particularly their coordinators; (iv) all the field research assistants and interviewers; and (v) above all, all the ELFE families who have placed their confidence in us and given up their time to the study.

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No competing interests reported.

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Physical activity and its correlates among pregnant women from the French national cohort ELFE

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Version 1

Abstract

Figures

Introduction

Methods

Study Design and Participants

Measure of PA and sedentary behaviour

Potential correlates

Statistical analyses

Results

PA and sedentary behaviour during late pregnancy

Proportion of pregnant women meeting PA guidelines

Correlates of meeting PA guidelines for LTPA and of having a high MPA level

Discussion

Associated correlates

Implications for research and policy

Strengths and limitations of the study

Conclusions

Abbreviations

Declarations

Ethical approval and consent to participate

References

Additional Declarations

Supplementary Files

Status:

Version 1