Call to Action for Promoting Exercise Is Medicine in Pregnancy—Collaboration Is Key

INTRODUCTION Physical activity during pregnancy elicits several biopsychosocial health benefits for both the mother and developing fetus, including reducing the risk for perinatal complications (e.g., gestational diabetes) (1), improving mental health outcomes (2), and preventing downstream chronic diseases such as childhood obesity (3). Accordingly, international recommendations for prenatal physical activity indicate that pregnant individuals without contraindications for being active should strive for 150 min of moderate-intensity activity per week (4). Problematically, less than 20% of pregnant individuals adhere to physical activity recommendations, and activity levels decrease as gestation progresses (5). As such, physical inactivity is a highly prevalent, but modifiable, risk factor for perinatal complications (5). Several studies have aimed to identify key facilitators of prenatal physical activity adherence (6,7). For example, studies have shown that offering pregnant individuals affordable supervised exercise programs facilitates adherence to guidelines by increasing social support and self-efficacy to be active by reducing safety related concerns (7). Applying a socioecological framework, a majority of identified facilitators for prenatal physical activity center around interpersonal and intrapersonal factors (7). Importantly, for population-level sustained behavior change, it is important to consider higher levels of engagement, such as community and policy-based strategies. One such strategy may be the integration of prenatal physical activity prescription, counseling, and referral into primary care. EXERCISE IS MEDICINE IN PREGNANCY In line with the Exercise is Medicine initiative, this commentary calls to action the integration of prenatal physical activity prescription, counseling, and referral into primary care. Most pregnant individuals have a maternal healthcare provider (e.g., obstetrician/gynecologist, midwife, family physician, nurse practitioner) who monitors their pregnancy and fetal development (8). For approximately 40 wk, maternal healthcare providers become a critical support system for pregnant individuals, not only to manage the physical health of the mother and developing fetus but also to provide care for maternal mental and emotional health. Prenatal appointments include critical assessments through the gestational period, such as gestational diabetes screening and gestational weight monitoring. Notably, pregnancy is often described as a teachable moment when there is opportunity for health behavior change intervention and greater communication with healthcare systems (9). As such, maternal healthcare providers are well positioned to close the knowledge gap by offering physical–activity–related support during their appointments. Exercise is Medicine is a global initiative that promotes the inclusion of exercise prescription, counseling, and referral into primary care with the idea that all individuals who seek healthcare will then receive integral physical–activity–related information and support (10). Translating this to pregnancy, maternal healthcare providers should integrate physical activity discussions into prenatal care appointments. Importantly, physical activity in pregnancy is an effective resource to mitigate complication risks and improve maternal physical and mental health. For example, a systematic review and meta-analysis noted that 150 min of moderate-intensity activity per week was associated with reduced risk of prenatal depression, gestational diabetes, gestational hypertension, and preeclampsia, complications that could have long-term implications for maternal and fetal health (1,2). Given that pregnant people rely on health professionals for recommendations and advice for a safe pregnancy, the knowledge gap on the benefits of physical activity and how to perform physical activity in pregnancy may be closed by maternal healthcare providers. Research related to Exercise is Medicine and health promotion initiatives have included developing training resources for healthcare providers to assess physical activity vital signs and offering prescriptions by means of guidelines and referrals to exercise professionals. Studies that have assessed whether this initiative does indeed lead to increased inclusion of physical activity in clinical interactions have shown positive results. For example, O’Brien et al. (11) tested the effect of educational exercise workshops with physicians with varying degrees of physical activity competence and confidence to prescribe exercise. The workshop included training on assessing physical activity vital signs, communication strategies for discussing physical activity with patients, and referrals to resources and personal (11). Findings showed that confidence for integrating physical activity into their practice significantly increased, and at the 3-month follow-up, the majority of participants reported a significant increase in writing and discussing physical activity prescriptions and referrals (11). Importantly, receiving physical activity guidance from a health professional is directly related to behavioral outcomes in the patient as well (12). For example, a scoping review evaluating exercise referral schemes noted that participants who received a referral reported greater participation in physical activity and improved markers of aerobic fitness (12). Therefore, this may be a promising pathway to facilitate greater adherence to prenatal physical activity. As such, we recommend knowledge translation efforts for prenatal physical activity focus on training maternal healthcare providers to integrate physical activity into primary care and promoting a collaborative approach with exercise professionals and researchers. A recent scoping review examined barriers and facilitators from the provider’s perspective on integrating prenatal exercise into their appointments (13). Findings highlighted that the majority of healthcare professionals agreed that prenatal exercise is important and should be discussed with their patients; however, most also indicated not providing specific recommendations (i.e., specific to guidelines) and seldom offering referrals (13). When assessing key barriers, maternal healthcare providers indicate that they lack time, sufficient knowledge, and resources to prescribe or refer prenatal physical activity. In fact, a qualitative study that examined facilitators of prenatal exercise prescription found that providers want more knowledge on both how to and what to prescribe or refer to their patients (14). Accordingly, we propose a collaborative approach utilizing the Exercise is Medicine model to encourage inclusion or prenatal physical activity in healthcare. PROPOSING A COLLABORATIVE APPROACH By integrating exercise prescription, counseling, and referral into primary care, pregnant individuals will receive this important information during their prenatal visits. Moving forward, it is critical to integrate exercise prescription, counseling, and referral practices into continuing education opportunities for maternal healthcare providers. Training for providers should include improving prescription practices, such as taking a person-oriented approach to understanding exercise goals, current behaviors, barriers, and facilitators (15). This can be done by integrating communication practices into continuing education, such as motivational interviewing, which includes strengthening the patient–provider relationship and facilitating health behavior change by positioning the patient as the driver of their own health and the provider as a resource for support (including prescriptions and/or referrals) (15). Next, it is necessary for exercise professionals and researchers to work with healthcare providers to establish a repertoire of community-based referral schemes and identify supervised programs or physical activity resources that a pregnant individual may benefit from. Initiatives like Exercise is Medicine can assist with this knowledge translation and implementation effort by developing and disseminating prenatal exercise resources, developing and testing training opportunities for maternal healthcare providers, and bridging medical professionals and exercise researchers and professionals for referrals and further support. Indeed, lack of awareness or access to qualified exercise professionals can be a barrier to implementing such a collaborative model. As such, we recommend equipping the provider with resources and knowledge to prescribe and support exercise (e.g., motivational interviewing practices and knowledge of guidelines), and community support for referrals to qualified exercise professionals. In doing so, key barriers identified by providers, including lack of time, knowledge, and specific resources, can be addressed (13). Together, we can effectively promote prenatal physical activity through primary care and offer resources and support options though collaboration. Directions for future research include developing a richer understanding of needs and barriers to effective knowledge translation. Namely, healthcare professional knowledge of guidelines and people to refer to is important, but we also need to investigate individual barriers to translating that knowledge to practice (e.g., self-efficacy to prescribe or discuss guidelines). Other examples may include provider biases or assumptions for prescribing or referring physical activity, such as safety concerns. Future research could investigate the needs of providers specifically, which may vary by community; therefore, a targeted approach to addressing barriers and leveraging facilitators to promote collaboration with healthcare and exercise professionals should be sought.

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