Weight Control/Pregnancy

American Journal of Health Promotion

1-7
Aquatic Activities During Pregnancy ª The Author(s) 2017
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Prevent Excessive Maternal Weight Gain DOI: 10.1177/0890117117697520
journals.sagepub.com/home/ahp
and Preserve Birth Weight: A Randomized
Clinical Trial

Mariano Bacchi, MSc1, Michelle F. Mottola, PhD, FACSM2,3, Maria Perales, PhD4,5,
Ignacio Refoyo, PhD6, and Ruben Barakat, PhD6

Abstract
Purpose: The aim of the present study was to examine the influence of a supervised and regular program of aquatic activities
throughout gestation on maternal weight gain and birth weight.
Design: A randomized clinical trial.
Setting: Instituto de Obstetricia, Ginecologı́a y Fertilidad Ghisoni (Buenos Aires, Argentina).
Participants: One hundred eleven pregnant women were analyzed (31.6 + 3.8 years). All women had uncomplicated and
singleton pregnancies; 49 were allocated to the exercise group (EG) and 62 to the control group (CG).
Intervention: The intervention program consisted of 3 weekly sessions of aerobic and resistance aquatic activities from weeks
10 to 12 until weeks 38 to 39 of gestation.
Measures: Maternal weight gain, birth weight, and other maternal and fetal outcomes were obtained by hospital records.
Analysis: Student unpaired t test and w2 test were used; P values .05 indicated statistical significance. Cohen’s d was used to
determinate the effect size.
Results: There was a higher percentage of women with excessive maternal weight gain in the CG (45.2%; n ¼ 28) than in the EG
(24.5%; n ¼ 12; odds ratio ¼ 0.39; 95% confidence interval: 0.17-0.89; P ¼ .02). Birth weight and other pregnancy outcomes
showed no differences between groups.
Conclusion: Three weekly sessions of water activities throughout pregnancy prevents excessive maternal weight gain and
preserves birth weight.
Trial Registration: The clinicaltrial.gov identifier: NCT 02602106.

Keywords
pregnancy, aquatic exercise, maternal weight gain, birth weight

A sedentary lifestyle and poor eating habits have been linked to

metabolic, cardiovascular, and psychological diseases.1 These
diseases are suggested comorbidities to obesity with increasing 1
Faculty of Physical Activity and Sport, Flores University, Argentine
prevalence in childhood.2-4 Physical exercise may stop the ris- 2
R. Samuel McLaughlin Foundation–Exercise & Pregnancy Laboratory, School
ing trend of childhood obesity and its comorbidities.5 of Kinesiology, Faculty of Health Sciences, University of Western Ontario,
Developmental Origins of Health and Disease starts during London, Canada
3
pregnancy, and an adverse intrauterine environment could be a Department of Anatomy & Cell Biology, Schulich School of Medicine &
Dentistry, Children’s Health Research Institute, University of Western
precursor for the development of future complications later in Ontario, London, Canada
life.6 Pregnancy modifies all systems in order to ensure ade- 4
Research Institute of Hospital 12 de Octubre (“iþ12”), Madrid, Spain
5
quate fetal growth and development creating constant adjust- Camilo José Cela University, Madrid, Spain
6
ments and adaptations to the woman throughout gestation.7 AFIPE Research Group, Technical University of Madrid, Spain
One of the most important adaptations from a metabolic point
Corresponding Author:
of view is the increasing insulin resistance that may progress to Ruben Barakat, AFIPE Research Group, Technical University of Madrid, Martin
gestational diabetes mainly due to an inadequate diet and lack Fierro 7 (28040), Madrid, Spain.
of physical exercise. 8,9 The scientific literature provides Email: barakatruben@gmail.com
2 American Journal of Health Promotion XX(X)

positive benefits for moderate and regular exercise during preg-

nancy to improve maternal and fetal well-being.10 Enrollment Assessed for eligibility (n=184)

Over the past 20 years, the influence of exercise on maternal

Excluded (n=44)
and fetal outcomes has been studied with interesting results.
Not meeting inclusion criteria (n=25)
Exercise has been shown to have a positive influence on the
Declined to participate (n= 17)
process of pregnancy and childbirth.11-13 Maternal weight gain Other reasons (n=2)
and birth weight have been examined by researchers in recent
studies that report many beneficial effects of moderate exercise Randomized (n= 140)

during pregnancy.5,14,15 Prevention of excessive gestational

weight gain and appropriate birth weight is a proxy for a Allocation
healthy fetal environment.10 Babies born large (macrosomic
>4000 g) or small (<2500 g) are at risk for obesity and chronic Allocated to intervention (n= 70, exercise) Allocated to control(n= 70, control)
disease later in life.6
Many forms of exercise modalities are presented in inter- Follow-Up
vention studies with a wide variety of designs and variations.
Although most studies are based on land exercises, some stud- Lost to follow-up (n= 21) Lost to follow-up (n=8)
ies have used a “swimming” intervention, 16,17 “aquatic Discontinued intervention (n=7) Pregnancy-induced hypertension (n = 1)
activities” or “water aerobics,”18-24 and an “immersion” exer- Risk for premature labour (n = 5) Risk for premature labour (n = 2)
cise session.25-27 Kamioka et al28 reviewed the effects of aqua- Diagnosed incompetent cervix (n = 4) Personal reasons (n = 5)
tic exercise and concluded that there is insufficient evidence to Personal reasons (n = 5)
report benefits for aquatic exercise due to poor methodological
Analysis
and reporting quality and heterogeneity of nonrandomized clin-
ical trials. Analysed (n=49) Analysed (n=62)
The aquatic environment generates many alternatives that Excluded from analysis (n=0) Excluded from analysis (n=0)
are usually not available to pregnant women using land-based
exercise. Women participating in an aquatic exercise program
Figure 1. CONSORT 2010 flow diagram of the study participants.
report significantly less physical discomfort, improved mobi-
lity, and improved body image and health-promoting
behaviors.21 Buoyancy creates a feeling of physical comfort, Sample
improves mobility and postural balance, and facilitates the use
of different muscle groups, which, in turn, decreases postexer- We contacted a total of 184 pregnant women from a primary
cise pain.29 Therefore, there are several advantages to water care obstetric medical center (Instituto de Obstetricia, Gineco-
exercise, particularly in pregnancy.30 logı́a y Fertilidad Ghisoni, Buenos Aires, Argentina; Figure 1).
We believe that new studies are necessary and alternative The study participants were recruited by nurses during the first
forms of exercise using the aquatic environment during preg- prenatal visit. Women were included if they had singleton and
nancy are needed to promote healthy pregnancies. Indeed to uncomplicated pregnancies. For practical reasons, women not
better understand whether regular and supervised aquatic exer- planning to give birth in the same obstetric center and not under
cise can be used to promote maternal and fetal well-being is of medical follow-up throughout the entire pregnancy period were
clinical relevance and of public health interest. not included in the study. In addition, women were not included
The aim of the present study was to examine the influence of if they had medical conditions that prevented them from exer-
a supervised and regular program of aquatic activities through- cising safely31 such as:
out gestation on maternal weight gain and birth weight. We
 heart disease,
hypothesized that excessive maternal weight gain would be
 thrombophlebitis,
prevented, with more babies born with adequate weight in the
 pulmonary embolism,
intervention group compared to the control women.
 cervical incompetence,
 multiple pregnancy,
 vaginal bleeding,
Materials and Methods  premature leakage of membranes,
Design  intrauterine growth restriction,
 preeclampsia,
The present randomized clinical trial (RCT Registration:
 risk of premature labor, and
NCT02602106) was conducted between March 2013 and May
 prepregnant type 1 or 2 diabetes mellitus.
2015 following the ethical guidelines of the Declaration of
Helsinki, last modified in 2000. The research protocol was
reviewed and approved by the ethical committee of Universi- Type of randomization. A simple randomization process was used
dad de Flores, and all women gave written informed consent. to allocate the study participants. Regarding prerandomization
Bacchi et al. 3

evaluation, exclusion criteria were applied based on the clinical Table 1. Maternal Characteristics.a
history of the all pregnant women and the first prenatal consult
Variables EG (n ¼ 49) CG (n ¼ 62) P
to identify contraindications for performing physical exercise.
A computer-generated list of random numbers was used to Age, years 30.4 + 4 31.0 + 5 .57
allocate the participants into the 2 study groups (1:1 ratio) BMI 23.1 + 3.2 24.0 + 4 .10
according to admission order and following the randomization Prepregnancy BMI, n (%)
list. To guarantee the concealment for the randomization <18 1 (2) 2 (3.2) .87
18-24.9 32 (65.3) 36 (58.1)
procedure, each sequential number corresponded to a sealed
25-29.9 13 (26.5) 19 (30.6)
opaque envelope containing information about the study group >30 3 (6.1) 5 (8.1)
(exercise or control). Blinding of the study to the randomization Parity, n (%)
arm was impossible due to the characteristics of intervention No previous gestation 39 (79.6) 44 (71) .57
program (physical exercise). One previous gestation 8 (16.3) 15 (24.2)
The randomization blinded process (sequence generation, Two or more previous gestations 2 (4.1) 3 (4.8)
allocation concealment, and implementation) was performed Smoking during pregnancy, n (%)
No 46 (94) 57 (92) .54
by 3 different authors. The treatment allocation system was set
Yes 3 (6) 5 (8)
up so that the researcher who was in charge of randomly assign- Occupation, n (%)
ing participants to each group did not know in advance which Housewife 15 (30.6) 20 (32.3) .78
treatment the next person would receive, a process termed Sedentary job 13 (26.5) 13 (21)
“allocation concealment.” Allocation concealment prevents Active job 21 (42.9) 29 (46.8)
researchers from (unconsciously or otherwise) influencing Previous miscarriage, n (%)
which participants are assigned to a given intervention group. None 37 (75.5) 45 (72.6) .91
One 11 (22.4) 16 (25.8)
The women randomly allocated to the control group (CG;
Two or more 1 (2) 1 (1.6)
n ¼ 70) received standard care from health professionals, and Previous low birth weight, n (%)
when asked by telephone interviews, they reported no regular No 49 (100) 61 (98.4) .37
exercise during their pregnancies. Women who were randomly Yes 0 (0) 1 (1.6)
allocated to the exercise group (EG; n ¼ 70) received similar Previous preterm labor, n (%)
standard care and participated in a specific aquatic activities No 47 (95.9) 58 (93.5) .58
program. Women were excluded if they did not conform to the Yes 2 (4.1) 4 (6.5)
specifications of the allotted group. Abbreviations: BMI, body mass index at the beginning of the study; CG, control
group; EG, exercise group; SD, standard deviation.
a
Data are expressed as mean (SD), unless otherwise indicated. We analyzed
continuous and nominal data with the Student t test for unpaired data and the
Measures w2 test, respectively.

Characteristics of women in both groups were recorded at the

first prenatal visit (Table 1). Total maternal weight gain (kg),
birth weight (g), and other maternal and fetal outcomes were
obtained from hospital records.
Body mass index (BMI) was calculated as weight in kilo-
grams divided by the square of height in meters, and women
were classified as underweight (BMI < 18.5 kg/m2), normal
weight (BMI  18.5-24.9 kg/m2), overweight (BMI  25-
29.9 kg/m2), or obese (BMI  30.0 kg/m2).
Primary outcomes. Total maternal weight gain during pregnancy
(kg) and birth weight (g) were considered as primary outcomes.
Gestational weight gain was calculated by the subtraction of
weight measured at the first prenatal visit (representing preg-
ravid weight) from weight measured at the last visit to the clinic
before delivery. Gestational weight gain was classified as
“adequate” or “excessive” according to the 2009 Institute of
Medicine guidelines.32 Recommended weight gains for under-
weight, normal-weight, overweight, and obese women are 12.5
to 18 kg, 11.5 to 16 kg, 7 to 11.5 kg, and 5 to 9 kg, respectively.
Newborns were classified as having low birth weight or macro-
somia when birth weight was less than 2500 g and greater than
4000 g, respectively.33
Secondary outcomes. Gestational age (days), maternal blood
pressure, infant length, head circumference, and Apgar scores
were also recorded from medical records and analyzed.
Intervention
The exercise intervention program started at 8 to 11 weeks’
gestation and finished at 38 to 39 weeks’ gestation. The women
exercised for an average of 25.8 + 3.3 weeks, and a total of 85
sessions were planned for each participant. The women who
did not meet the minimum required attendance of 80% of the
sessions were excluded from the statistical analysis.
The exercise program was designed following the American
College of Obstetricians and Gynecologists (ACOG) guide-
lines31 to ensure safety and effectiveness. The exercise inten-
sity was light to moderate according to Borg rating of perceived
exertion scale34 and ranged from 10 of 11 (“fairly light”) to 12
of 14 (representing “somewhat hard”).
The exercise program was performed in a swimming pool of
different depths, depending on the type of exercise, 3 times per
week on alternate days. Each session lasted between 55 and 60 min-
utes. All sessions were supervised by a qualified fitness specialist.
4 American Journal of Health Promotion XX(X)
The structure of the exercise was the same in all of the
sessions; the women started with a gradual warm-up that con-
sisted of 8 to 10 minutes of walking at different intensities,
static stretching of most muscle groups, and joint mobility
exercises in the shallow area of the swimming pool.
The central part of the work was divided between:
(A) aerobic exercises or dance (accompanied by music);
(B) strength exercises and aquatic activities (propulsion
exercises) in standing, supine, and ventral positions
for 15 to 18 minutes; and
(C) swimming lengths of the pool using all styles except
butterfly for 8 to 10 minutes. Finally, a cooldown was
performed for 10 to 12 minutes at the end of each
session, including static stretching, relaxing, breath-
ing, and flotation exercises.
Aquatic materials like foam rubber balls of differing sizes
and swimming accessories such as floats, pull boys (buoyancy
aiding devices), water noodles, armbands, and rubber rings
were used. Swimming mitts were also provided for muscle
conditioning and floating weights for resistance movement.
Water temperature was 28.5 C to 29 C.
Statistical Analysis
We made power calculations for the primary outcome mea-
sures of excessive maternal weight gain considering a preva-
lence of *35% in the usual care group using previous studies
conducted in the same population5 and assuming a reduction of
25% in the intervention group. Under these assumptions, a
2-sample comparison (w2) with a 5% level of significance and
a statistical power of 0.80 gave a study population of *43
patients in each group. Assuming a maximum lost to follow-
up of 10%, 47 women were needed for each group
at baseline.35
For treatment group comparisons, we analyzed continuous
and nominal data with Student t test for unpaired data and w2
tests, respectively. Data are shown as mean (standard deviation),
and P values .05 indicated statistical significance. Cohen’s d
was used to determine the effect size in the mean comparisons
and contingency coefficient in percentage comparisons. An
effect size ranging from 0 to 0.20 was considered a small effect
size, 0.20 to 0.50 was a moderate effect size, and >0.5 was a
large effect size.36 The odds ratio (OR) was used to calculate
the effect of intervention on the likelihood of having excessive
maternal weight gain. We conducted all statistical analyses
using the Statistical Package for Social Sciences (version
18.0 for WINDOWS; SPSS Inc, Chicago, Illinois), and the
level of significance was set to .05.
Results
A total of 184 pregnant women were contacted at their first
prenatal visit. Forty-four participants were excluded: 25 did not
meet the inclusion criteria,24 17 declined to participate, and 2
for personal reasons, leaving 140 healthy women randomized
into 1 of the 2 groups. Twenty-one women in the EG were lost
to follow up or excluded because of discontinued intervention
(n ¼ 7), risk of premature labor (n ¼ 5), incompetent cervix
(n ¼ 4), and personal reasons (n ¼ 5). A total of 8 participants
in the CG were excluded from the study because of severe
pregnancy-induced hypertension (n ¼ 1), risk for premature
labor (n ¼ 2), and personal reasons (n ¼ 5). Final analyses
occurred on 111 healthy pregnant women, 49 in the EG and
62 in the CG (Figure 1).
The demographic characteristics of participants included in
both training and CGs were similar (P > .5; Table 1). Adher-
ence to training in the experimental group was >85%. No par-
ticipant changed from the CG to the intervention group or
vice versa.
Primary Outcome
The results showed no differences in total maternal weight
gained (EG ¼ 13.4 + 10.8 kg vs CG ¼ 13.2 + 3.1 kg; P ¼
.9) and birth weight (EG ¼ 3259.4 + 518.0 g vs CG ¼ 3370.7
+ 339.0 g; P ¼ .1); however, there was a higher percentage of
women with excessive maternal weight gain in the CG (45.2%;
n ¼ 28) than in the EG (24.5%; n ¼ 12; OR ¼ 0.39; 95%
confidence interval: 0.17-0.89; P ¼ .02; Table 2).
Secondary Outcomes
The results of other pregnancy outcomes showed no differ-
ences between the study groups (Table 2).
Discussion
The aim of the present study was to evaluate the influence of a
regular and supervised program of aquatic activities throughout
pregnancy on maternal weight gain and infant birth weight. To
our knowledge, this is the first RCT examining the effect of an
aquatic intervention during pregnancy on maternal and new-
born outcomes. The main novelty was to integrate into a pro-
gram of water activities during pregnancy different types of
exercises such as aerobic, resistance, stretching, propulsion,
flotation, and so on. In addition, in the present study, swimming
lengths were only a small part of the program sessions, while
most of the activities were based on aqua exercises (including
resistance exercise), giving a well-rounded approach to
improving fitness. Our results showed the effectiveness of a
structured aquatic program on the control of excessive maternal
weight gain.
Few studies have used aquatic activities as part of an exer-
cise intervention, and those that did presented positive results
with no adverse effects for mother and fetus; however, only a
small number used an RCT design.18-20 Furthermore, no stud-
ies examined the influence of an aquatics program on maternal
weight gain and birth weight.
Baciuk et al18 used an RCT to examine the influence of an
aquatic exercise program on maternal cardiovascular capacity
during pregnancy, labor, and neonatal outcomes (birth weight
Bacchi et al. 5

Table 2. Primary and Secondary Outcomes in Study Groups.a

EG (n ¼ 49) CG (n ¼ 62) P

All (N ¼ 111)
Maternal weight gain, kg 12.7 + 2.6 13.9 + 4.3 .10
Excessive maternal weight gain, n (%) 12 (24.5) 28 (45.2) .02; OR ¼ 0.39; CI ¼ 0.17-0.89*
Gestational age, days 274.1 + 7.5 273.1 + 8.3 .50
Preterm delivery, <37 weeks, n (%) 2 (4.1) 3 (4.8) .84
Newborn
Birth weight, g 3376.7 + 355 3395.7 + 612 .84
Birth weight categories
Low <2500, n (%) 1 (2.0) 2 (3.2) .53
Adequate 2500-4000, n (%) 44 (89.8) 51 (82.3)
Macrosomia >4000, n (%) 4 (8.2) 9 (14.5)
Birth length, cm 49.1 + 2.0 48.3 + 2.9 .20
Head circumference, cm 35.1 + 1.2 34.8 + 1.5 .51
Apgar score 1 minute 8.8 + 0.3 8.9 + 0.2 .12
Apgar score 5 minutes 9.9 + 0.3 9.9 + 0.2 .56
Abbreviations: CG, control group; CI, confidence interval; EG, exercise group; OR, odds ratio; SD, standard deviation.
a
Data are expressed as mean (SD) unless otherwise indicated. We analyzed continuous and nominal data with the Student t test for unpaired data and the w2 test,
respectively.
*p < 0.05.

included); however, maternal weight gain was not measured.
They found no differences between study groups for analyzed
variables. Cavalcante et al19 found no influence of a water
aerobics program on maternal and newborn outcomes in 71
low-risk sedentary pregnant women using an RCT design.
Granath et al20 also used an RCT design and compared the
influence of a land-based program versus water aerobics on
low back or pelvic pain and sick leave in 390 healthy pregnant
women. The intervention was performed once a week, and they
found that water aerobics reduced pregnancy-related low back
pain and sick leave.
Lynch et al17 investigated the influence of a monitored swim-
ming program during pregnancy on maternal fitness and fetal
outcomes with a prospective observational study in 23 healthy
sedentary pregnant women from 16 to 28 weeks of pregnancy.
They evaluated the effects of swim-training on maternal heart
rate, blood pressure and fetal heart rate, and umbilical artery
systolic/diastolic ratio. The authors reported that a structured and
well-supervised swimming program can improve maternal phys-
ical work capacity without untoward effects on fetal well-being.
Smith and Michael21 evaluated the effect of an aquatic exercise
program on discomforts of pregnancy in 40 healthy pregnant
women with a quasi-experimental (pretest/posttest) design. The
authors found a positive association between the aquatic pro-
gram during pregnancy with physical functioning, decreasing
maternal discomfort, improving maternal body image, and
improving health-promoting behaviors.
Juhl et al16 examined the association between swimming
during pregnancy and adverse maternal and fetal outcomes
such as preterm birth, fetal growth measures, small for gesta-
tional age, and congenital malformations, especially regarding
the use of disinfection by-products in swimming pool water.
They studied 74 486 singleton pregnancies using self-reported
exercise data (swimming, bicycling, or no exercise). The
authors found that swimming in pool water was not associated
with adverse reproductive outcomes.
A recent pilot study examined the effectiveness of a pro-
gram of aquatic activities for high-risk, hospitalized pregnant
women on bed rest as reflected by changes in blood pressure,
amniotic fluid index, and the total length of gestation of preg-
nancy. The authors reported that women who received an aqua-
tic exercise program had increased amniotic fluid index and
length of gestation compared to controls.22
Silveira et al23 studied the impact of water aerobic exercise
on cardiocirculatory fetal responses (cardiotocography pat-
terns) by a nonrandomized controlled trial in 133 previously
sedentary pregnant women. The authors reported no adverse
effects of water activity–based exercise on any fetal responses.
Recently, Brearley et al24 in an observational study exam-
ined the body temperature changes in pregnant women before,
during, and after an aqua-aerobics class. The authors reported
that maternal body core temperatures are maintained within
safe limits during moderate-intensity aqua aerobic classes.
The main difference between our results and the literature
cited above is the effectiveness of controlling maternal weight
gain. Our program of aquatic exercise decreased the percentage
of women with excessive weight gain. This may be due to the
length of our program (19-20 weeks, *85 sessions) and time of
the sessions (55-60 minutes), both of which are greater than the
interventions used by other researchers. Land-based interven-
tions may have more influence on birth weight, which may be
due to the increased workload for pregnant women generated
by land exercise compared to water activities.
Limitations
Limitations of the current study included no assessment of
nutritional intake of the pregnant women, although they were
6 American Journal of Health Promotion XX(X)
SO WHAT?
What is already known on this topic?
Comparative analysis between the present study and the
other previous studies mentioned above becomes com-
plicated due to the different study designs utilized. More
RCTs are needed in this field to clarify current knowl-
edge and generate new scientific evidence. The bottom
line however, in examining the scientific literature with
the necessary caution, would suggest that the result from
our program of 3 weekly sessions of water activities
throughout pregnancy is safe for mother and baby and
prevents excessive maternal weight gain while preserving
birth weight.
What does this article add?
New evidence regarding the benefits of regular water
exercise during pregnancy now includes one of the most
important pregnancy outcome measures, maternal weight
gain as a modifiable risk factor for chronic disease. Exces-
sive pregnancy weight gain can be prevented by a program
of aquatic activities, without adverse maternal and fetal
outcomes. After initial prenatal screening, pregnant
women can start aquatic activities early and maintain an
aquatic program until late pregnancy with no obstetrical
complications, thus encouraging health-care practitioners
to recommend aquatic activities throughout pregnancy.
What are the implications for health promotion
practice or research?
It is known that excessive maternal weight gain is asso-
ciated with important maternal (hypertension, gesta-
tional diabetes) and fetal (macrosomia) complications.
From a clinical point of view, it is important to find new
innovative strategies (for health professionals) to pro-
mote an adequate maternal weight for their clients.
Supervised aquatic activities may be recommended to
pregnant women as a safe and alternate program to land
exercise that also encourages adherence because preg-
nant women appear to enjoy being active in water.
all exposed to the same standard care. Future work should
include assessment of dietary intake for both intervention and
control women in an RCT design.
Acknowledgments
The authors would like to acknowledge the technical assistance of the
Instituto de Obstetricia, Ginecologı´a y Fertilidad Ghisoni (Buenos
Aires), Argentina.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: This work
was partially supported by the Technical University of Madrid (AL16-
PID-15), Spanish Ministry of Culture, Education and Sport (PRX15/
00249), and University of Flores (Argentina).
References
1. Owen CG, Whincup PH, Orfei L, et al. Is body mass index before
middle age related to coronary heart disease risk in later life?
Evidence from observational studies. Int J Obes (Lond). 2009;
33(8):866-877.
2. Rocchini AP. Childhood obesity and a diabetes epidemic. N Engl
J Med. 2002;346(11):854-855.
3. Wang Y, Lim H. The global childhood obesity epidemic and the
association between socio-economic status and childhood obesity.
Int Rev Psychiatry. 2012;24(3):176-188.
4. Ogden CL, Carroll M, Curtin LR, Lamb MM, Flegal K. Preva-
lence of high body mass index in US children and adolescents,
2007-2008. JAMA. 2010;303(3):242-249.
5. Ruiz J, Pelaez M, Perales M, Lopez C, Lucia A, Barakat R.
Supervised exercise-based intervention to prevent excessive
gestational weight gain: a randomised controlled trial. Mayo Clin
Proc. 2013;88(12):1388-1397.
6. Ornoy A. Prenatal origin of obesity and their complications:
gestational diabetes, maternal overweight and paradoxical effects
of fetal growth restriction and macrosomia. Reprod Toxicol.
2011;32(2):205-212.
7. Wolfe L, Brenner I, Mottola M. Maternal exercise, fetal well-
being and pregnancy outcome. Exerc Sport Sci Rev. 1994;22:
145-194.
8. Cheung N. The management of gestational diabetes. Vasc Health
Risk Manag. 2009;5(1):153-164.
9. Karagiannis T, Bekiari E, Manolopoulos K, Paletas K, Tsapas A.
Gestational diabetes mellitus: why screen and how to diagnose.
Hippokratia. 2010;14(3):151-154.
10. Barakat R, Perales M, Garatachea N, Ruiz JR, Lucia A. Exercise
during pregnancy. A narrative review asking: what do we know?
Br J Sports Med. 2015;49(21):1377-1381.
11. Morris SN, Johnson NR. Exercise during pregnancy: a critical
appraisal of the literature. J Reprod Med. 2005;50(3):181-188.
12. Mudd LM, Owe KM, Mottola MF, Pivarnik JM. Health benefits
of physical activity during pregnancy: an international perspec-
tive. Med Sci Sports Exerc. 2013;45(2):268-277.
13. Barakat R, Perales M, Bacchi M, Coteron J, Refoyo I. Is exercise
throughout pregnancy safe to mother and new born? Randomized
controlled trial. Am J Health Promot. 2014;29(1):2-8.
14. Davenport MH, Ruchat SM, Giroux I, Sopper MM, Mottola MF.
Timing of excessive pregnancy-related weight gain and offspring
adiposity at birth. Obstetr Gynecol. 2013;122(2 pt 1):255-261.
15. Barakat R, Pelaez M, Cordero Y, et al. Exercise during pregnancy
protects against hypertension and macrosomia: randomized clin-
ical trial. Am J Obstet Gynecol. 2016;214(5):649.e1-e8.
16. Juhl M, Kogevinas M, Andersen PK, Andersen AM, Olsen J. Is
swimming during pregnancy a safe exercise? Epidemiology.
2010;21(2):253-258.
Bacchi et al.
17. Lynch AM, McDonald S, Magann EF, et al. Effectiveness and safety of
a structured swimming program in previously sedentary women during
pregnancy. J Matern Fetal Neonatal Med. 2003;14(3):163-169.
18. Baciuk EP, Pereira RI, Cecatti JG, Braga AF, Cavalcante SR.
Water aerobics in pregnancy: cardiovascular response, labor and
neonatal outcomes. Reprod Health. 2008;5:10.
19. Cavalcante SR, Cecatti JG, Pereira RI, Baciuk EP, Bernardo AL,
Silveira C. Water aerobics II: maternal body composition and
perinatal outcomes after a program for low risk pregnant women.
Reprod Health. 2009;6:1.
20. Granath AB, Hellgren MS, Gunnarsson RK. Water aerobics
reduces sick leave due to low back pain during pregnancy.
J Obstet Gynecol Neonatal Nurs. 2006;35(4):465-471.
21. Smith S, Michael Y. A pilot study on the effects of aquatic exer-
cises on discomforts of pregnancy. J Obstet Gynecol Neonatal
Nurs. 2006;35(3):315-323.
22. Sechrist DM, Tiongco CG, Whisner SM, Geddie MD. Physiolo-
gical effects of aquatic exercise in pregnant women on bed rest.
Occup Ther Health Care. 2015;29(3):330-339.
23. Silveira C, Pereira BG, Cecatti JG, Cavalcante SR, Pereira RI.
Fetal cardiotocography before and after water aerobics during
pregnancy. Reprod Health. 2010;7:23.
24. Brearley AL, Sherburn M, Galea MP, Clarke SJ. Pregnant women
maintain body temperatures within safe limits during moderate-
intensity aqua-aerobic classes conducted in pools heated up to 33
degrees Celsius: an observational study. J Physiother. 2015;61(4):
199-203.
25. Katz VL, McMurray R, Turnbull CD, Berry M, Bowman C, Cefalo
RC. The effects of immersion and exercise on prolactin during preg-
nancy. Eur J Appl Physiol Occup Physiol. 1990;60(3):191-193.
26. Kent T, Gregor J, Deardorff L, Katz V. Edema of pregnancy: a
comparison of water aerobics and static immersion. Obstet Gyne-
col. 1999;94(5 pt 1):726-729.
7
27. Hartmann S, Huch R. Response of pregnancy leg edema to a
single immersion exercise session. Acta Obstet Gynecol Scand.
2005;84(12):1150-1153.
28. Kamioka H, Tsutani K, Mutoh Y, et al. A systematic review of
nonrandomized controlled trials on the curative effects of aquatic
exercise. Int J Gen Med. 2011;4:239-260.
29. Katz VL. Water exercise in pregnancy. Semin Perinatol. 1996;
20(4):285-291.
30. Katz VL. Exercise in water during pregnancy. Clin Obstet Gyne-
col. 2003;46(2):432-441.
31. ACOG Committee Obstetric Practice. ACOG Committee opin-
ion. Number 267, January 2002: exercise during pregnancy
and the postpartum period. Obstet Gynecol. 2002;99(1):
171-173.
32. IOM. Institute of Medicine (US) and National Research Council
(US) Committee to Reexamine IOM Pregnancy Weight Guide-
lines. In: Rasmussen KM, Yaktine AL, eds. Weight Gain During
Pregnancy: Reexamining the Guidelines. Washington (DC):
National Academies Press (US); 7, Determining Optimal Weight
Gain; 2009. Available at: https://www.ncbi.nlm.nih.gov/books/
NBK32801/
33. Belizán JM, Nardı́n JC, Carroli G, Campodónico L. Selection of
mothers with increased risk of delivering low birthweight new-
borns at a public maternity hospital in Rosario, Argentina. Bull
Pan Am Health Organ. 1989;23(4):414-423.
34. O’Neill ME, Cooper KA, Mills CM, et al. Accuracy of Borg’s
ratings of perceived exertion in the prediction of heart rates during
pregnancy. Br J Sports Med. 1992;26(2):121-124.
35. Moher D, Dulberg C, Wells G. Statistical power, sample size, and
their reporting in randomized controlled trials. JAMA. 1994;
272(2):122-124.
36. Cohen J. A power primer. Psychol Bull. 1992;112(1):
155-159.