Pregnancy and postpartum are two significant time periods in the lives of most women. During reproductive years (ie, pregnancy and postpartum), the development of obesity and/or diabetes is occurring at an unprecedented rate,1–4 and both are even more prevalent among women living in rural communities.5 Because of this, the maintenance of a healthy lifestyle during these phases is important, as excessive weight gain and retention are associated with adverse health outcomes.6 Risks associated with excessive gestational weight gain during pregnancy include preeclampsia, gestational diabetes, macrosomia, congenital defects, low birthweight, preterm birth, and increased prevalence of obstetric intervention at delivery.7,8 Postpartum weight retention is also an independent risk factor for long-term maternal health consequences including obesity, type II diabetes, cardiovascular disease, and postpartum depression.9,10 Concerns for maternal weight retention are substantiated by the fact that at six months postpartum, approximately 50% of women retain ≥10 pounds, approximately 25% retain ≥20 pounds, and many of these women gain additional weight during the first postpartum year.11,12 Therefore, there is an urgent need to develop effective intervention strategies to reduce weight gain during pregnancy and postpartum.
The need for effective intervention strategies is even more critical among women living in rural areas. Women in rural areas experience poorer obstetric outcomes and face impeded access to healthcare resources compared to their urban counterparts.5,13 Additionally, compared with other locations, most rural areas (in the United States) have fewer women’s healthcare providers.5 In Kentucky specifically, 76 of the 120 counties have no obstetricians and most residents drive between 30 and 60 minutes for access to a maternity center.14 This lack of access to obstetric services prevents women from receiving adequate prenatal care and professional guidance about weight status and physical activity during pregnancy and postpartum. This issue is exacerbated in rural areas where obstetric services are being eliminated (possibly due to the increased costs associated with providing labor and delivery services in these areas), leaving obstetricians overworked as they may be the sole healthcare provider serving a high volume of patients.15
Physical activity interventions (with and without dietary components) have been shown to reduce gestational weight gain and retention and improve maternal and infant health outcomes during and after pregnancy;16–21 however, many of these interventions are not feasible or available to women in rural settings (eg, many involve access to a centralized fitness facility). Following delivery, the focus of medical attention shifts to the health of the infant, while maternal health status is often disregarded.22 The American College of Obstetricians and Gynecologists (ACOG) suggests that ongoing medical care and resources need to be provided to women during the first year postpartum.23 Specifically, ACOG recommends using technology (eg, email, texts, apps) to help engage women during the first year after delivery.23 While mobile apps have become popular during pregnancy,24 few address physical activity, none appear to be evidence-based, and research does not support the use of current apps on the market for educational advice during pregnancy.25 Equally important, other commercially available pregnancy apps only provide information for mothers while pregnant; thus, women are not provided with information or guidance during the critically important postpartum months.
Mobile health apps offer the promise of engaging in programs without the challenges of traveling long distances and navigating sparse or absent community programming, which is especially relevant to women living in rural communities.26 While mobile health apps have been used extensively in urban populations,27 few such programs have been developed for women in rural settings, and to our knowledge, none have been developed specifically for pregnant and postpartum women in rural communities. Therefore, the purpose of this study was to utilize focus groups and in-depth interviews to gain insight from pregnant women, postpartum women, and their healthcare providers regarding their needs and perspectives related to physical activity during and after pregnancy in a rural setting. Ultimately, these insights may provide important information that can inform the development of specific features for a mobile application designed to improve health outcomes in pregnant and postpartum women in rural communities.
Because education is necessary, but insufficient to elicit meaningful increases in physical activity during pregnancy,28 it is important to utilize a theoretical model of behavior change when designing an intervention tool (in this case, a mobile app) that addresses more than just knowledge. Further, the majority of physical activity apps have minimal theoretical content despite the fact the apps based on theory tend to be better and more effective.29
Previous work has demonstrated an educational intervention utilizing the Health Belief Model did favorably influence health beliefs about physical activity during pregnancy.30 For this study, we used the Health Belief Model (and its key constructs of perceived severity, perceived susceptibility, perceived barriers, perceived benefits, cues to action, and self-efficacy)31 to not only design the questions for the data collection but also to support the rationale for the identified mobile app features. The results of the study will allow for the integration of participant desires with important mobile app features supported by theoretical evidence linking them to changes in physical activity behaviors.
This study was reviewed and approved by Western Kentucky University’s Institutional Review Board (IRB: 19-413) and the study was conducted in accordance to the Declaration of Helsinki. To obtain perspectives on a mobile health app, focus groups and in-depth face-to-face personal interviews were conducted with pregnant and postpartum women and healthcare providers serving these women from Bowling Green, Kentucky and surrounding areas. A total of 38 (pregnant: n=14, postpartum: n= 13, healthcare providers: n=11) people participated in the study. All pregnant and postpartum participants were recruited through local advertising (ie, Facebook), word-of-mouth, and chain referral sampling.32 Healthcare providers were recruited through the first author’s professional connections with the Medical Center labor and delivery staff and local obstetric clinics. Inclusion criteria for pregnant and postpartum women were: 1) age 18–44 years (ie, childbearing age); 2) pregnancy: confirmed viable pregnancy (4–40 weeks gestation); postpartum: delivered a baby within the past seven months; and 3) English-speaking. Exclusion criteria included inability to provide voluntary informed consent. All healthcare providers who treat obstetric or postpartum patients were invited to participate (obstetricians, nurse midwives, nurses, women’s health physical therapists).
Focus groups and interviews took place between October 2019 and February 2020. Before beginning the focus groups and interviews, all participants provided written consent to participate, be recorded, and have anonymized responses used for analyses and publication. At the start of each session (after written consent was obtained), all pregnant/postpartum participants completed a written form with demographic information including age, body mass index, gestation age/week postpartum, marital status, annual income, subjective assessment of income, race/ethnicity, educational attainment, health status, and parity. Healthcare providers completed a written form requesting information on their age, gender, race, educational attainment, job title, and physical activity level. IBM SPSS Statistics, Version 27 was used to determine means, standard deviations, and descriptive variables (number and percentages) for all demographic variables.
Semi-structured questions (eight questions, Table 1) were used to guide the focus groups and interviews. Constructs from the Health Belief Model were used to guide the development of questions. The Health Belief Model has been shown to be useful to guide the development of culturally appropriate intervention strategies for weight management.31 Through exploration of questions addressing these constructs (perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy),31 the goal was to identify barriers, facilitators, and other influences on physical activity during pregnancy and postpartum. Such insights will help inform the researchers on ways to develop an app to address these factors. In addition, specific questions regarding desired mobile app features were administered and responses were aligned with the same constructs of the Health Belief Model.
Table 1 Focus Group and Interview Questions According to Domains of the Health Belief Model
Focus groups were held at Western Kentucky University’s Health Sciences Complex. With participants’ permission, all interview and focus group responses and subsequent discussions were audiotaped (Evistr Digital Voice Recorder, Evistr Technology, LTD). A moderator asked a series of questions (eg, facilitators and barriers to physical activity and weight status during pregnancy), as well as opinions regarding desired features in a mobile health app. Focus group sessions lasted between 45 and 70 minutes. In-depth (individual) interviews lasted between 10 and 25 minutes. Focus group sessions included the study principal investigator (PI), a nurse practitioner with experience in group care models, as well as one-to-two graduate students from Exercise Science and/or Public Health. In-depth interviews included the PI and the interviewee only.
Three focus groups were held, with six, five, and three pregnant women in each session. Only four and two postpartum women were able to attend focus groups due to challenges finding an agreeable location and time; thus, we elected to conduct face-to-face in-depth interviews instead. Seven one-on-one interviews were held. In-depth interviews were conducted with the women at their home or another location that was most convenient for them. The questions asked in the postpartum in-depth interviews were the same as those asked in the postpartum focus groups (Breakdown of focus groups and interviews for each group is depicted in Figure 1).
Figure 1 Breakdown of focus group and interviews among pregnant women, postpartum women, and healthcare providers.
Most healthcare provider sessions were conducted as in-depth interviews. Six healthcare providers were interviewed one-on-one in the provider’s office. One focus group was held for healthcare providers when researchers were invited to a standing meeting of obstetricians at The Medical Center in Bowling Green, Kentucky. After consenting to participate and be recorded, healthcare providers were asked a series of questions regarding concerns for their patients and how a mobile app could best serve the women they treat. The same questions were used for healthcare provider in-depth interviews and the healthcare provider focus group.
Standard qualitative content analysis procedures for focus group and interview data were utilized.33 Specifically, recordings of all in-depth interviews and focus groups were transcribed first by Trint transcription services, then edited for clarity and accuracy by a member of the research team (CD). Content analysis was conducted using Erlingsson & Brysiewicz’s guidelines for analyzing qualitative data.34 Three researchers (RT, SB, CD) independently reviewed and coded the data into patterns or themes that emerged during discussions. Codes were created by identifying themes in the responses to each question, then summarizing each reoccurring theme under one unifying code. For example, a quote such as “I don’t know what I can and can’t do” would be coded as “lack of guidance”. The themes and codes were identified for every question asked in each subpopulation (pregnancy, postpartum, and healthcare provider). Each coder independently identified the most common codes, and all coders discussed the results to reach a consensus about the codes most frequently mentioned in response to each question. From the codes, key themes were determined.
Qualitative data and social science are critical to understanding key aspects of public health, medical interventions, and wellbeing.35,36 Specifically, focus groups provide a crucial way to connect with people who are directly involved in health interventions.37 In reporting the results from qualitative data collection methods, it is important to fully and adequately represent the words, thoughts and ideas of the participants who helped formulate the themes and results in this paper, which formed the basis for decisions on structuring the following results and discussion sections.
Demographic information for pregnant and postpartum women as well as healthcare providers can be found in Tables 2 and 3, respectively. The average age of pregnant women was 29.9 years, and the average BMI (during pregnancy) was 28.8 kg/m2, while the average age of postpartum women was 31.0 years, and the average BMI was 27.6 kg/m2. The majority of the pregnant women were Caucasian (n=13, 93%) with 7% (n=1) identifying as Latina. Eleven women in the postpartum group were Caucasian (85%), with one participant identifying as African American (8%) and one participant identifying as Latina (8%). Based on birth records at The Medical Center in 2019, this sample is generally representative of the pregnant population in Bowling Green, KY (80% Caucasian, 10% African American, and 4% Asian). Healthcare professionals interviewed included obstetricians/MDs, certified midwives, postpartum nurses, and physical therapists. The average age of healthcare providers was 39 years and six of the 11 (55%) were female. All healthcare providers were Caucasian (n=11).
Table 2 Pregnant and Postpartum Participant Characteristics
Table 3 Healthcare Provider Characteristics
Themes from Focus Groups and Interviews
Tables 4–6 contain concepts that emerged in response to each question, as well as representative quotes from participants, which were used to identify main themes. Quotes that contributed specifically to one of the two main themes or the development of a specific mobile app feature are designated as such within the tables (Table 4: Pregnancy Focus Group Responses, Table 5: Postpartum Focus Group and Interview Responses, Table 6: Healthcare Provider Focus Group and Interview Responses).
Table 4 Pregnancy Focus Group Responses
Table 5 Postpartum Focus Group and Interview Responses
Table 6 Provider Focus Group and Interview Responses
Rural women and healthcare providers expressed numerous perspectives about physical activity during and after pregnancy, allowing us to identify two overarching/key themes: 1) physical activity as critical for weight control, and 2) the need for evidence-based exercise information. Participant responses were also used to identify fundamental mobile app features to improve physical activity during and after pregnancy.
Theme 1: Physical Activity as Critical for Weight Control
All participants (pregnant women, postpartum women, and healthcare providers) expressed concern about weight gain and retention, highlighting the potential role of exercise in mitigating these concerns. Many pregnant women expressed that their primary concern is not necessarily the pregnancy weight gain itself, but the ability to lose what they gain after the baby is born. A woman pregnant with her first child said:
I actually had just started to lose weight when I found out I was pregnant. My best friend was getting married in July. February I started losing weight. And by April, I found out I was pregnant. My goal was 50 pounds [weight loss], I actually made it to like 46 before the wedding. But I do not wanna gain all of that back, and then, you know, have more trouble losing it again. That’s a big worry for me, is that I would gain too much, and then be like, how am I ever gonna lose this back?
Postpartum women also expressed concern about weight gain and weight retention after birth, as well as the health implications associated with excessive weight gain and/or retention. Postpartum participants described concerns about not only losing pregnancy-related weight gain but also continuing to gain weight after giving birth as a result of poor lifestyle choices, as one postpartum woman said:
It is harder to get active again. And if you do not find yourself like getting up and just doing little things, you find yourself gaining more weight because you have that tendency to like, continue to eat because that’s what you are used to, because you are just carrying a child. So you do not think, oh, I am no longer pregnant, I probably should not be eating like this anymore.
Participants identified lifestyle habits, mental health challenges like depression, and childcare responsibilities as reasons they continued to gain weight after birth. An obstetrician who has been practicing in the community for over 30 years noted that the implications of weight gain during pregnancy extend beyond the current pregnancy, particularly considering multiparty with short intervals. Pointing to an example of a prenatal chart, he noted:
And their next pregnancy weight will be at the top there. And I have had women where I had three pregnancy flow sheets. This weight [end of pregnancy 1] was that weight [start of pregnancy 2]. Then this weight [end of pregnancy 2] was that weight [start of pregnancy 3].
This physician and others expressed concern about weight gain and the implications of weight retention over time and over multiple pregnancies. Healthcare providers also emphasized the complexity of working with pregnant women who are experiencing weight retention or obesity, as well as how commonly they are faced with providing care for these patients. One healthcare provider explained:
I mean, first of all, we have a lot of patients coming into pregnancy, you know, in the overweight or obese categories to start with. And of course, that we have a little bit different guidelines for ideal weight gain. So, yeah, that’s a struggle. If I had to just, off the thumb, two thirds of our patients [are overweight or obese]. It’s a struggle.
Another obstetrician described how it is easy to motivate pregnant women to be active, but motivation decreases during the postpartum period, suggesting an important opportunity to make an impact on lifestyles during this critical time period. He said:
I had one patient who was diabetic and was obese, she lost 50 pounds during the pregnancy just being on her diabetes diet. But as soon as that baby was born, she went back to her old ways and gained all of that weight right back. And that’s the key; trying to keep people motivated. And like I said, sometimes they will do things for the child that they would not do for themselves.
Taken together, participants among all groups expressed concerns about weight control during and after pregnancy, and all supported the idea that exercise could potentially mitigate these concerns. Taken in the context of the Health Belief Model, it appears that women view themselves as susceptible to the effects of sedentary behavior, and that these can have serious consequences (ie, severity).31 However, exercise must be prescribed carefully and properly to be effective for pregnant and postpartum women. As described below, this need for evidence-based information from a trusted source constitutes a key concern for participants.
Theme 2: The Need for Evidence-Based Exercise Information
To increase exercise during pregnancy and postpartum, participants described a need for high-quality, evidence-based, trustworthy exercise information from qualified professionals. Pregnant and postpartum women indicated a desire to know explicitly what frequency, intensity, time, and type of exercises they should be doing at specific time points of pregnancy and postpartum. According to our participants, this information is not readily available to them currently. Many women stated that they often did not exercise because they were unsure of what to do, and this uncertainty contributed to a fear of causing harm to themselves or their child. Taken in the context of the Health Belief Model framework, women perceived a high level of risk and believed this risk may outweigh the perceived benefits; thus, likely limiting their decision to participate in physical activity. A woman pregnant with her first baby stated:
I think my concern is, like, it’s similar to yours in that I do not really know what I can do. And I also do not trust an instructor- like if it’s a group class to be able to tell me if it’s appropriate for my body because I have had people tell me something that’s appropriate and then it does not feel right. Or … And the other thing is that I think like a lot of exercise programs are created for a biological, like a biologically male pelvis, and they are not necessarily created for a female pelvis. So why would they be OK for a pregnant woman either? So there’s just like general concerns in terms of how somebody can actually instruct me.
Women also reported that existing resources and information fail to clearly describe recommended levels of regular daily activities. For example, a restaurant server, who was three months pregnant with her first child, discussed her uncertainty of the safety of physical exertion:
I was waiting tables when I first found out I was pregnant. And it was nothing for me to lift 5-gallon buckets of ice. And here I am, you know, 3 months pregnant. And they are like, what are you doing? And I am like uh- oh! You know. So I do not necessarily think about, right off the bat, oh, I should not be doing this. And then you think afterwards, did I do something to hurt the baby? So you have that fear of not knowing what level you should go to.
Women described the physical activity advice given by their healthcare providers as arbitrary and not particularly helpful, as described by a pregnant participant:
That piece of advice [to listen to your body] is totally discouraging because your body is doing something completely different than it has ever done before. So “listen to your body” is like, I do not know what the hell my body is doing.
Women reported similar perspectives after having a baby, as one postpartum woman stated:
Well it’s kind of weird because you go to your 6-week appointment. She’s like everything looks good, see you for your annual, and you kind of feel like you’re just thrown to the wolves.
Consistent with their patients, healthcare providers admitted that they seldom provided exercise education during or after pregnancy as part of routine care. As one obstetrician said, “… just with all the things you have to cover, it’s not a huge part of what we do”, indicating that during prenatal care, obstetricians tend to focus on what they view as more critical issues, for example, smoking cessation. In addition, healthcare providers report feeling unable to discuss physical activity due to the demands of clinical productivity, which limit the amount of time they can spend with each patient, which is particularly relevant in rural areas where healthcare provider shortages exist. Another obstetrician admitted that he did not sufficiently discuss exercise with his patients:
Well, with weight gain, I mean, my first thing is what have you been doing? I have got my basic talk for their OB visit. It’s probably not as in-depth as maybe it should be, but it just kind of gets buried in all of the other education we have to do.
As pregnant and postpartum women are provided with more evidence-based physical activity information, many common misconceptions about exercise during pregnancy will be dispelled. Misconceptions about exercise during pregnancy came up in data collection with pregnant women, postpartum women, and healthcare providers. Healthcare providers expressed concern about how these misconceptions exacerbate certain unhealthy behaviors during and after pregnancy. For example, a pregnancy and postpartum nurse educator discussed how she addresses pregnancy parking spots with her patients, “You know. Here’s another myth. You know, those parking spots that are there for you. Don’t park in them. Park and walk.” Many patients reinforced healthcare providers’ concerns, harboring misperception that physical activity is potentially dangerous for pregnant women and their unborn children.
Healthcare providers also expressed concern that cultural and social misconceptions may be encouraging pregnant women to consume far too many calories while also not burning enough through physical activity. One obstetrician with 34 years of experience said, “They are under the mindset that “I am pregnant. I’m building the baby. So I don’t really have to do anything after that.” Providers often mentioned additional problems with energy balance stemming from the misconception that pregnant women should be “eating for two.” Healthcare providers acknowledged many challenges associated with overcoming cultural ideas and expectations, as these messages are widespread and embedded into everyday life through word of mouth and media.
Pregnant and postpartum women report receiving information suggesting they should limit movement after having a baby, and some women reported that friends or family members showed disapproval of exercise routines or encouraged them to rest. On the contrary, most healthcare providers suggest that moving early and often will facilitate an improved recovery after delivery. Healthcare providers discussed how communication can and should be adapted to better reflect the reality that moving after delivery can be helpful. One postpartum clinical nurse and nurse educator said:
I really think changing the mindset of all these moms is super beneficial and reminding them that they can do that [exercise] despite what was done 20 years ago … I think that they need to know. First of all, it’s OK to get up and move. You know that they need that little you know- this is why it’s good to get up and move like that. This is how it helps your body. This is what it does for you. It helps your sleep. You know, like all those kind of things. So they need to know that they can do this …. It’s like I tell our C-section moms, hey we need you to get up and walk the hallway, they are kind of like, I can do that? And we are like yes, it will help you. Yeah, it will help you, and so I think if we can get that message across, that could be really good.
Taken together, women and healthcare providers expressed that common misconceptions about physical activity during and after pregnancy may limit women’s willingness to be physically active. The need for evidence-based exercise information that supports overall health and encourages weight control led to our final set of insights, developing mobile technology to improve physical activity levels among pregnant and postpartum women.
Approaches for Addressing Concerns Through Key Mobile App Key Features
Participants identified a number of desired app features to increase physical activity during and after pregnancy, many of which address the concerns described above, and nearly all of which fall under proven theories for behavior change such as the Health Belief Model.38 First, participants described the ways in which progress tracking and goal setting help women meet evidence-based fitness and weight control goals. One pregnant woman who already uses mobile technology to assist with her exercise levels stated that having an exercise goal to obtain motivates her. Regarding the notifications her watch gives her to move, she said,
[If the watch says] you’re almost there, to close all your rings, I’m like okay, I’ll just get up and like walk around the house or something. Just like close my rings.
This perspective demonstrates how an individualized progress-tracker may push women to reach their fitness benchmarks.
Similar to tracking physical activity progression, participants described progress tracking for nutrition and weight management. Although the goal of the study was to inquire about physical activity during and after pregnancy, participants frequently mentioned weight gain and nutrition during data collection. Pregnant and postpartum women and healthcare providers expressed interest in an app feature providing tracking information on appropriate weight gain tailored to each woman’s needs (ie, pre-pregnancy BMI, exercise level, age), and the inclusion of physical activities that could improve or mitigate inappropriate weight gain.
To enhance trustworthiness of exercise information and overcome exercise misconceptions, which were important topics of conversation during data collection, women and healthcare providers suggested that the app contain safe, evidence-based physical activity guidance. For example, a postpartum woman with a four-month old baby said:
And if somebody could, like, offer me something, it would be like, like what reps to do. Like I feel like at one point if I had a set like routine of 30 reps of ABCDE and F and do that every day, and it would at least help tone or maintain or something. I would have done it because what would happen is, I would get those things and then like I would not know what to do.
Participants also indicated that workouts included in the app should be tailored specifically to the time point of pregnancy or postpartum, because existing resources do not provide this type of tailored guidance, and pregnant and postpartum bodies are constantly changing. One pregnant participant described her ideas for how the app could communicate with her based on gestation week:
You have hit the, whatever, 13 week mark. You should be fine to like run or maybe start walking. And then maybe when it gets closer to the ninth month, like hey, let us slow down a little this week, just some walking.
This representative quote suggests that women would like a mobile app to tailor the physical activity information to the specific week of pregnancy. They want clear guidance regarding safe and recommended activities for specific time points of pregnancy (and postpartum). Obstetric healthcare providers also suggested tailoring exercise information to the specific time point of pregnancy. As an example, one obstetrician stated:
Suggestions for the exercises that are safe in pregnancy, or like the exercise of the day, like a yoga move that like would be helpful for like low back pain if they are, you know- like targeted to what week they are at. You know, if maybe they are at 33 weeks, the yoga move that would be more helpful than something at 10 weeks.
Participants also proposed a community forum as an important app feature to increase social support, stay or become active, and positively impact mental health. For example, a stay-at-home mom who was 35 weeks pregnant with her third baby stated:
So I go to those forums a lot, like what to expect when you are expecting and read about other moms and what they are going through. And if I were to see like, hey, I am a runner. I cannot run anymore, but here’s some really beneficial workouts I am doing that might- we are both due in March. Maybe this would be good for you too. So you’d be able to talk to other moms about stuff they are doing. I do like that a lot.
Similarly, when asked about what would help facilitate exercise during postpartum, a woman with a six-month-old baby said, “I think postpartum people just need encouragement that they’re doing a good job. Or even trying”. Another postpartum woman stated, “So I think a forum style thing, where people can talk to each other and ask questions. Just ask, kind of like the group.” A community forum of other new or expectant mothers going through these exciting but challenging time periods together could provide the sense of social support and community that these women clearly desire. In turn, the added social support can assist them with reaching clinically important physical activity goals.
Postpartum women expressed concern for mental health after having a baby, noting that a community forum in a mobile app may provide necessary assistance with physical activity and social support, both of which can favorably impact mental health. When asked about the risks of sitting too much after having a baby, a mother of three with a 4-month old who was back to work as a teacher said:
I think that like, probably the biggest risk would just be even like your mental health with it. Like after I had [my baby] I would notice like, if I was just like- I always joked that I had my square on the couch and I just wanted to stay there, all the time. And I think you can get into kind of like a habit … and like it can affect your mental health.
A mother of three whose youngest spent several weeks in the neonatal intensive care unit also expressed concern for mental health, and inquired about ways a mobile app could potentially assist with mental health after delivery. She asked:
Is there anything [in the plans for the app] in there for like postpartum depression? We both suffered from it with him … So it was rough …. But with him- it hit hard. Like I have never experienced depression ever, ever …. Or something [an app feature] to keep your mind off the negativity. Like to keep the negative thoughts out of your head.
All participant groups expressed a desire for push notifications to remind them to move. For example, a postpartum woman said, “You go to your phone and have like, a little encouraging message that encourages you to work out and be better for you and the baby.” Healthcare providers agreed that push notifications could serve as an important potential app feature. For example, one obstetrician stated,
Or maybe there’s just something in that app that kind of reminds them, did you go for a 10-minute walk today? Or did you watch what you ate for lunch? I think those are keys.
Participants suggested several additional mobile app features, including links to time-efficient workouts and symptom-tracking. Generally, women report feeling like they do not have a lot of free time (ie, “I remember thinking, I need to exercise, but like, I just don’t have the time”); thus, workouts should be designed to complete in a short window of time. Regarding symptom tracking, participants also mentioned wanting to be able to keep track of how they are feeling, specifically whether a workout is advisable based on symptoms, and customize workouts accordingly. One pregnant participant stated:
I think you definitely need that [symptom tracking] because I am almost through my second trimester and I still have the days of oh my gosh, I am so nauseous. I am so tired. I have had a lot of dizzy spells, to where every time I stood up I would have to sit back down immediately. So, I mean, you know in that situation, I do not wanna get up and exercise, I am going to die. You know, I was waiting tables and I did not know to limit myself yet because here I am, you know, 8 weeks pregnant, why am I limiting myself? And I passed out in the middle of the restaurant.
As an additional safety feature, healthcare providers suggested symptom tracking with flagging for when to contact the provider. Healthcare providers indicated that they often feel like their patients do not know what is normal or what is not normal and what would warrant contact with the provider. A women’s health specialist/physical therapist said:
I could have helped better and possibly kept them moving longer, kept them off pain meds, and things like kept them off bed rest or limited activity. I mean, there’s all of these things that had we gotten to them sooner, we could have prevented. Red flags for you have got to get to the doctor.
Pregnant and postpartum women differed on the desired app features and structure. Pregnant women generally desired flexibility in the workouts and the schedule of the workout program. As one pregnant woman stated, “If you have the flexibility, you can account for how a pregnant woman is feeling in a day and that’s forever going to be changing.” On the contrary, postpartum women desired structure to help ensure their success using the mobile health app to be physically active. A postpartum woman said, “If I don’t follow a schedule and regimen and I try to skip around, I won’t be successful.”
This study gained novel perspectives from pregnant women, postpartum women, and obstetric healthcare providers on their concerns and their patients’ needs and desires for assistance related to physical activity during pregnancy and postpartum. Broadly, these perspectives encapsulated two main themes: 1) physical activity as critical for weight control and 2) the need for evidence-based exercise information. In addition to aforementioned themes, participants identified specific features and approaches for future integration into a mobile app to positively influence physical activity behaviors during and after pregnancy.
All participant groups identified the importance of utilizing physical activity for weight control. Our findings are similar to previous work which demonstrates that both patients and healthcare providers are concerned about gestational weight gain, yet patient-provider information exchanges about gestational weight gain lack sufficient depth to facilitate uptake of healthy lifestyle behaviors.39 Our findings suggest that pregnant women intend to lose weight after giving birth; however, postpartum women have found weight loss (and even preventing additional weight gain) after pregnancy to be challenging. There exists an urgent need for both pregnant and postpartum women to implement successful strategies to assist with both weight gain during pregnancy and weight retention afterwards.
Future intervention strategies should focus on providing women with evidence-based exercise information, which is another important theme identified by study participants. Misconceptions and misinformation surrounding physical activity during pregnancy and postpartum40,41 combined with a lack of evidence-based information regarding exercise during and after pregnancy contribute to women not knowing how to safely and effectively exercise. Some women may avoid exercise during pregnancy and postpartum because they are nervous to cause harm to their unborn child42 or to themselves, and both of these could possibly be attributed, at least partially, to a lack of consistent information and guidance.42,43 Our data are consistent with a previous study by Saligheh et al who found that postpartum participants mentioned a lack of high-quality exercise programs as a major barrier to exercise after having a baby.43 An opportunity exists to update traditional practices and services44 by providing pregnant and postpartum women with technology and evidence-based exercise advice. Utilizing this contemporary platform is advantageous in that it can be tailored to the individual, contains personal health tracking, utilizes real-world settings, improves efficiency and frequency of communication between patients and healthcare providers, respects the considerable time demands of mothers, and may be more accessible to low-income women in rural areas.45,46 Further, previous research demonstrates that postpartum women, who are often unable to leave the home due to childcare needs or safety concerns, strongly value online support and resources.47
Pregnant and postpartum women also report a lack of guidance from healthcare providers on this topic. There exists a potential missed opportunity for healthcare providers to focus on utilizing physical activity as a means to positively influence body weight (and other important health outcomes) during and after pregnancy. Our data are consistent with previous studies suggesting that both patients and healthcare providers view discussions of physical activity favorably; however, oftentimes the counseling is limited and not fully consistent with guidelines.48 Women in the present study reported that the advice from their healthcare providers was often arbitrary and not specific or particularly helpful during and after pregnancy. Previous research shows similar barriers perceived by pregnant and postpartum women;42,49,50 it seems common that healthcare provider advice regarding physical activity is often insufficient and inconsistent.
Another important consideration as to why physical activity information is not being adequately provided to pregnant and postpartum women is that most obstetric healthcare providers do not have specific training in exercise physiology, as most medical schools do not have exercise education in their curriculum.51 With this in mind, giving detailed exercise information may not be something they feel qualified to provide. One solution to this could be to involve an exercise expert (ie, physical therapist or exercise physiologist) on the obstetric healthcare team;8 however, this option poses logistical and financial challenges as currently no structure exists for direct referral to an exercise expert, and there is no insurance coverage for the patient to receive services from an exercise expert at low or no cost to them. An additional problem with adding exercise experts to the obstetric care team is that similar to obstetricians, a shortage in physical therapists and fitness professionals also exists in rural areas, which furthers the potential for technology to assist with interventions and activity assistance.52
Healthcare providers also recognized the lack of knowledge and uncertainty that pregnant and postpartum women experience pertaining to their body and exercise. Healthcare providers brought up that these misunderstandings exacerbate unhealthy lifestyles during and after pregnancy. Many misconceptions about activity during pregnancy exist, which is logical given that ACOG has amended its recommendations for physical activity during pregnancy five times since 1985,53 and overarching recommendations have changed drastically over the past 35 years with the arrival of high-quality evidence of the safety and efficacy of exercise during pregnancy. The normalization and expectation of substantial weight gain and “taking it easy” during pregnancy are culturally embedded as social norms. It is well-established that people conform their lifestyle behaviors to social norms set by others, and pregnant women are even more susceptible to the influences of social norms.54 Cultural messages which encourage less activity during pregnancy are reinforced as social norms, and therefore healthcare providers recommended that a future mobile app have reminders or tips about the lack of validity of such messages.
Given the fact that rural women are disproportionality impacted by more serious health issues such as obesity and smoking,55,56 healthcare providers may also not prioritize physical activity guidance. However, physical activity may potentially be used as part of therapy for weight loss and/or smoking cessation;19,57 thus, making an important case for facilitating communication between patients and healthcare providers about physical activity during and after pregnancy. In addition to higher rates of smoking and obesity, which have potential negative impacts on the health of the mother and baby, healthcare providers also explained that many of their patients experience low socioeconomic status and therefore encounter substantial stress facing everyday obstacles (ie, “And then we just have such a huge segment of the population who, just honestly, they’re just trying to survive day to day.”). While physical activity could be an effective way to mitigate this stress, it is important to recognize that exercise may not be a priority for women who are struggling financially. Future efforts should focus on the widespread benefits of physical activity during and after pregnancy, including stress relief,58 mental health,59,60 and smoking cessation.61 In addition, future intervention strategies that do not involve added expenses (eg, gym memberships, exercise equipment) should be considered for use among rural women.
The present study also revealed that women desire social support to encourage them to be active and positively influence their mental health during pregnancy and postpartum. Our findings regarding women’s desire for social support are consistent with research which demonstrates that postpartum women desire social support from peer groups.47 Social support is an important facet of future app development, as social support is useful for encouraging appropriate prenatal care and healthy behaviors during pregnancy62 as well as exercise during postpartum.43 Previous work demonstrates that social support, especially after birth, is important for mothers of all ages to reduce the risk of developing postpartum depression in addition to encouraging healthier behaviors.63–65 Concerns for mental health were evident among our study participants, as many women described challenges associated with mental health after having a baby and desired mobile app features that could assist with managing postpartum depressive symptoms. Mental health concerns are substantiated by the fact that up to 84% of the women experience some form of a depressive disorder after pregnancy, and postpartum depressive disorders can have serious health implications for both mother and baby.66 For instance, postpartum depression contributes to the high maternal morbidity and mortality rates in the United States.67,68 Further, mental health disorders may be worse for women residing in rural settings where there is less access to mental health resources/services and fewer opportunities for social interaction.64,69,70
While mental health concerns are prevalent during and after pregnancy, physical activity holds the potential to improve depressive symptoms during and after pregnancy.66,71 In fact, physical activity is an essential factor for preventing postpartum depressive disorders.66 Therefore, a mobile app has the potential to serve pregnant and postpartum women by providing support, a community of women, and exercise guidance, all of which could potentially help with depressive symptoms and other physical activity-related outcomes. Taken together, there is an opportunity for a mobile app, specifically designed and operated by exercise experts, to provide evidence-based exercise information and social support to pregnant and postpartum women. This allows the desired information to assist and support women without placing an additional burden on healthcare providers.
While the mobile app features were identified by participants themselves and not selected based on behavior change theories, we feel confident these features will positively influence physical activity behaviors during pregnancy as nearly all of the identified features are linked to behavior change theory constructs. Strong evidence suggest that interventions designed with behavior change theories are effective at influencing behavior at the personal, community, and population levels.38 Among physical activity mobile apps specifically, apps developed with cognizance of theoretical concepts of health behavior are more effective (and subsequently more expensive).29 During pregnancy, addressing constructs of the Health Belief Model in the form of education has been successful in influencing physical activity beliefs during pregnancy.30 The key identified app features fall directly in line with many of the constructs of the Health Belief Model (See Table 7), and thus, we believe the present study provides a sound framework, based on theory, that will allow for the development of a mobile app that can improve physical activity behaviors during pregnancy.
Table 7 Participant Identified App Features and Their Application to the Health Belief Model
For example, nearly all behavioral theories, including the Health Belief Model, suggest self-efficacy as an important determinant of health behaviors and eliciting health behavior changes.30,72 In the present study, the majority of the features identified are likely to positively influence self-efficacy towards exercise behaviors. In fact, many of the concerns identified by participants (ie, I do not know what to do?) are ultimately going to contribute to low levels of self-efficacy for exercise during pregnancy, which may play a role in the small percentage of pregnant women achieving recommended physical activity guidelines.73 Specific and evidence-based information about physical activity during pregnancy will not only increase self-efficacy but will also overcome a common barrier to exercise for many pregnant and postpartum women.42
Further, previous work suggests that a broad array of interventions, including those with educational brochures/information, positively influenced self-efficacy towards exercise during pregnancy74 and exercise levels during pregnancy,30 which is especially relevant given women in rural areas of America are likely to lack self-efficacy and education about the benefits and safety for exercise during pregnancy.75 In addition, many of the features identified will help overcome common barriers to exercise during and after pregnancy.42 Another example that can positively influence self-efficacy is self-monitoring/progress tracking, which has been identified as the most important behavioral strategy in lifestyle interventions and76 and consistent online self-monitoring has been successful in changing exercise behavior pregnant women and early postpartum women.77 Further, if a goal has been set for a behavior such as reaching physical activity guidelines, self-monitoring allows for the tracking of progress towards that goal, which can be very beneficial towards reaching a goal.76 Additional examples can be found in Table 7. Taken together, we believe the app features identified by participants in the present study hold potential to positively influence physical activity-related health behaviors as evidenced by previous work with online interventions among pregnant and postpartum women.77
One limitation of the present study is that most of the pregnant and postpartum participants had relatively high educational attainment and income levels. To elaborate, over three-fourths of our study participants reported an income level at least $15,000 above the average income reported for the region. Also, all of the healthcare providers were Caucasian. Therefore, it is possible that the characteristics of our study participants limit the generalizability of our results. Further, all women who participated were able attend and to transport themselves to the location of the focus groups. There is likely a subset of pregnant/postpartum women residing in rural places that could not access the focus groups (due to lack of transportation, childcare concerns, work schedules, or other reasons); once again, findings cannot be generalized to these women. Although the focus groups and interviews were carefully facilitated to encourage honest answers and everyone to participate, it is also possible that some women may not have wanted to publicly share their views. A final limitation is that all emerging ideas were organized into two broad themes in order to streamline results, as is customary in qualitative work; however, it is possible some ideas did not fit well into either key concept and were not discussed in detail. A final limitation is that our in-depth interviews were shorter in duration than what would be considered ideal; however, the other qualities essential to in-depth interviewing are relevant and present (eg, semi-structured format, flexibility, a personal relationship); thus, we decided to still classify these as in-depth interviews.78 Despite the limitations, we feel our study presents novel data that will allow for the design and development of an app that currently does not exist and meets a critical need – a physical activity app for pregnant and postpartum women in rural communities. Further, we feel strongly that using direct feedback and opinions from the population we intend to serve (pregnant women, postpartum women, and healthcare providers in a rural setting) to inform the selection of features was a critically important (and oftentimes overlooked) step towards successfully developing this mobile app.
Our results are the first to identify the perspectives of three key groups of individuals in a rural community (pregnant women, postpartum women, and obstetric healthcare providers) regarding physical activity during and after pregnancy, and how a mobile app could be developed to best serve the community. Perspectives gained from the present study contribute to enhanced understanding of the concerns of the population as well as the identification of desired app features that should be thoughtfully considered in future mobile health interventions among rural women. Given the challenges faced by pregnant and postpartum women, the development of a mobile app tailored to women in a rural setting has strong potential to overcome these challenges and improve clinical outcomes.
ACOG, American College of Obstetricians and Gynecologists; BMI, Body Mass Index; HBM, Health Belief Model.
Data Sharing Statement
The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.
This study was reviewed and approved by Western Kentucky University’s Institutional Review Board (IRB: 19-413).
Consent to Participate
All participants read and signed an informed consent document before study participation began.
We wish to acknowledge of all the women who participated in our focus groups and interviews for their time and honesty. We also want to thank Brenna Menke and Angel Parker for their assistance with data collections.
All authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave final approval of the version to be published; and agree to be accountable for all aspects of the work.
This study was funded by the NIGMS-funded Institutional Development Award (IDeA) Networks of Biomedical Research Excellence (INBRE) in Kentucky (P20GM103436).
The authors have no relevant financial or non-financial interests to disclose.
1. Reece EA, Leguizamon G, Wiznitzer A. Gestational diabetes: the need for a common ground. Lancet. 2009;373(9677):1789–1797. doi:10.1016/S0140-6736(09)60515-8
2. Chan JC, Malik V, Jia W, et al. Diabetes in Asia: epidemiology, risk factors, and pathophysiology. JAMA. 2009;301(20):2129–2140. doi:10.1001/jama.2009.726
3. Godfrey KM, Reynolds RM, Prescott SL, et al. Influence of maternal obesity on the long-term health of offspring. Lancet Diabetes Endocrinol. 2017;5(1):53–64. doi:10.1016/S2213-8587(16)30107-3
4. Pastore I, Chiefari E, Vero R, Brunetti A. Postpartum glucose intolerance: an updated overview. Endocrine. 2017;59(3):481–494.
5. ACOG Committee Opinion. No. 586: health disparities in rural women. Obstet Gynecol. 2014;123(2 Pt 1):384–388. doi:10.1097/01.AOG.0000443278.06393.d6
6. Chen HY, Chauhan SP. Association between Gestational Weight Gain Adequacy and Adverse Maternal and Neonatal Outcomes. Am J Perinatol. 2019;36(6):615–623. doi:10.1055/s-0038-1672196
7. Smith SA, Hulsey T, Goodnight W. Effects of obesity on pregnancy. J Obstet Gynecol Neonatal Nurs. 2008;37(2):176–184. doi:10.1111/j.1552-6909.2008.00222.x
8. Tinius RA, Cahill AG, Cade WT. Origins in the Womb: potential Role of the Physical Therapist in Modulating the Deleterious Effects of Obesity on Maternal and Offspring Health Through Movement Promotion and Prescription During Pregnancy. Phys Ther. 2017;97(1):114–123. doi:10.2522/ptj.20150678
9. Rooney BL, Schauberger CW, Mathiason MA. Impact of perinatal weight change on long-term obesity and obesity-related illnesses. Obstet Gynecol. 2005;106(6):1349–1356. doi:10.1097/01.AOG.0000185480.09068.4a
10. Herring SJ, Rich-Edwards JW, Oken E, Rifas-Shiman SL, Kleinman KP, Gillman MW. Association of postpartum depression with weight retention 1 year after childbirth. Obesity. 2008;16(6):1296–1301. doi:10.1038/oby.2008.71
11. Rasmussen KM, Catalano PM, Yaktine AL. New guidelines for weight gain during pregnancy: what obstetrician/gynecologists should know. Curr Opin Obstet Gynecol. 2009;21(6):521–526. doi:10.1097/GCO.0b013e328332d24e
12. Pregnancy Nutrition Surveillance System (PNSS) and Institute of Medicine and National Research Council, 2009.
13. Elixhauser A, Wier LM. Complicating Conditions of Pregnancy and Childbirth, 2008: Statistical Brief #113. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD); 2006.
14. ACOG Workforce Fact Sheet: Kentucky. The American Congress of Obestricians and Gynecologists. 2014. Available from: https://www.acog.org/~/media/Departments/Government%20Relations%20and%20Outreach/WF2011KY.pdf?dmc=1.
15. American Hospital Association. Rural Report: challenges Facing Rural Communities and the Roadmap to Ensure Local Access to High-quality, Affordable Care. 2019. Available from:https://www.aha.org/guidesreports/2019-02-04-rural-report-2019.
16. Streuling I, Beyerlein A, Rosenfeld E, Hofmann H, Schulz T, von Kries R. Physical activity and gestational weight gain: a meta-analysis of intervention trials. BJOG. 2011;118(3):278–284. doi:10.1111/j.1471-0528.2010.02801.x
17. Streuling I, Beyerlein A, von Kries R. Can gestational weight gain be modified by increasing physical activity and diet counseling? A meta-analysis of interventional trials. Am J Clin Nutr. 2010;92(4):678–687. doi:10.3945/ajcn.2010.29363
18. Jiang H, Qian X, Li M, et al. Can physical activity reduce excessive gestational weight gain? Findings from a Chinese urban pregnant women cohort study. Int J Behav Nutr Phys Act. 2012;9(1):12. doi:10.1186/1479-5868-9-12
19. Ruchat SM, Mottola MF, Skow RJ, et al. Effectiveness of exercise interventions in the prevention of excessive gestational weight gain and postpartum weight retention: a systematic review and meta-analysis. Br J Sports Med. 2018;52(21):1347–1356. doi:10.1136/bjsports-2018-099399
20. Physical Activity and Exercise During. Pregnancy and the Postpartum Period: ACOG Committee Opinion, Number 804. Obstet Gynecol. 2020;135(4):e178–e188. doi:10.1097/AOG.0000000000003772
21. Wang QW, Chen L, Hu CL, Shao ZY, Wang Y, Li L. [Influence of physical activity on postpartum weight retention among women, one year after childbirth]. Zhonghua Liu Xing Bing Xue Za Zhi. 2013;34(11):1077–1079. Chinese.
22. Wendland CL. The vanishing mother: cesarean section and “evidence-based obstetrics”. Med Anthropol Q. 2007;21(2):218–233. doi:10.1525/maq.2007.21.2.218
23. ACOG Committee Opinion. No. 736: optimizing Postpartum Care. Obstet Gynecol. 2018;131(5):e140–e150. doi:10.1097/AOG.0000000000002633
24. Brown HM, Bucher T, Collins CE, Rollo ME. A review of pregnancy apps freely available in the Google Play Store. Health Promot J Austr. 2019;31(3):340–342. doi:10.1002/hpja.270
25. Brown HM, Bucher T, Collins CE, Rollo ME. A review of pregnancy iPhone apps assessing their quality, inclusion of behaviour change techniques, and nutrition information. Matern Child Nutr. 2019;15(3):e12768. doi:10.1111/mcn.12768
26. Douthit N, Kiv S, Dwolatzky T, Biswas S. Exposing some important barriers to health care access in the rural USA. Public Health. 2015;129(6):611–620.
27. Joiner KL, Nam S, Whittemore R. Lifestyle interventions based on the diabetes prevention program delivered via eHealth: a systematic review and meta-analysis. Prev Med. 2017;100:194–207. doi:10.1016/j.ypmed.2017.04.033
28. Tinius R, Edens K, Link K. et al. Effect of Evidence-Based Materials and Access to Local Resources on Physical Activity Levels, Beliefs, and Motivation During Pregnancy in a Rural Setting. J Phys Act Health;2020. 1–11. doi:10.1123/jpah.2019-0440
29. Cowan LT, Van Wagenen SA, Brown BA, et al. Apps of steel: are exercise apps providing consumers with realistic expectations?: a content analysis of exercise apps for presence of behavior change theory. Health Educ Behav. 2013;40(2):133–139. doi:10.1177/1090198112452126
30. Shafieian M, Kazemi A. A randomized trial to promote physical activity during pregnancy based on health belief model. J Educ Health Promot. 2017;6:40. doi:10.4103/jehp.jehp_19_15
31. James DC, Pobee JW, Oxidine D, Brown L, Joshi G. Using the health belief model to develop culturally appropriate weight-management materials for African-American women. J Acad Nutr Diet. 2012;112(5):664–670. doi:10.1016/j.jand.2012.02.003
32. Penrod J, Preston DB, Cain RE, Starks MT. A discussion of chain referral as a method of sampling hard-to-reach populations. J Transcult Nurs. 2003;14(2):100–107. doi:10.1177/1043659602250614
33. Kreuger RA, Morgan D. The Focus Group Kit.
34. Erlingsson C, Brysiewicz P. A hands-on guide to doing content analysis. Afr J Emerg Med. 2017;7(3):93–99. doi:10.1016/j.afjem.2017.08.001
35. Kleinman A. Writing at the Margin: Discourse Between Anthropology and Medicine. Berkeley: University of California; 1995.
36. Lambert H, McKevitt C. Anthropology in health research: from qualitative methods to multidisciplinarity. BMJ. 2002;325(7357):210–213. doi:10.1136/bmj.325.7357.210
37. Kratz CA. In and Out of Focus. Am Ethnol. 2010;37(4):805–826. doi:10.1111/j.1548-1425.2010.01286.x.
38. Davis R, Campbell R, Hildon Z, Hobbs L, Michie S. Theories of behaviour and behaviour change across the social and behavioural sciences: a scoping review. Health Psychol Rev. 2015;9(3):323–344. doi:10.1080/17437199.2014.941722
39. Nikolopoulos H, Mayan M, MacIsaac J, Miller T, Bell RC. Women’s perceptions of discussions about gestational weight gain with health care providers during pregnancy and postpartum: a qualitative study. BMC Pregnancy Childbirth. 2017;17(1):97. doi:10.1186/s12884-017-1257-0
40. Krans EE, Chang JC. Low-income African American women’s beliefs regarding exercise during pregnancy. Matern Child Health J. 2012;16(6):1180–1187. doi:10.1007/s10995-011-0883-9
41. Gouveia R, Martins S, Sandes AR, et al. [Pregnancy and physical exercise: myths, evidence and recommendations]. Acta Med Port. 2007;20(3):209–214. Portuguese.
42. Evenson KR, Moos MK, Carrier K, Siega-Riz AM. Perceived barriers to physical activity among pregnant women. Matern Child Health J. 2009;13(3):364–375. doi:10.1007/s10995-008-0359-8
43. Saligheh M, McNamara B, Rooney R. Perceived barriers and enablers of physical activity in postpartum women: a qualitative approach. BMC Pregnancy Childbirth. 2016;16(1):131. doi:10.1186/s12884-016-0908-x
44. Cheng CY, Fowles ER, Walker LO. Continuing education module: postpartum maternal health care in the United States: a critical review. J Perinat Educ. 2006;15(3):34–42. doi:10.1624/105812406X119002
45. Henriksson P, Sandborg J, Blomberg M, et al. A Smartphone App to Promote Healthy Weight Gain, Diet, and Physical Activity During Pregnancy (HealthyMoms): protocol for a Randomized Controlled Trial. JMIR Res Protoc. 2019;8(3):e13011. doi:10.2196/13011
46. O’Brien OA, McCarthy M, Gibney ER, McAuliffe FM. Technology-supported dietary and lifestyle interventions in healthy pregnant women: a systematic review. Eur J Clin Nutr. 2014;68(7):760–766. doi:10.1038/ejcn.2014.59
47. Finlayson K, Crossland N, Bonet M, Downe S. What matters to women in the postnatal period: a meta-synthesis of qualitative studies. PLoS One. 2020;15(4):e0231415. doi:10.1371/journal.pone.0231415
48. Whitaker KM, Wilcox S, Liu J, Blair SN, Pate RR. Patient and Provider Perceptions of Weight Gain, Physical Activity, and Nutrition Counseling during Pregnancy: a Qualitative Study. Womens Health Issues. 2016;26(1):116–122. doi:10.1016/j.whi.2015.10.007
49. Stengel MR, Kraschnewski JL, Hwang SW, Kjerulff KH, Chuang CH. “What my doctor didn’t tell me”: examining health care provider advice to overweight and obese pregnant women on gestational weight gain and physical activity. Womens Health Issues. 2012;22(6):e535–540. doi:10.1016/j.whi.2012.09.004
50. Leiferman J, Sinatra E, Huberty J. Pregnant Women’s Perceptions of Patient-Provider Communication for Health Behavior Change during Pregnancy. Open JObstetrics Gynecol. 2014;4:672–684. doi:10.4236/ojog.2014.411094
51. Dacey ML, Kennedy MA, Polak R, Phillips EM. Physical activity counseling in medical school education: a systematic review. Med Educ Online. 2014;19(1):24325. doi:10.3402/meo.v19.24325
52. Rural Health Care has Plenty of Challenges, Promising Opportunities. American Physical Therapy Association. 2019. Accessed from: https://www.apta.org/PTinMotion/News/2019/06/26/NEXT2019RuralHealthCare/.
53. Cioffi J, Schmied V, Dahlen H, et al. Physical activity in pregnancy: women’s perceptions, practices, and influencing factors. J Midwifery Womens Health. 2010;55(5):455–461. doi:10.1016/j.jmwh.2009.12.003
54. Bevelander KE, Herte K, Kakoulakis C, Sanguino I, Tebbe AL, Tunte MR. Eating for Two? Protocol of an Exploratory Survey and Experimental Study on Social Norms and Norm-Based Messages Influencing European Pregnant and Non-pregnant Women’s Eating Behavior. Front Psychol. 2018;9:658. doi:10.3389/fpsyg.2018.00658
55. James CV, Moonesinghe R, Wilson-Frederick SM, Hall JE, Penman-Aguilar A, Bouye K. Racial/Ethnic Health Disparities Among Rural Adults – United States, 2012–2015. MMWR Surveill Summ. 2017;66(23):1–9. doi:10.15585/mmwr.ss6623a1
56. Dipietro L, Evenson KR, Bloodgood B, et al. Benefits of Physical Activity during Pregnancy and Postpartum: an Umbrella Review. Med Sci Sports Exerc. 2019;51(6):1292–1302. doi:10.1249/MSS.0000000000001941
57. Linke SE, Ciccolo JT, Ussher M, Marcus BH. Exercise-based smoking cessation interventions among women. Womens Health. 2013;9(1):69–84. doi:10.2217/WHE.12.63
58. Parker KM, Smith SA. Aquatic-Aerobic Exercise as a Means of Stress Reduction during Pregnancy. J Perinat Educ. 2003;12(1):6–17. doi:10.1891/1058-1243.12.1.6
59. Demissie Z, Siega-Riz AM, Evenson KR, Herring AH, Dole N, Gaynes BN. Associations between physical activity and postpartum depressive symptoms. J Womens Health. 2011;20(7):1025–1034. doi:10.1089/jwh.2010.2091
60. Demissie Z, Siega-Riz AM, Evenson KR, Herring AH, Dole N, Gaynes BN. Physical activity and depressive symptoms among pregnant women: the PIN3 study. Arch Womens Ment Health. 2011;14(2):145–157. doi:10.1007/s00737-010-0193-z
61. Nagpal TS, Fagan MJ, Prapavessis H. Smoking cessation during pregnancy and the potential role of exercise: a narrative review. Med Res Arch. 2017. 5(7).
62. Schaffer MA, Lia-Hoagberg B. Effects of social support on prenatal care and health behaviors of low-income women. J Obstet Gynecol Neonatal Nurs. 1997;26(4):433–440. doi:10.1111/j.1552-6909.1997.tb02725.x
63. Kim TH, Connolly JA, Tamim H. The effect of social support around pregnancy on postpartum depression among Canadian teen mothers and adult mothers in the maternity experiences survey. BMC Pregnancy Childbirth. 2014;14(1):162. doi:10.1186/1471-2393-14-162
64. Jesse DE, Kim H, Herndon C. Social support and self-esteem as mediators between stress and antepartum depressive symptoms in rural pregnant women. Res Nurs Health. 2014;37(3):241–252. doi:10.1002/nur.21600
65. Guillory J, Niederdeppe J, Kim H, et al. Does social support predict pregnant mothers’ information seeking behaviors on an educational website? Matern Child Health J. 2014;18(9):2218–2225. doi:10.1007/s10995-014-1471-6
66. Kolomanska D, Zarawski M, Mazur-Bialy A. Physical Activity and Depressive Disorders in Pregnant Women-A Systematic Review. Medicina. 2019;55(5). doi:10.3390/medicina55050212
67. Palladino CL, Singh V, Campbell J, Flynn H, Gold KJ. Homicide and suicide during the perinatal period: findings from the National Violent Death Reporting System. Obstet Gynecol. 2011;118(5):1056–1063. doi:10.1097/AOG.0b013e31823294da
68. Slomian J, Honvo G, Emonts P, Reginster JY, Bruyere O. Consequences of maternal postpartum depression: a systematic review of maternal and infant outcomes. Womens Health. 2019;15:1745506519844044. doi:10.1177/1745506519844044
69. Carpenter-Song E, Snell-Rood C. The changing context of rural America: a call to examine the impact of social change on mental health and mental health care. Psychiatr Serv. 2017;68(5):503–506. doi:10.1176/appi.ps.201600024
70. Snell-Rood C, Hauenstein E, Leukefeld C, Feltner F, Marcum A, Schoenberg N. Mental health treatment seeking patterns and preferences of Appalachian women with depression. Am J Orthopsychiatry. 2017;87(3):233–241. doi:10.1037/ort0000193
71. Nakamura A, van der Waerden J, Melchior M, Bolze C, El-Khoury F, Pryor L. Physical activity during pregnancy and postpartum depression: systematic review and meta-analysis. J Affect Disord. 2019;246:29–41. doi:10.1016/j.jad.2018.12.009
72. Holloway A, Watson HE. Role of self-efficacy and behaviour change. Int J Nurs Pract. 2002;8(2):106–115. doi:10.1046/j.1440-172x.2002.00352.x
73. Hesketh KR, Evenson KR. Prevalence of U.S. Pregnant Women Meeting 2015 ACOG Physical Activity Guidelines. Am J Prev Med. 2016;51(3):e87–89. doi:10.1016/j.amepre.2016.05.023
74. Chan CWH, Au Yeung E, Law BMH. Effectiveness of Physical Activity Interventions on Pregnancy-Related Outcomes among Pregnant Women: a Systematic Review. Int J Environ Res Public Health. 2019;16:10. doi:10.3390/ijerph16101840
75. Melton B, Marshall E, Bland H, Schmidt M, Guion WK. American rural women’s exercise self-efficacy and awareness of exercise benefits and safety during pregnancy. Nurs Health Sci. 2013;15(4):468–473. doi:10.1111/nhs.12057
76. Looney SM, Raynor HA. Behavioral lifestyle intervention in the treatment of obesity. Health Serv Insights. 2013;6:15–31. doi:10.4137/HSI.S10474
77. Kim HK, Niederdeppe J, Graham M, Olson C, Gay G. Effects of Online Self-Regulation Activities on Physical Activity Among Pregnant and Early Postpartum Women. J Health Commun. 2015;20(10):1115–1124. doi:10.1080/10810730.2015.1018639
78. Boyce C, Neale P (2006). Conducting In-depth interviews: a Guide for Designing and Conducting In-depth Interviews for Evaluation Input. Available from:http://www.pathfind.org/site/DocServer/m_e_tool_series_indepth_interviews.pdf?docID=6301.
79. Sytsma TT, Zimmerman KP, Manning JB, et al. Perceived Barriers to Exercise in the First Trimester of Pregnancy. J Perinat Educ. 2018;27(4):198–206. doi:10.1891/1058-1243.27.4.198