Aerobic Exercise on Prenatal Sleep Quality and Maternal-fetal Attachment
Condition: Effects of Aerobic Exercise in Pregnant Women
Study type: Interventional

Summary: 
      A growing body of evidence suggests that exercise is an important contributor to maternal
      health and is beneficial to infants. A single-blinded randomised experimental study was used
      to evaluate the effect of aerobic exercise on sleep quality and maternal-fetal attachment in
      pregnancy women. 140 eligible pregnant women were systematically assigned, with a random
      start to experimental group (n = 70) received a 20 minutes aerobic exercise video and was
      instructed to exercise at least three times a week for 3 months at home, while the control
      group (n = 70) received the usual care only. The Pittsburgh Sleep Quality Index and Modified
      Maternal-Fetal Attachment Scale were used to assess outcomes measured before the intervention
      and at 4 and 12 weeks postintervention. Paired sample t-tests were conducted before and after
      aerobic exercise to measure whether there were any statistically significant changes in
      outcome variables.
    

Detailed description: 
      3.1 | Study design In this study, a single-blinded, randomized, controlled trial with a
      prospective pretest-posttest experimental design was implemented to examine the effects of
      low-impact aerobic exercise with modified yoga movements on sleep quality and maternal-fetal
      attachment in pregnant women.

      3.2 | Participants Participants for this study were recruited from the prenatal clinic of a
      medical center in southern Taiwan. A sample size of 63 per group was considered sufficient to
      estimate a medium effect of .50 with α-value of 0.05 and a power of 0.08 (Polit & Beck,
      2011). Considering a 20% attrition rate over 3 months, 140 pregnant women were enrolled.

      3.3 | Intervention The intervention group received a DVD with low-impact aerobic exercises
      developed by the researchers in collaboration with a qualified prenatal yoga teacher. The
      program incorporated modified yoga movements suitable for pregnant women. The DVD provides an
      illustration with the written caption, "Please take enough water before exercise, and wear
      loose and comfortable clothes in a suitable environment. If you feel tired, stop exercising
      immediately." The DVD's narrator then says, "Now you are ready to prepare a comfortable,
      solid chair with a chair back." With a soft musical background, the exercise actions were
      arranged in following order: warm-up → neck → shoulder → arm → chest → waist →leg →
      regulating the breathing. The first 14.5 minutes of the yoga exercises were performed in a
      sitting position, followed by 3.5 minutes in standing position, and then returning to 2
      minutes in sitting position. The exercises were developed as a progressive program in order
      to achieve the goals of strength-conditioning, moderate-intensity exercise (ACOG, 2015). The
      yoga teacher instructed the participants to touch their heart with their right hand and their
      abdomen with their left hand, feeling a connection with the fetus in the warm-up and in the
      final breath-regulating stage of exercise (2 minutes). An expert video producer edited the
      DVD for sound, animation, and subtitles. The exercise program requires twenty minutes to
      complete. Women were instructed to use the DVD 3 times a week for 3 months. The DVD was
      reviewed for content validity by two clinical obstetric nursing experts, and in addition, two
      pregnant women in their second trimester reviewed the DVD for face validity.

      3.5 | Procedure and ethical considerations The present study was carried out from January to
      October 2014 after approval was obtained from the institutional review board of the
      participating institution. One hundred and forty women who met the inclusion criteria and
      returned their consent documents were systematically assigned, from a random starting point
      to experimental (n = 70) or a control (n = 70) group. Women usually talk to each other during
      the prenatal check and this could cause study data contamination, so we used a month as the
      unit of allocation to avoid between-group data contamination. The first month collecting data
      was control group decided by drawing lots (two lots which were marked "E" for experimental
      group and marked "C" for control group in a sack). Research assistant drew the lot from the
      sack. Then, the following month, group allotment was systematically assigned in sequence to
      either the experimental group or the control group.

      In addition to routine care, the experimental group was given the DVD and instructed to
      engage in the aerobic exercise program shown on the DVD. The control group received routine
      prenatal care only. The two groups were asked to complete the demographic data form, the
      MMFAS, and the PSQI at 3 time periods: before the intervention, at 4 weeks, and 12 weeks
      post-intervention. All participants in both groups received a small gift after completing the
      pretests. The latter two sets of questionnaires were mailed with postage-paid, pre-addressed
      envelopes to all of the participants for them to complete and return. Sixty-one participants
      in the experimental group and 62 participants in the control group completed the 1-month
      posttests; 51 participants in the experimental group and 47 participants in control group
      completed the 3-month posttests. The CONSORT diagram of this study is shown in Figure 1. The
      experimental group participants were asked to complete an open-ended question on the
      subjective benefits of practicing aerobic exercise.

      3.6 | Data analysis Tests for differences in baseline characteristics between the two groups
      included the χ2 test for categorical variables and the t-test for continuous variables. The
      effectiveness of yoga-based low-impact aerobic exercise on maternal-infant attachment and
      sleep quality was determined by a paired t-test. All results with p < .05 were considered
      statistically significant. The SPSS (version 17.0 for Windows, SPSS Inc., Chicago, IL, USA)
      statistical software package was used to analyze the data.
    

Intervention name(s): aerobic exercise program
Intervention type(s): Behavioral
Intervention description(s): The program incorporated modified yoga movements suitable for pregnant women. The DVD provides an illustration with the written caption, "Please take enough water before exercise, and wear loose and comfortable clothes in a suitable environment. If you feel tired, stop exercising immediately." The DVD's narrator then says, "Now you are ready to prepare a comfortable, solid chair with a chair back." With a soft musical background, the exercise actions were arranged in following order: warm-up → neck → shoulder → arm → chest → waist →leg → regulating the breathing. The first 14.5 minutes of the yoga exercises were performed in a sitting position, followed by 3.5 minutes in standing position, and then returning to 2 minutes in sitting position. The exercises were developed as a progressive program in order to achieve the goals of strength-conditioning, moderate-intensity exercise (ACOG, 2015).
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: In addition to routine care, the experimental group was given a DVD and instructed to engage in the aerobic exercise program shown on the DVD. The DVD with low-impact aerobic exercises developed by the researchers in collaboration with a qualified prenatal yoga teacher. The program incorporated modified yoga movements suitable for pregnant women. Women in experimental group were instructed to use the DVD 3 times a week for 3 months. The control group received routine prenatal care only.
Masking: Single (Participant)
Primary purpose: Supportive Care
Keywords: aerobic exercise; prenatal care; sleep quality; maternal-fetal attachment