Indian Pediatrics 2001; 38: 1017-1022  

Physical Activity and Pregnancy Outcome in Rural Undernourished Women

From the Departments of Obstetrics and Gynecology and Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi (UP), India and *Division of Biostatistics, University College of Medical Sciences and Guru Teg Bahadur Hospital, Shahdara, Delhi 110 095, India.

Correspondence to: Dr. Sonika Aggarwal, Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India.
E-mail: [email protected]

Manuscript received: December 1, 2000;Initial review completed: February 13, 2001;Revision accepted: March 5, 2001.

In Africa heavy household tasks in undernourished women reduced infant birth weight(1,2). Similarly, Naeye and Peters(3) reported that birth weight was significantly lower (without shortening the gestation), in undernourished American women doing hard physical activity after 28 weeks of pregnancy. Alegre et al.(4) from Spain also recorded reduced birth weight for women working in paid jobs. In active duty, well nourished military service pregnant women, the rate of low birth weight deliveries and chances for pregnancy induced hypertension were greater(5). However, pregnant resident doctors doing active duty did not show any adverse effect on birth weight(6). The data from French national survey(7), Cardiff births survey(8) and the Boston city hospital(9) documented that birth weight was not associated with maternal employment including standing work in the last trimester. Conversely Hatch et al.(10) in American women on low-moderate and heavy exercise found increase in birth weight by 100 g and 300 g respectively. Rabin et al.(10) also reported marginal increase in birth weight in British women doing full time employment and those having longer hours of sleep. There is a paucity of similar data from India. The present report analyses the impact of physical activity on pregnancy outcome in undernourished rural women in India.

Subjects and Methods

Profile of Selected Study Area in District Varanasi

The present study was undertaken in Kashi Vidhyapeth (21-villages; population 32307) and Harhua (28 villages; population 33770) blocks during 1987-1993. In the latter block Integrated Child Development Services (ICDS) were operative. The female field workers for the study area villages in the Kashi Vidhyapeth block were selected with know-ledge of reading/writing (mostly high school). In the ICDS block, the Anganwadi workers assisted in the study. They enrolled women of reproductive age group, monitored their weight and missing menstrual period every month. They collected information regarding conception, followed pregnancy and measured the infant (weight and length) within 48 h of birth. The infant was examined and measured again by the nutritionist/doctor within one week of birth. The nutritionist/medical doctor examined women for records of physical activity, dietary intake and anthropometric data with the help of the field workers. No nutrition supplement or iron-folate tablet were given by the team to the registered pregnant women. The socio-demographic and biological data of this block pregnant women has been discussed in earlier publications(12,13). The physical activity data were available on 1458 un-supplemented and 873 supplemented(nutrition supplement in the ICDS block) women from the study blocks. A written consent was available from these women and the family cooperated with the nutritionist. All families did not agree to observations of physical activity with presence of a study team member. However, this is unlikely to cause any bias. All births were singleton without any congenital malformation. No study woman had any illness likely to affect physical activity or pregnancy outcome. The methods of registration and data collection have been described in detail earlier(13).

Physical Activity

It was classified as mild, moderate and hard as per earlier recommendations(14). The time for activity and rest was noted by observation method as well as by interview. The activity classification was as follows: (a) Mild: sitting down, standing still, breast feeding, feeding the child, cutting vegetables, eating, watching; (b) Moderate: cooking, drawing water, shopping, washing utensils and clothes, carrying light load, collecting wood, child care, sweeping and cleaning, walking, weeding rice/trans-planting seedlings/harvesting, removing husk from rice or wheat by pounding and (c) Hard: drawing large buckets of water from the well, carrying heavy load ( >20 kg), chopping wood, cleaning land, planting seeds, removing bran from cereals by pounding, digging potatoes, bathing and milking cattle. One of the nutritionist collected the information by spending the day questioning and observing five women in the same hamlet of the village. Caloric expenditure on activities and rest was calculated according to the WHO(15).

Anthropometric Measurements

Maternal weight, height and mid-arm circumference were measured as per standard techniques(13). Birth weight was recorded on a modified Tansi scale(12,13). Infant length was measured on an infantometer. Abdominal girth was measured by fiber glass tape at the level of umbilicus by cross over technique. Fundal height was measured as the distance between symphsis pubis and highest point of the uterine fundus. The fundus was defined by gentle pressure on a plane at right angle to the abdominal wall which was marked.

Hemoglobin and Dietary Intake Measurement

Hemoglobin was estimated by Cyan-methemoglobin method using Drabkin’s solu-tion. Hemoglobin standard was provided by M/s. Ranbaxy, India Ltd, New Delhi. Women with hemoglobin <7.0 g/dl were referred to the health facility and excluded from the study. Dietary survey was done by 24 h recall method using standardized utensils. All estimations were undertaken in all pregnant women at three points 16 ± 2; 28 ± 2 and 36 ± 2 week of gestation. Anthropometric measurements for prepregnancy period were also available.

Statistical Methods

Mean, standard error, Chi square and multiple regression analysis were performed by using the SPSS package.

Results

Physical Activity

At three measurements, women worked for 9.73, 9.59 and 9.38 h a day with day rest of 2.4, 2.7 and 3.2 h and night rest of 7.6, 7.9 and 7.8 h. At first measurement, mild and hard physical activities were 26.2% and 15% changing to 45% and 13% at third measurement, respect-ively. The level of moderate activity also decreased with increase in gestation. Almost 92.6% activity was for the household work. The time spent in extra mild activity was 2.0, 2.4 and 3.2 h at three measurements, respect-ively. The calculated energy expenditure decreased in the third trimester (Table I).

Socio-Biological Characteristics

The mean +SE height was 149.8±0.11 cm. Prepregnancy weight <40 kg was observed in 35.8% and <45 kg in 76.7% of women. Only 5% weighed >50 kg (mean = 42.5 kg). Even at third measurement (36 ± 2 week), 27.4 women remained > 45 kg and only 30% were in weight group >50 kg. The mean weight was 47.8 ± 0.12 kg. The mean (±SE) Mid arm circum-ference were 21.9 (±0.04), 22.1 (±0.04), 22.5 (±0.04) and 22.7 (±0.07) cm for prepregnancy and at three measurement points. The abdominal girths (mean ± SE) at three measurement points were 70.8 ± 0.3, 78.2 ± 0.12 and 85.2 ± 0.12 cm. The corresponding means for fundal height were 12.1 ± 1.7, 22.8 ± 1.9 and 31.5 ± 1.3 cm, respectively. The mean hemoglobin were 10.0 ± 0.3, 9.6 ± 0.03 and 10.0 ± 0.04 g/dl at three measurements, respectively. At the three measurement points the daily caloric intakes were 1670 ± 4.8, 1715 ± 4.8 and 1746 ± 4.9 kcal, and protein intakes 52.8 ± 0.16, 54.1 ± 0.16 and 55.1 ± 0.16 g, respectively.

Table I - Time (min) Spent for Physical Activity and Rest During Day by the Rural Pregnant Women (Mean ± SD)

Table II - Multivariate Analysis to Study Impact of Hard Physical Activity on Birth Weight and Length

Impact of Hard Physical Activity

The result of multiple regression analysis to study the impact of hard physical activity on weight and length of infant at birth is given in Table II. At second measurement hard physical activity significantly improved infant weight, while at third measurement it had a significant negative influence on birth weight, as well as length. However, it did not influence the gestation. Birth weight, parity and fundal height at second measurement significantly influenced the infant length. The amount of rest, mild and moderate activity during three measurements did not influence birth weight/ length and gestation. Abdominal girth at second measurement had negative effect on infant length. Weight gain in pregnancy significantly decreased if women undertook hard physical activity around first and second measurement (correlation coefficients being - 5.493 ± 2.661; p <0.04 and –6.269 ± 2.653; p <0.02, respectively). Rest for longer duration around third measurement was advantageous for weight gain in pregnancy (correlation coefficient being 6.050 ± 2.584; p <0.02). The other variables which influenced birth weight positively were weight gain in pregnancy, 

prepregnancy midarm circumference and calories intake. Women receiving nutrition supplement under integrated child develop-ment services (450-500 kcal with 20 g protein, in last trimester of pregnancy/day) showed marginal improvement in birth length (48.1 ± 1.1 vs 47.9 ± 1.1 cm; p <0.001). The gain in birth weight was discussed in the earlier report(13).

Discussion

The present study women were under-nourished, underfed and were doing heavy physical work for domestic duties, during pregnancy which negatively influenced infant weight and length at birth. Maternal under-nutrition has been associated with placental changes suggestive of hypoxia; resulting in reduced placento-fetal circulation(16), these changes possibly get aggravated due to hard physical activity(1). In contrast, well nourished pregnant women undertaking regular exercises improve placento-fetal circulation(10). Avail-able studies support the hypothesis that undernourished women involved in hard physical activity have lower weight babies, without affecting the length(1,3). It seems that present study rural women due to existing pre-pregnancy under nutrition, poor dietary intake and hard physical activity suffered fetal growth retardation throughout gestation since weight as well as length were reduced. Nutrition supplement in third trimester improved birth weight by 58 g(13) and also improved fetal length (0.2 cm). In contrast well nourished women in pregnancy are either not affected(6-9) or birth weight increases in women under-taking regular hard physical activity(10,11).

To conclude the observations on rural pregnant women suggest that hard physical activity in these undernourished (pre-preg-nancy) women, with low caloric intake caused fetal growth retardation (weight as well as length). The study further suggests that longer period of rest in the third trimester increased maternal weight gain during pregnancy.

Contributors: SA and AA performed literature review, data collection and drafted the manuscript. KNA and DKA were responsible for designing the study, interpreting the results and help in drafting the manuscript. AB performed data analysis. SA will act as the guarantor for the study.

Competing interests: None declared.
Funding: Indian Council of Medical Research and United States Agency for International Development

 

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