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- Materials and methods
Objective: Limited prevalence data for unhealthy pregnancy health behaviours make it difficult to prioritise primary prevention efforts for maternal and infant health. This study's objective was to establish the prevalence of cigarette smoking, sufficient fruit and vegetable intake and sufficient physical activity among women accessing antenatal clinics in a Queensland (Australia) health service district.
Method: Cross-sectional self-reported smoking status, daily fruit and vegetable intake, weekly physical activity and a range of socio-demographic variables were obtained from women recruited at their initial antenatal clinic visit, over a three-month recruitment phase during 2007.
Results: Analyses were based on 262 pregnant women. The study sample was broadly representative of women giving birth in the district and state, with higher representation of women with low levels of education and high income. More than one quarter of women were smoking. Few women met the guidelines for sufficient fruit (9.2%), vegetables (2.7%) or physical activity (32.8%) during pregnancy.
Conclusions: There were low levels of adherence to health behaviour recommendations for pregnancy in this sample.
Implications: There is a clear need to develop and evaluate effective pregnancy behaviour interventions to improve primary prevention in maternal and infant health. Brief minimal contact interventions that can be delivered through primary care to create a greater primary prevention focus for maternal and infant health would be worth exploring.
Health behaviours during pregnancy are associated with pregnancy-related and long-term health outcomes for both the mother and infant. Cigarette smoking,1 poor nutrition,2 insufficient levels of physical activity,3 and inappropriate weight gain4 during pregnancy have been associated with a number of poor maternal and infant outcomes. These outcomes include an increased risk of: pregnancy complications,5 caesarean sections,4 low birth weight,1 pre-term birth,4,6 inappropriate weight gain during pregnancy7 and chronic disease in adult life.2,8 Adherence to health behaviour recommendations during pregnancy has been shown to decrease the risk of gestational diabetes mellitus,9 attenuate pregnancy symptoms10 and improve mental health.11,12 Poor pregnancy health behaviours and associated maternal and infant health outcomes have been linked with increased costs of health care delivery through longer hospital admissions and intensive care admissions4,13,14 and greater childhood health care costs.15 Understanding the prevalence of these behaviours is important for health promotion and service planning.
Abstinence from cigarette smoking is recommended during the entire gestational period and there are demonstrated benefits of cessation at any stage of pregnancy.16 Abstinence from cigarette smoking during pregnancy decreases the risk of low birth weight and preterm birth.16 Between 10% and 25% of women give up smoking when they are planning a family or become pregnant,17 but available data indicate that between 12% and 40 % smoke during pregnancy.18
The recommended diet for pregnancy follows the national dietary guidelines. The recommended fruit intake increases from two to four serves during pregnancy.19 In addition, five serves of vegetables per day are recommended during pregnancy.19 Minimal population consumption data are available for fruit and vegetable intake during pregnancy. Moreover, national intake data indicate a low prevalence of recommended consumption of fruit and vegetables in non-pregnant women.20 Therefore, with increased requirements in pregnancy, it is likely that the proportion of women meeting these guidelines is even lower than in the general population.
Moderate exercise for at least half an hour on most, if not all, days is recommended during pregnancy,21 mirroring physical activity guidelines for the general population.22 These guidelines also recommend previously inactive women become active during their pregnancy.23 No Australian data exist for activity levels during pregnancy, however, we know that approximately 50% of non-pregnant women meet physical activity guidelines23 and that pregnancy represents a life stage in which women decrease their physical activity levels.24,25 Thus, it is likely that the prevalence of pregnant women meeting physical activity recommendations is lower than that of the non-pregnant population.
To date, we have limited data on the prevalence of pregnant women's consumption of fruit and vegetables and levels of physical activity. Importantly, no previous studies have collected data on all the health behaviours identified above with regard to their impact on maternal and infant health outcomes in pregnant populations. The lack of data on the prevalence of pregnancy health behaviours make it difficult to establish the need for and to prioritise further primary prevention efforts, or to set targets for healthy pregnancy behaviours at the population level. This study addressed these gaps and aimed to establish the prevalence of cigarette smoking, sufficient fruit and vegetable intake, and sufficient physical activity among women accessing antenatal clinics in a South-East Queensland health service district (HSD).
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- Materials and methods
This study aimed to establish the prevalence of health behaviours known to influence maternal and infant pregnancy outcomes among women accessing antenatal clinics in a South-East Queensland HSD. To our knowledge, no other paper has reported the prevalence of these health behaviours simultaneously or compared behaviours with population guidelines. Poor adherence to recommended guidelines for smoking cessation, fruit and vegetable intake, and physical activity behaviours was observed.
The prevalence of cigarette smoking in this study is above the state estimate,36 but is similar to that documented in other studies.18,40 Proportions of women consuming sufficient serves of fruit and vegetables were significantly lower than those in the last reported population intake data.41 A smaller proportion of women were sufficiently physically active compared with the national average for non-pregnant women.23
Given the strong evidence for the role of health behaviours during pregnancy on maternal and infant health, low levels of adherence to public health recommendations for these behaviours are of concern. Continued smoking remains a public health concern requiring effective smoking cessation interventions for pregnant women. The intake of sufficient fruit and vegetables has been proposed as the most important public health message for the decrease of chronic disease.42 Thus, the low prevalence of women meeting the dietary guidelines warrants further attention. There also exists an urgent need to identify and address the barriers to women undertaking sufficient physical activity during pregnancy.
More than 40% of women in this study were overweight or obese at the beginning of pregnancy. Overweight and obesity in pregnancy is associated with an increased risk of maternal and infant health complications.4 Evidence also suggests that awareness of weight gain guidelines may influence pregnancy weight gain. Cogswell et al. (1999) demonstrated that women advised to gain less or more than the Institute of Medicine weight gain guidelines were 3.6 times more likely to report actual gains below or above recommendations, compared with women advised to gain within the guidelines.43 Women not advised about weight gain were more likely to gain weight outside the recommended weight gain range.43 It is important that all pregnant women have knowledge of pregnancy weight gain guidelines.
Our recruitment rate was similar to other epidemiological studies that attempt to estimate population prevalence of health behaviours,25,44 and as expected given our method of recruitment45 via antenatal clinic staff, rather than dedicated research staff. However, we may have had more than acceptable error in our estimation of prevalence of sufficient fruit intake and sufficient physical activity with our sample size. We did not collect pregnancy history information or demographic details about women who were approached but did not consent to participate. This procedure would have provided a richer picture of our study participants. However, the demographics of our study sample demonstrate fair representativeness of young women and women with lower levels of education, despite documented difficulties in the engagement of these groups in research more generally46 and their less regular use of antenatal services.47,48 We still had a lower representativeness of women from lower income households, but given what we know about the associations between socio-economic status and healthy behaviours,40,49,50,51 such sampling bias would only have resulted in an underestimate of the actual size of the problem. Nevertheless, this does limit the generalisability of the results beyond the sample population and points to a continued need for future studies to focus on recruiting marginalised groups.
A strength of the study is the use of CATI to circumvent literacy issues that may be apparent in written self-report studies.45,52 Additionally, the collection of data regarding a suite of health behaviours at the start of pregnancy is the first reported study of this kind. The use of self-report measures also introduces potential biases. Objective measures of all behaviours may have strengthened findings. The tools selected were valid, reliable and suitable for telephone delivery.53,54
These results suggest three important avenues for investigation and effective practice changes that can be implemented. First, as data have not previously been collected regarding these health behaviours during pregnancy, tracking of behaviour change throughout pregnancy is recommended. Second, research investigating patterns of occurrence of multiple risk factors for unhealthy behaviours, particularly stratification according to socio-demographic and other health behaviours would provide more information for planning interventions. Finally, there is a need to support women who face greater barriers to meeting health recommendations. Structuring health services to allow systematic delivery of support and services to women in this environment would be one avenue to reach women at a time in which the majority of them are in contact with the health service.55 Positioning pregnancy care in accessible community locations to enable greater service utilisation and accessibility is recommended.56