EBP Maternity

PICO MaternityChristin Philipose, Emma Kaye, Jane Lee, Jubbie Acutim, Kessiah Tolentino, Miriam Samekhova

PICO QuestionPICO Question: Does daily exercise or other physical activity during pregnancy reduce the risk of preterm delivery compared to those who do not exercise during pregnancy?

Population: Pregnant women

Intervention: Daily exercise/physical activity

Comparison: No exercise

Outcome: Reduce risk of preterm delivery

Three Research Studies 1) Exercise Throughout Pregnancy Does not Cause Preterm Delivery: A Randomized,

Controlled Trial (Level II study)2) The Impact of Exercise During Pregnancy on Neonatal Outcomes: A Randomized

Controlled Trial (Level II study)3) Risk of prematurity, low birthweight and pre-eclampsia in relation to working hours

and physical activities: A Systematic Review (Level I study)

Exercise Throughout Pregnancy Does not Cause Preterm Delivery: A Randomized, Controlled Trial. By: Ruben Barakat, Mireia Pelaez, Rocio Montejo, Ignacio Refoyo, and Javier Cateron

Abstract:

“The aim of the current study was to examine the influence of an aerobic exercise program throughout pregnancy on gestational age at the moment of delivery. This study was a randomized controlled trial. Three hundred and twenty Caucasian (Spanish) healthy pregnant women with singleton gestation were randomly assigned to either an exercise (n = 160) or a control (n = 160) group. Gestational age (weeks) and other outcomes were measured. The exercise program included 85 sessions (general fitness class, 3 times/week, 55–60 min/session from weeks 8–10 to weeks 38–39 of pregnancy). Two hundred and ninety women were analyzed. Results: The mean gestational age did not differ between groups (EG= 39.7± 1.3 vs CG= 39.6 ± 1.1 weeks, P = .81). Relative to preterm deliveries in EG we found 6 (4.3%) and 11 (7.2%) in CG, (P = .73). Conclusions: A supervised program of moderate exercise performed throughout pregnancy is not a risk of preterm delivery for healthy pregnant women” (Barakat et al., 2014 p. 1012)” (Barakat et al., 2014 p. 1012)

Research Question- The researchers did not directly state the research question but they did state that the aim of their research was to analyze the effect of aerobic, physical exercise group during pregnancy on the gestational age of the baby (Barakat et al., 2014 p. 1012).

Hypothesis- The researchers hypothesized that pregnant women who do participate in a supervised exercise group are not at risk for having a preterm delivery (Barakat et al., 2014 p. 1012).

Independent Variable- the amount of exercise the pregnant women participated in

Dependent Variable- the length of pregnancy

This hypothesis is a directional hypothesis because the researchers hypothesis states the anticipated path of the relationship between exercising (IV) and the duration length of pregnancy (DV).

MethodologyThis study was a Randomized Controlled Trial (Level II evidence). Three hundred and twenty Caucasian women who were pregnant and healthy were randomly placed in the control group or the exercise group. The participants were recruited from the hospital database (Barakat et al., 2014 p. 1013).

The inclusion criteria in the study were pregnant women with no medical complications. The women recruited were pregnant with one child, Caucasian, and around 31 years old (Barakat et al., 2014 p. 1013)

The researchers excluded pregnant women who had “hemodynamically significant heart disease, restrictive lung disease, incompetent cervix, multiple gestation, ruptured membranes, preeclampsia/pregnancy induced hypertension” (Barakat et al., 2014 p. 1013). The researchers also excluded pregnant women who refused to obtain regular physical exams from their doctor, women who were in an additional exercise group or who were exercising more than three times a week, and women who did not intend on giving birth in the obstetrics department of the study hospital (Barakat et al., 2014 p. 1013).

MethodologyThere were a total of eighty-five exercise classes that the pregnant women had to participate in. The classes met thrice a week for 1 hour or 55 minutes and were of moderate intensity. The women participated from their 8th-10th week of pregnancy till the 38th-39th week of pregnancy (Barakat et al., 2014 p. 1013).

The length of the pregnancy and other outcomes (including increase in weight during pregnancy, delivery route, blood pressure, length of baby, weight of baby, Apgar Scores, PH of the umbilical cord, and 1 hour serum sugar level of the baby) were assessed by the researchers (Barakat et al., 2014 p. 1012).

Data was obtained through the hospital database, interview with the pregnant women at the beginning of the study, and through questionnaire (Barakat et al., 2014 p. 1013).

SamplingThree hundred and twenty women pregnant women were initially randomly placed into the control or exercise group but at the end two hundred and ninety women were analyzed after people dropped out of the study. There were 138 people in the exercise group and 152 people in the control group which is an adequate sample size (Barakat et al., 2014 p. 1013).

The type of sampling used in this study was probability sampling because the participants were placed at random in either the control or experimental group.

The researchers implemented a simple random sampling since they had a specific group that they were interested in (healthy, pregnant women), had a “sampling frame”, and they chose a group of people to be placed into either the control or exercise group (Lobiondo- Wood & Haber, 2014 p. 240).

SamplingBy first defining their population of pregnant, healthy women and then using a computer to create a random list of numbers for choosing the patients, the researchers implemented simple random sampling (Barakat et al., 2014 p. 1013).

The sampling method did not result in any validity issues.

There was no selection bias because the participants were randomly placed into a random group based on a list generated by the computer at random (Barakat et al., 2014 p. 1013).

There was also no reactive effects such as the Hawthorne Effect because the women in the exercise group all participated in the same activities.

InterventionsThe exercise program was approximately 1 hour long, and met thrice a week from the 8th-10th week until the 38th to 39th week of pregnancy. There was a mean of 85 exercises classes altogether (Barakat et al., 2014 p. 1013).

The subjects all wore a heart rate monitor while exercising and the Borg Exertions scale was implemented (Barakat et al., 2014 p. 1013).

During every class, the women did abdominal core workouts for 35 minutes and they did 10 minute warm ups and cool downs.They did pelvic floor exercises, toning, and resistance exercises that involved shrugging the shoulder and doing should rotations, raising the arms and legs, tilting the pelvis, and doing rocking exercises. (Barakat et al., 2014 p. 1013)

They did 1 set of abdominal curls and they also used exercise bands that are low in resistance or barbells (3 kg/exercise) to do bicep curls, arm extensions, arm side lifts, leg circles, knee curls, knee extensions, and other extensions (Barakat et al., 2014 p. 1013).

Interventions

Ethical IssuesThere was no ethical issues involved in this study since all the women who participated in the study were a part of the exercise group that was supervised by professionals and the control group. All the measurements used in this study were non invasive and standard so they did not pose any risk of harm to the patient. The researchers conducted the study using the proper protocol (Barakat et al., 2014 p. 1012).

“This research study was approved by the Ethical Committee of Hospital Universitario de Fuenlabrada in Spain and followed the ethical guidelines outlined in the Declaration of Helsinki” (Barakat et al., 2014 p. 1012).

The researchers obtained a written informed consent from all the participants in the study. All the subjects of this study were made well aware of the purpose of the study and the protocol involved (Barakat et al., 2014 p. 1012).

Ethical IssuesThe risks involved in this study was an early or preterm delivery from doing the exercises in the exercise program. However, the researchers ensured that the exercises were mild to moderate and appropriate for the women who were pregnant.

The women were not asked to do any strenuous exercises, the Valsalva maneuver, ballistic movements, high impact exercises, or be in high temperature or humid rooms (Barakat et al., 2014 p. 1013).

To minimize risks the exercise sessions were supervised by a professional fitness trainer who worked with 10-12 participants and also an obstetrician was present as well (Barakat et al., 2014 p. 1013).

The exercises were also done in the Health Care Center, which was very large and had plenty of good lighting and good setting conditions (altitude 600 m, temp-19-21°C, humidity- 50-60%) (Barakat et al., 2014 p. 1013).

Participants also wore a heart rate monitor during the exercise sessions.

Reliability of tools The study measured the increase in weight of the pregnant women(kilograms), weight of the baby when it was born (grams), length of the baby when it was born (centimeters), pH of the umbilical cord, glucose tolerance exam which was conducted orally (grams/deciliter), blood pressure, and Apgar Score (Barakat et al., 2014 p. 1016).

The researchers discussed the reliability of some but not all of the tools. The researchers reported “There were no significant differences (P>0.5) in background variables between 2 study groups; these background variables included maternal age, BMI, parity, previous PD, previous miscarriages and previous low birth weight (<2500 g). Maternal characteristics could potentially influence the main study outcome were also not significantly different between the groups” (Barakat et al., 2014 p. 1014).

The researchers also reported that as for age of gestation and additional outcomes of the pregnancy they didn’t find any statistically important difference between the control and exercise group (Barakat et al., 2014 p. 1014).

Reliability of toolsThe researchers failed to incorporate certain factors that could affect the reliability of the tools such as whether the pregnant women were doing other physical activity at home or at the gym on their own (Barakat et al., 2014 p. 1017).

Also they should have assessed whether the women were married and how economically stable they are because these are factors can influence birth factors including the time of delivery and weight of the infant and mother (Barakat et al., 2014 p. 1017).

This affects the reliability because if researchers wanted to conduct the study again then the results of the study may not be the same since the measurements used in the study may not be consistent and accurate.

There is also no mention of whether the researchers took the physiological measurements more than one time in order to ensure consistent results.

Validity of Tools The researchers did not report the validity of all the tools but they did report some. They just implied that they used standard measurements but they did not include whether they checked to see if the scales and devices were calibrated accurately before using them. They also did not mention if each person received the same training and used the same methods to collect the data (Barakat et al., 2014 p. 1013).

The researchers did not include whether they took the blood pressure electronically or manually for the patient and whether they took it on the arms or legs or another extremity. This could have caused a difference in the measurement of the blood pressure.

They did not report whether they used the same weight machines, rulers, and other tests for all the patients or if they used different companies with different calibrations. This is especially important for the glucose tolerance exam (Barakat et al., 2014 p. 1013).

Some of the data (esp. the data in the beginning of the study) was obtained through the hospital database. The researchers should have obtained that data by measuring it themselves in a consistent manner with proper training for each person in order to avoid errors in the data and results (Barakat et al., 2014 p. 1013).

Antecedent Variable The antecedent variables were taken into consideration and was necessary for this study.

Included: the age, BMI, weight, day to day overall activity level, level of education, smoking, gestational diabetes, number of hours they stand in a day, prior preterm births, prior miscarriages, prior births of low weight infants, and hours spent on completing household duties (Barakat et al., 2014 p. 1015).

Should have been considered: were whether the pregnant women were married and whether they were financially stable as this could have been an effect on the duration of their pregnancy term (Barakat et al., 2014 pp. 1016- 1017).

Intervening VariablesCertain intervening variables should have been included:

● Pregnant women’s health and nutrition status during the course of the pregnancy (Barakat et al., 2014 pp. 1016-1017).○ This should have taken in consideration because if the nutrition status is poor then

the mother could be at risk for having a preterm delivery ● Whether the pregnant women were participating in other exercise or physical activity on

their own outside the exercise group (Barakat et al., 2014 p. 1017).

Since these intervening variables were omitted, the reliability and validity of the study could be compromised.

Women who had preterm delivery, it may or may not have been directly related to participating in an exercise group; it could have been related to poor nutrition or lack of financial stability to attain prenatal vitamins or any other necessary materials.

Limitations of the studyThe researchers stated that the study incorporated a non-blinded study methodology and therefore it was very hard to implement this study among pregnant women although it is the ideal option for a randomized controlled trial (Barakat et al., 2014 pp. 1016-1017).

They did not consider whether the pregnant women were married or not which could have affected the outcome of the study(Barakat et al., 2014 pp. 1016-1017).

They should have considered the financial and social status of the women as this could have had an affect on the outcome as well (Barakat et al., 2014 pp. 1016-1017).

Although the researchers made sure that the women were not a part of another exercise program, they should have monitored other exercises that the women took part in on their own (Barakat et al., 2014 pp. 1016-1017).

Results 290 women were evaluated = 138 in exercise group + 152 in the control group (Barakat et al., 2014 p. 1013):

● Preterm delivery = 6 in exercise group & 11 in control group (Barakat et al., 2014 p. 1014)○ Caesarean (out of the preterm delivery results) = 3 in exercise group & 8 in control group (Barakat et

al., 2014 pp. 1014-1015)

The values of the Apgar Scores were very close:

● In one minute: 8.6 in exercise group and 8.8 in control group; in five minutes: 10 in exercise group and 9.9 in control group

The pH value of the umbilical cord were the same in both groups (Barakat et al., 2014 p. 1015).

The blood sugar of the mother, gestational diabetes and average blood pressure was very similar between the pregnant women in the exercise group and the control group (Barakat et al., 2014 p. 1015).

Women who participated in exercise classes had gained less weight than those who participated in the control group (Barakat et al., 2014 p. 1015). The weight, length and overall physical status of the infant were the same between the control group & exercise group (Barakat et al., 2014 p. 1015).

Conclusion In conclusion of the study, the researchers found that participating in an exercise group of moderate or mild intensity does not increase the chance of having a preterm delivery for women with no medical issues.

This study is not strong enough to be credible because even though the researchers used standardized measurements and tests, they did not report the validity of the tools used for measurement were calibrated properly and whether the methods and tests used were consistent among all participants. Additionally, the researchers failed to mention whether the tools that were used came from the same company and if it was consistent throughout all of the subjects and if people who took the measurements had the same training.

They obtained some of their information from the hospital database but they should have obtained these results by measuring and assessing themselves using consistent methods and training.

Despite the flaws, the study did incorporate many factors and made sure to have an adequate sample. They analyzed the information in an appropriate manner and the study was an RCT , which strengthens the level of evidence of this study. The researchers also looked at many other studies and compared their own study to what others have done in order to evaluate the results and methods of their own study .

In Relation to our PICO QuestionThe findings of this study has made it possible to generalize it to our PICO question because the population is homogenous (Caucasian) pregnant women and the study has an adequate sample. Even though the sample could have been bigger, the study can be applied to the PICO question because the study was based on the risk of preterm delivery among pregnant women and exercising.

The study also studied women who were pregnant with one child with no medical complications, which controls any external factors that could cause an early delivery.

This study is also an RCT, which also shows a high level of evidence and my article is peer reviewed which strengthens the findings of this study.

The Impact of Exercıse Durıng Pregnancy on Neonatal Outcomes: A Randomızed Controlled Trıal

by: MURTEZANI, A., PAC ̧ARADA, M., IBRAIMI, Z., NEVZATI, A., & ABAZI, N.

Abstract: “The effect of exercise training during the course of pregnancy on the newborn’s birth weight is unclear. the study examines the effect of aerobic and strength conditioning exercise performed during the second and the third trimester of pregnancy in nulliparous, previously inactive women on the newborn’s outcome.

Methods: sixty-three nulliparous, previously sedentary, were randomly assigned to either an exercise (N.=30) or a control (N.=33) group. The subjects participated in the exercise group (EG) focused on aerobic and strength-conditioning exercise in three sessions for about 20 weeks. we registered the birth weight, birth length, gestational age at time of delivery, Apgar score and head circumference of the newborn.

Results. here were no statistically significant differences between the two groups in mean birth weight, length, head circumference, and length of gestation. there was a significant different between two groups in Apgar scores at 1 min (P=0.036) and 5 min (P=0.015) with newborns of the EG scoring higher than the CG.

Conclusion. Supervised, aerobic and strength conditioning exercise performed over the second and third trimester of pregnancy does not have a negative impact on the newborn’s body size and health”

(MURTEZANI, PAC ̧ARADA, IBRAIMI, NEVZATI, & ABAZI, 2014)

Hypothesis: regular attendance to moderate intensity exercise during pregnancy will not result in reduced birth

weight in previously inactive women.

Independent Variable: Exercise group

Dependent Variable of mother's: age, gestational weeks, education level, history of smoking (yes/no), height, pre-pregnancy weight, weight, and pre-pregnancy BMI

Dependent Variable of neonate: birth weight, birth length, head circumference, gestational age, Apgar score 1 minute, Apgar score minutes, and gender

The exercise group vs. inactive control group was directional because the researchers in this study stated that there was a positive correlation between exercise in pregnancy and the newborn. The researchers have also stated that there would be no negative outcomes to the newborn if previously inactive women started exercising.


MethodologySixty-three nulliparous women who were inactive for 6 months were randomly assigned to an exercise or control group. The two groups were then further excluded if patient experiences or have had diseases that could interfere with participation. The remaining participants were examined twice during the study, the first between 14-20 weeks of gestation and the second at 36-38 weeks of gestation.

The design used by this research is a randomized controlled trial. This research is identified as a randomized controlled trial because randomization, control, and manipulation were applied to this experimental research. The researchers used a computer to randomize the participants to different groups (either the control or exercise group).

Inclusion criteria included pregnant women who were inactive for 6 months and who are also in their second and third trimester of pregnancy. These women had to be recruited by a healthcare professional before they began the study.

Exclusion criteria included pregnancy induced hypertension, development of varicose veins and deep vein thrombosis, cardiovascular and respiratory disorder, low back pain, multiple pregnancy excessive maternal weight gain, previous spontaneous abortion, preeclampsia, persistent bleeding after 12 weeks of gestation, and other diseases that could interfere with participation


Methodology (cont.)


SamplingProbability sampling is included in this study because the subjects were randomly assigned to either the exercise group or the control group. The random assignment procedure was performed using random numbers generated by a computer program.

The sampling method was well established because there were two screenings prior to the actual experiment to assure that the participants were qualified for this experiment.

The sampling method did result in validity issues. These issues included selection bias and selection effects where 35 people being unqualified for this experiment, due to unmet inclusion criteria and refused to participate. Reactive effects have also occurred during the experiment when 9 participants had hypertension, vascular disease, intrauterine growth restriction, amniotic fluid leakage, injury, premature birth, or they were unreachable.


InterventionsThe exercise-training program started in the second trimester and continued until the end of pregnancy.

The exercise session began with a warm up, core and strength training, aerobics, and then a cool down. The control group was followed up throughout the entire pregnancy period. The researchers did not note any instructions for the control group.

Participants were also interviewed with a questionnaire that asked characteristics about the mother, such as age, weight, education level, etc. A postpartum test was also recorded which included the Apgar score at 1 and 5 minutes, birth weight, birth length, and head circumference, as well as the gestational age at the time of delivery. The Apgar score assesses the condition and prognosis of newborns. The score assesses for breathing effort, heart rate, muscle tone, reflexes, and skin color at 1 and 5 minutes. The higher the score the better the baby is doing. A score of 7-10 is normal, 4-6 may need resuscitation, and below 3 requires immediate resuscitation.



Ethical IssuesThere were no known ethical issues during the course of the study.

All subjects voluntarily participated in this study and fulfilled informed consent form. The IRB was not mentioned, however the study was approved by the Research Ethics Committee of the University of Prishtina.

Some risks included pregnancy induced hypertension, development of varicose veins and deep vein thrombosis, cardiovascular and respiratory disorder, low back pain, multiple pregnancy excessive maternal weight gain, previous spontaneous abortion, preeclampsia, persistent bleeding after 12 weeks of gestation, and other diseases that could interfere with participation

During the course of the study, 9 participants had withdrawn from the experiment due to hypertension, vascular disease, intrauterine growth restriction, amniotic fluid leakage, injury, premature birth, or were unreachable.


Validity and ReliabilityThe validity and reliability of the tools were not mentioned in this study.

Tools included are the Apgar scale, weighing scale, BMI chart, and a ruler to measure height. These tools are not considered valid and reliable because the researchers have not confirmed any measuring errors or considered the reliability or validity of the tools the health care professionals used. We are not sure if the BMI chart is up to date or if the weighing scale was calibrated before each use, etc.



Antecedent VariablesIncluded: mother’s education level, age, weight, height, BMI, and smoking history. Newborn’s Apgar score at 1 and 5 minutes after birth, birth weight, birth length, head circumference, and gestational age.

Should have been included: medical history of complications or diseases, stress level, occupation and number of work hours per week, medication use, nutrition, and drug or alcohol abuse can induce preterm delivery and can affect the results of the study.


Intervening VariablesAn intervening variable that should have been considered is the type of exercise the participants would have performed. A strenuous exercise routine could have an impact on the mother and the fetal development during the course of pregnancy compared to a lighter activity.


ResultsDuring the course of the study, there were a total of 9 women who had to withdraw due to medical and personal reasons. And out of the 63 remaining participants, there were no significant differences between the control and exercise group of the mothers. However, there was a statistical difference between the control and exercise group in newborns in the Apgar score at 1 min and 5 min. The newborns of the exercise group had a higher score than the newborns in the control group.

The researcher did discuss the threats and issues in relation to the results. Nutritional status and the fact that there was a low population sampling for this study have affected the results. However, the researchers disregarded that the nutritional intake would have affected the results because in both the EG and CG the gestational weight gain was similar.

The study was strong enough for the results to be credible. Even though the population of the study was small to show significant results, this experiment was a randomized controlled trial. In addition, the participants had very similar characteristics and criterion before and during the course of this study, which makes the results unbiased and true.



The results were not significant except for difference in Apgar scores between the EG and CG. The newborns in the exercise group had a higher Apgar score than the newborns in the control group. Confidence interval was not included. The P-Value was reported in this study. No risk ratios were reported. Power data was included and stated, “This study utilized a small sample, did not provide power calculations and may have been underpowered.”


ConclusionTo conclude the research study, Supervised, aerobic and strength conditioning exercise performed over the second and third trimester of pregnancy does not have a negative impact on the newborn’s body size and health.”

The researchers collected its information through questionnaires and different types of tools. Some tools that were used is the Apgar scale, weighing scale, and the BMI chart. The researcher failed to include reliability and validity of the tools.

The study was strong enough for the results to be conclusive. Even though the sample size wasn’t substantial enough, the study still showed a striking outcome.The study was developed by using a RCT including inclusion and exclusion criteria which helps narrow the sample size down more accurately. Using this method for sampling strengthens the level of evidence.

No known ethical issues were observed during the process of the study.All individuals participated voluntarily in this study and signed an informed consent form. The study was approved by the Research Ethics Committee of the University of Prishtina.

In relation to our PICO questionEven though the sampling size was small, it is possible to generalize the result to our PICO question. This is because this study has answered our question if exercise induces preterm delivery, which the results showed that there were no significant results that exercise would induce preterm deliveries. In addition, this study included many variables which gave a visual comparison that exercising had more positive outcomes during pregnancy than a sedentary lifestyle.

ABSTRACT

BACKGROUND:Occupational activities are suspected of having an adverse impact on outcomes of pregnancy.

AIM:To assess the evidence relating three major adverse outcomes (preterm delivery, low birthweight (LBW) and pre-eclampsia/gestational hypertension) to five common occupational exposures (prolonged working hours, shift work, lifting, standing and heavy physical workload).

Risk of prematurity, low birthweight and pre-eclampsia in relation to working hours and physical activities: A Systematic Review

Purpose of the ReviewResearch Question- The researchers conducted a systematic review aimed to establish what were the reasonable approaches for employers so that a policy could be determined in the future if pregnant women can work without limitation during their pregnancy and not affect their baby’s health

Population: European women who were associated with the European Union legislation that mandates employers to assess health and safety risks for pregnant women.

Sampling: non-probability focusing on pregnant women at work

Methodology The researcher assigned “1 point for each of the following features that were present in the study”

1. Self-reported outcome

2. Outcome of pre-eclampsia, gestational hypertension or very low birth weight

3. Exposure related to physical workload (standing, lifting or physical activity)

Exposure-outcome pairing was scored 0-3, and scores >2 were considered to indicate important potential for inflationary bias (a bias that could cause important overestimation of relative risks) The researchers directed their study for forty-one years of systematic search combining medical subject heading terms. Standard details were abstracted that were then used to summarize the design features of studies, to rate their methodological quality and to provide estimates of effect”

LoBiondo-Wood, G., Haber, J., 2014.

Methodology The researcher performed a “meta-analysis using Sharpe and Sterne STATA macro and also conducted a sensitivity analysis to check the impact of excluding papers of lower quality, and explored possible bias using funnel plots.” “A number of reproductive hazards associated with work that were well established.


SamplingThe studies were selected through Randomized Controlled Trial (RCT) that the researchers did 49 studies on preterm delivery, 33 studies on birth weight and 8 studies on preeclampsia or gestational hypertension.

The researchers abstracted a standard set of information, including details of the study populations, setting, timing of investigations, study design, exposure contrasts, strategies for assessment of exposures and outcomes, response rates, confounders considered and estimates of effect



Inclusion Criteria The researchers utilized meta-analysis because of potentially important differences in definitions of outcome from one study to another, the researcher did not attempt for any occupational association with gestational hypertension subjects. The authors conducted a Systematic search using “Medline and Embase Electronic bibliographic databases for the period of 1966 to December 2005 Medical heading terms and keywords were chosen carefully. Medical subject heading were appropriate and the authors also used simple search terms



Valdility The validity of the tools used was unbiased. The researchers used data reports including details of the study populations, setting, timing of investigations, study design, exposure contrasts, strategies for assessment of exposure and outcome. The researchers used medical subject terms such as pregnancy, reproductive health, pre eclampsia, birth weight, gestational age, and small for gestational age, fetal growth retardations, labour complications and pregnancy complications. Simple search terms were used such as occupational activity, standing, manual lifting, heavy lifting, and shift work

It showed comparison of different factors of how pregnant woman's child could be affected with working long hours, shift work, lifting, standing, and typical workload that these pregnant women are capable of doing

Researchers provided relative risk, calculated odds ratios with exact confidence interval using “STAT V8 software. The authors’ works are reliable and constructed funnel plots that were associated with meta-analysis. The plots, which are available from the authors on request suggested a degree of publication bias. The completeness of their work was satisfactory across studies. The research was “judged by 9-point criteria, the median score was 7.5”



Similarity of Groups & TreatmentsThe subjects were European women who were associated with the European Union legislation that mandates employers to assess health and safety risks for pregnant women. The “type of sampling that was used was non-probability focusing on pregnant women at work

it was necessary to keep pregnant women not to work around establishments that had radiation or lead in its facilities. The researchers did consider the extraneous variable by expanding their research out of the country. They held “telephone interview and face-to-face interview with pregnant women in the US, China, Canada, and other countries”

The researchers analyze the data appropriately by conducting multiple comparisons’ with other ethnicity of pregnant women around the world



Ethical ConcernsThe ethical concern were highlighted which shows pregnant women in their trimester were instructed to work by their employers that put concerns to the life of the child and the mother at risk for preterm, low birth weight, and pre-eclampsia

The researcher considered all avenues on what the subject’s exposure to their work. Safety during pregnancy was the main concern for these subjects


ResultsThe result was significant because most people believed that pregnant women are prone to injury or could affect their baby if they are in an environment where long working hours, shifting work, lifting, and standing are accompanied in their daily workload throughout their pregnancy. The “end result of the study suggested that there were no indications that pregnant women could not work during pregnancy that could indicate hazardous to their child.” As long as there are no radiation or lead or any environmental hazards that exposes these women, these women should deliver a healthy baby. The researcher suggested that the employer should limit extreme exposures in these women’s late pregnancy but no mandatory restrictions on any of the activities considered in the this review

The researchers identified that in relation to all the occupational activities and health outcomes examined, the potential to reduce further research varies. The researcher suggests that the highest priority for future studies should be in relationship with long working hours and lifting. A need for well designed cohort studies in which relevant exposures are assessed prospectively at different stages of pregnancy and subsequent health outcomes.


Results The researcher discussed that “the health outcomes that we examined in this review are clinically important. Preterm delivery is a major determinant of perinatal mortality, and of neonatal and infant morbidity. Low birthweight is also related to infant morbidity and mortality, as well as to predicting adverse outcomes in childhood and later life, such as poorer growth and development, and higher risks of neurological and cognitive deficit, high blood pressure, non-insulin-dependent diabetes, coronary heart disease, stroke and obstructive lung disease… The extent of epidemiological evidence that we identified on occupational risks varied. For some associations a substantial body of research had been published, whereas for others relatively few reports were retrieved… The samples were observed with a possibility of publication bias, with more complete reporting of positive than non-positive findings, especially from smaller studies. Therefore, the generalizability could be conducted again to a different population if desired to be.



ConclusionThe summary of findings was provided. The result was significant because most people believed that pregnant women are prone to injury or could affect their baby if they are in an environment where long working hours, shifting work, lifting, and standing are accompanied in their daily workload throughout their pregnancy. The “end result of the study suggested that there were no indications that pregnant women could not work during pregnancy that could indicate hazardous to their child”

As long as there are no radiation or lead or any environmental hazards that exposes these women, these women should deliver a healthy baby. The researcher suggested that the employer should limit extreme exposures in these women’s late pregnancy but no mandatory restrictions on any of the activities considered in the this review


Conclusion cont...The researchers analyze the data appropriately by conducting multiple comparisons’ with other ethnicity of pregnant women around the world.


In Relation to our PICO QuestionSince exercise is not operationally defined it can be anything that includes movement. This article in relation to exercise investigates occupational activities of physical workload, standing, lifting, and working hours. It correlates to our PICO question because our population was focused on pregnant women with the intervention of exercise (being the labor work) in this case. It did not clearly indicate if there is a correlation of induced preterm delivery with no exercise. The outcome of this study indicated that physical activity does not jeopardize the health of the baby during pregnancy. Being that this a level one study, the results can be generalized because the findings were dispersed from 21 cohort studies that had sample sizes that varied from <50 to extremely large >3500. Many of the risks estimates were based on findings from >1000 pregnancies with a confidence interval of 95%.

ReferencesBarakat, R., Pelaez, M., Montejo, R., Refoyo, I., & Coteron, J. (2014). Exercise Throughout Pregnancy Does not Cause Preterm Delivery: A Randomized, Controlled Trial. Journal of physical activity & health, 11(5), 1012-1017.

Bonzini, M., Coggon, D., & Palmer, K. (2006). Risk of prematurity, low birthweight and pre-eclampsia in relation to working hours and physical activities: A systematic review. Occupational and Environmental Medicine, 228-243.

LoBiondo-Wood, G., & Haber, J. (2014). Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice. St. Louis, Missouri: Elsevier

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http://www.minervamedica.it.libproxy.adelphi.edu:2048/en/getpdf/%252Bh51tU2JFGhOaTCd3EkCo9H6AZPwQ%252FYY4tLW5B9rodvK2bz%252BrOy71cdsFPPEU8i2hjHHRwIAYYHvsxPC1MxABQ%253D%253D/R40Y2014N06A0802.pdf




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