Part 4 (2/2)

Support for this view has been provided both by compet.i.tive athletes, who anecdotally reported improved performance following delivery (Sady and Carpenter, 1989), and by case studies of recreational athletes (Hutchinson, 1981). Additionally, physical activity during pregnancy has also been linked with the promotion of good maternal posture, prevention of excess maternal weight gain and the prevention of lower back pain (Dewey and McRory, 1994) as well as reduced risk of gestational diabetes (Dye et al., 1997). Evidence for the value of exercise for women's physical health in general is reported by Haas et al. (2005) who nd that a lack of exercise is a.s.sociated with poorer health status pre-pregnancy, during pregnancy and after pregnancy.

There is also literature considering the potential impact of exercise on maternal perceptions of their physical and psychological wellbeing during pregnancy. For some time, there have been studies showing that women who exercise during pregnancy typically report fewer pregnancy-a.s.sociated symptoms than those who are sedentary (Hall and Kaufmann, 1987; Sternfeld, 1997; Wallace et al., 1986). This applied to symptoms of nausea, fatigue, leg cramps, ligament pain and lower back pain. In addition, work by Sternfeld et al. (1995) appeared to identify a temporal a.s.sociation between exercise and wellbeing such that increases in symptom reporting were preceded by a decrease in exercise, leading to the conclusion that women were feeling better because they were exercising. This kind of relations.h.i.+p needs to be viewed with caution, rst because of the social pressure to conform to the positive messages about exercise and second since it could be used to put women in a position where exercise was in fact prescribed as a solution to some of the physical symptoms of pregnancy. Nevertheless, such ndings would have been instrumental in the revisions of the ACOG guidelines.

As far as psychological wellbeing is concerned, research conducted within the general population over the past 20 years has also pointed to the benets of exercise and physical activity. There is an extensive literature on this topic, much of which also attempts to take account of reservations about confounding variables. For example, people do not choose to exercise at random. There may be signicant other differences between active and inactive people that are responsible for differences in mental health (as measured in the biologically oriented exercise studies) and that are more relevant than activity in terms of outcomes and benets. Furthermore, people may have differential expectations of intervention exercise programmes, which may in themselves have an effect on psychological wellbeing.

Nevertheless, this work demonstrates unequivocally that physical activity and psychological health appear to be related in a bi-directional 101 manner. There have been several reviews and meta-a.n.a.lyses (e.g. Long and van Stavel, 1995; North et al., 1990) which show that exercise reduces anxiety and depression and increases self-concept, self-esteem, aspects of cognitive functioning and mood. Longitudinal studies have been carried out investigating the effects of exercise training on psychological wellbeing with a range of populations, including students, groups of older people, people with psychiatric or medical disorders and members of specic groups like the police or the military. Virtually none of these have shown aerobic exercise to have a deleterious effect on psychological health and studies involving comparisons of intervention and control groups demonstrate that the active group show greater psychological improvement even when the control group undertakes another group activity apart from exercise (Steptoe, 1992). The overwhelming conclusion is that physical exercise can exert a positive effect on psychological wellbeing over and above that which might be attributed to other factors.

The ndings of studies investigating the impact of exercise on maternal wellbeing in pregnancy produce the same conclusions: in 1981 Sibley and colleagues found that women who partic.i.p.ated in swimming activity during the second trimester of pregnancy did not improve their tness but did have improved appet.i.te and a more restful sleep pattern; Wallace et al.

(1986) found higher levels of self-esteem and Dewey and McCrory (1994) reported fewer depressive symptoms in women who exercised. These ndings are endorsed by recent studies and reviews, for example Da Costa et al. (2003) and Morris and Johnson (2005), which have shown that exercise in pregnancy improves maternal wellbeing.

The initial focus of medical concern about the potential risks of exercise in pregnancy was driven by the historic need to reduce infant mortality and was centred around the need to reduce or moderate physical activity.

The positive benets of exercise, which have been demonstrated through these mainly physiological studies over time, have undoubtedly contributed to the change in the tenor of advice from ofcial sources such as the contemporary advice on exercise in pregnancy issued by the ACOG. As the 1994 guidelines suggested, women have now been granted permission, on the basis of what might be considered as suitably founded research, to continue with moderate, and even some strenuous, exercise in pregnancy, with the caveat that the pregnancy itself is designated as medically low risk. In fact, there is almost a suggestion that women should now partic.i.p.ate in exercise in order to ensure a healthy outcome for themselves and their baby. This may be a reection of what is acknowledged to be a highly body-conscious society as much as a concern for women's health and wellbeing. (See also below 'Body image as a barrier'.) As with diet, women's behaviour in pregnancy would seem to be determined by the exhortations of ofcial admonitions rather than solely by personal choice.

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Daily activities, health and outcomes Current gures on partic.i.p.ation in physical exercise, based on the UK General Household Survey, suggest that nearly 60 per cent of adults take part in sport or physical activity on a regular basis and around a quarter of the population report partic.i.p.ating in an active sport at least three times a week, the most popular activity being walking (Sport England, 2006).

However, the gures are lower than this for women, for those from minority ethnic groups and those with limited incomes. The gures suggest that around 50 per cent of women partic.i.p.ate in at least one type of active sport once a month. This does not necessarily equate to regular partic.i.p.ation in strenuous exercise activity. As for women during pregnancy, the gures do not relate. In fact, it is probably the case that for most women who become pregnant, physical activity is likely to centre around the regular routines of their daily lives, together with recreational activities involving some physical exertion such as swimming, dancing, weekly aerobics cla.s.ses, walking, gardening and so on. The competing demands of employment, relations.h.i.+ps and the household mean that these recreational activities may in themselves be limited. What does research have to say about daily activity, which may be less amenable to moderation or change?

Studies of the general population are more limited in this area, apart that is from studies of older people, who are considered to be at risk from inactivity in two ways (Milligan et al., 2004; Shepard and Montelpare, 1988). One of these is that the restriction of physical mobility reduces wellbeing through loss of independence and control. The other is the potential reduction in social partic.i.p.ation as a result of physical inactivity, also leading to reduced psychological wellbeing. Aside from studies of older people, Falloweld (1990) and Maloni (1996) point to the importance of job role in self-esteem in the general population, and of course jobs usually entail some kind of activity outside the home. Thus, the positive benets of routine activity are a.s.sumed to ow from the elements of independence and control. However, these types of studies are looking at either very specic elements of activity, such as physical mobility, or at what might be called components of a person's lifestyle. The signicance of levels of physical activity aside from formal exercise programmes is not as easily discovered in the research, although the increase in rates of obesity in Western cultures has led to concern that people's lives are too inactive for long-term health (Lees and Booth, 2004). Morris and Hardman (1997), for example, suggested that although the pleasurable, therapeutic/health, psychological and social dimensions of walking are evident, they had rarely been studied within the context of an occupational or domestic routine.

Outside specically physical activities, there is some interesting work by Ehlers et al. (1988) and others (Hofer, 1984; Wever, 1985) that emphasises the importance of social activities in stabilising biological rhythms which 103 may affect feelings of depression and reported somatic symptoms. It is possible therefore that the maintenance of a daily routine may serve to sustain social cues and protect against the impact of disruptions to regulating mechanisms, whether these are socially or biologically determined.

There is very little work looking at pregnant groups and daily activity in terms of pregnancy outcome or maternal wellbeing in the way that exercise has been examined. Launer et al. (1990), in a study looking at both employment- and non-employment-related physical activity in Western women, found that women who had three or more children and received no household help were at increased risk of delivering a small for dates baby, although not of having preterm delivery. Woo (1997) attributes the higher rates of small for dates babies in women with other children to the strenuous activities a.s.sociated with caring for young children something it was perhaps not necessary to carry out a study to discover! However, once again the research is not conclusive, with several other studies failing to nd an a.s.sociation between domestic activity and pregnancy outcome (Rabkin et al., 1990; Schramm et al., 1996). The difculty is, as before, of dening what is meant by strenuous activity. The impact of performing household ch.o.r.es may depend on the population being studied. Even the fundamental aspects of daily living may be a risk for some low-income women during pregnancy, for example climbing stairs and walking are particularly demanding. There may also be cultural differences: Hickey and colleagues (1995) report that carrying loads may be a.s.sociated with an elevated risk of premature birth in white women while strenuous home-based ch.o.r.es may heighten the risk in black women.

In terms of psychological wellbeing and activity, what research there is comes from studies of women whose pregnancies are deemed at risk and who are ordered bed rest, something they nd surprisingly unwelcome especially since they feel well (Curtis, 1986; Mackey and Coster-Schultz, 1992). This reduction in psychological wellbeing, which includes anxiety and depression beyond that related directly to the pregnancy risk, is attributed to restriction of activity, as with older people. Monaham and De Joseph (1991) have suggested that this is because of loss of control; bed rest at home still involves the competing demands from relations.h.i.+ps, households and careers which may be hard to manage and meant that women 'cheated' so that they could accomplish what they saw as necessary for the smooth functioning of their home life. Of course, women with low-risk pregnancies will not be required by medical pract.i.tioners to undergo total restriction on their activity, but they may nd that their routine is affected by the various discomforts of pregnancy itself, such as tiredness, nausea and increasing weight. Furthermore, women's own concerns or the reactions of others, arising perhaps from information they have received, may deter them from partic.i.p.ating in certain activities or discourage them from public outings (Unger and Crawford, 1996). Anderson et al. (1994) 104 found that pregnant women who reported more depressed mood also said that they were bored and that they wished they could socialise more.

Notwithstanding the very small amount of research on daily activity, the benets would appear to be very similar to that of exercise, for both the general population and for women during pregnancy. In particular, these refer to the sense of control and self-esteem a.s.sociated with being active and making choices about what activities to pursue, whether in the public or in the private domain. Having reviewed the larger literature on exercise we can clearly see that the emphasis is on taking responsibility for health through appropriate physical activities, something that is extremely familiar in the context of women's experiences during pregnancy in particular. We turn now to some examples of the kinds of advice that women receive, where they nd this advice and how they feel about it. In doing so, we have to consider the various sources of advice and nature of those sources. It is likely that the sources themselves have particular expectations about women's continuing partic.i.p.ation in activity during their pregnancy and that these will impact on women's own responses.

Activity advice Like advice on other areas of pregnancy, we can look at a variety of types of available advice that is available to women. Others have reviewed some of these types of literature in particular (e.g. Barker, 1998; Woollett and Marshall, 1997) and highlighted the typically biomedical discourses they represent. We have also discussed in Chapter 4 how published advice sustains a series of discourses of responsibility. A further discourse is that of moderation and self-management, something integral to the advice we have already mentioned in this chapter. Interestingly, while the ACOG guidelines quoted and discussed in the sections above may inform medical advice or ofcial literature, they are not directly available to women themselves. Advice on exercise activity is commonly included in general health advice during pregnancy, alongside advice on smoking, diet (see Chapter 5), alcohol and so on. Publications on pregnancy and birth may also refer directly to research data on such issues. For example, work by Kelly (2005) indicates that 15 minutes of exercise three times a week is acceptable, and Kardel (2005) suggests that it is acceptable for top athletes to continue vigorous exercise; such general statements may emerge in the print and electronic media. However, Lumbers (2002) points out that there is no simple exercise prescription and that generally the approach to advice is to encourage women to maintain existing exercise regimes but not to take up new ones. Kagan and Kuhn (2004) highlight the benets of moderate exercise, though of course the term moderate is notoriously unhelpful in terms of actual activity and will depend on the current or previous levels of 105 exercise activity. If information on exercise is difcult to interpret, then what about information on daily activity?

As we have pointed out already, there are plenty of sources of material available to women about pregnancy. Any search, real or virtual, will provide a list of hundreds of t.i.tles concerning pregnancy and childcare.

These are written by experts of various kinds: family doctors, obstetricians, celebrity mothers, midwives, childcare experts and so on. Taking only the pregnancy aspect of these publications, all of them provide at least some information and practical advice on the changes accompanying pregnancy, the common symptoms, antenatal testing, health concerns and anxieties, diet, childbirth choices, preparing for baby and so on. There are also monthly magazines available on the newsstands that deal with the same topics. The style of such publications and the prescriptiveness of advice vary according to the author but are universally concerned to give the same message how to ensure a safe and normal pregnancy and pregnancy outcome.

There are also publications specically on tness in pregnancy, many of which are published in America. For example, in Joan Butler's (1996) book Fit and Pregnant: The Pregnant Woman's Guide to Exercise (in its 10th edition), which is described in the publisher's catalogue as aterric book for active women who want to keep up their workouts', readers can learn, among other things, how the baby is affected by the exercise they do, and how to modify their exercise. Joan Butler is a nurse. Another t.i.tle, also written by experts in exercise and maternal health, is Fit Pregnancy for Dummies (Cram and Stouffer Drenth, 2004), which indicates that it helps women to understand how a t pregnancy helps with delivery and postpartum shape-up. There is also specialist material, for example the Runners World Guide to Running and Pregnancy, subt.i.tled How to Stay Fit, Keep Safe and Have a Healthy Baby (Lundgren, 2003). Publicity material for this book makes explicit reference to the differing messages women may encounter on exercise in the phrasenever be puzzled by conicting advice again', something we discuss further below. There is clearly a wide range of potentially helpful material for all kinds of women, which makes reference to the benets of exercise and physical activity as well as to the need to moderate such activity. Such material is fascinating in itself but it is not the subject of this current chapter or book. If the health messages about exercise are to be understood they need to be easily available to everybody.

Aside from these books on pregnancy and childbirth, which women would have to purchase or borrow through the public library system or from friends, women in the UK are routinely given The Pregnancy Book (Department of Health, 2006) via their antenatal clinics. The advice and information it contains cover all aspects of pregnancy, childbirth and the rst few weeks with a new baby. In the rst chapter 'Your health in 106 pregnancy', there is one full page on physical activity, which suggests that the more active women remain the easier it will be to adapt to the physical changes of pregnancy. As far as daily activity is concerned its recommendation is that women should 'keep up [their] normal daily physical activity or exercise' (Department of Health, 2006: 15) whether this is a sport or just walking to the shops, for as long as they feel comfortable. The same section also says that women should not exhaust themselves and that they may need to slow down as pregnancy progresses. With a recommendation to keep active on a daily basis, for example by walking, the text says that any amount of activity is better than nothing. Finally, swimming is recommended as a suitable form of exercise. These recommendations therefore chime with the types of exercise that most women do in fact the accompanying pictures are of women swimming, on a bicycle and gardening and with the research ndings, emphasising again the benets of exercise and activity. It is clearly making reference to the nature of daily lives by including routine activity such as shopping. However, the advice does also represent a message of moderation and slowing down, allowing women to act on such advice if it corresponds with other information they may have been given. On a following page, the emphasis is on exercise in pregnancy. As we indicated earlier, this refers to specic exercises that will benet both labour and postnatal recovery rather than how to continue existing exercise programmes. It therefore describes particular exercises that women might undertake, such as pelvic oor exercises, to generally improve their health.

Another major source of information is via the world wide web. In the UK, the BBC website is both popular and respected (plex interaction between women's own experiences, their understanding and expectations of their physical state and those of others, both generally and personally in terms of family or work colleagues.

Typically, investigation of women's partic.i.p.ation in exercise and activity outside the physiological has tended to take a health psychology approach, where the emphasis has been on identifying the factors which will determine appropriate changes in health behaviour in line with available evidence for positive outcomes (in terms of maternal and foetal health). The popular models of health behaviour (such as the Health Belief Model or the Theory of Planned Behaviour) incorporate the role of att.i.tudes and beliefs in determining health behaviours. In our view, while such an approach has provided some useful information that we have already referred to on predictors of exercise activity for example, in our view this has not generally taken account of the complexity of women's daily activities and the complexity of the differing and simultaneous demands for changes that occur during pregnancy. Thus, women may be expected to change their behaviour in line with cultural expectations mediated through professional advice, friends and family, as well as to manage the activities of their daily lives and to respond to the changes taking place in their bodies, within a relatively short time period. While the obvious benets of reducing smoking or alcohol or increasing exercise may be solved by one relatively simple process, this is not so for the various different activities that make up women's lives.

In our longitudinal study of daily activity in 57 pregnant women (Rousham et al., 2006) we found that as a whole, and perhaps not surprisingly, women's routine daily activity declined over the period of their pregnancy. This measured and reported change allowed for changes in weight, thus the reduction in activity over the course of pregnancy could not be attributed solely to the weight gains a.s.sociated with the pregnancy.

The reduction in activity occurred signicantly in domestic activity and leisure activity, sometimes including physical exercise activity, and included some elements of occupational activity. We have discussed some of the changes that women made at work in Chapter 4. Of particular interest here 108 is that although several of the women in the study had partic.i.p.ated in regular physical exercise activity prior to pregnancy, most of them had given this up during their pregnancy and their daily lives were therefore relatively inactive. Furthermore, most of them had essentially sedentary jobs. In discussing changes in physical activity, therefore, we are really looking at routine activity that is undertaken in order to perform the basic functions of living, rather than the limiting of physical exercise activity as recommended by the research.

In the context of the current chapter our focus is on how women described and explained their changes in behaviour and on whether the changes reected the advice they had received. We identied several 'barriers' to maintaining their habitual activities. These barriers include the physical symptoms of pregnancy, maternal perceptions of risk, poor maternal body image, reduced motivation, social and cultural discouragement and a lack of appropriate facilities. The relative impact of each of these barriers varied according to the point of pregnancy at which women were interviewed. We shall discuss some of these barriers briey here in the context of physical activity and exercise and then go on to examine what coping strategies they were able to negotiate to overcome these barriers and deal with advice.

The ndings from the study suggest that the perceived responsibilities of pregnancy begin early in pregnancy. Up to 25 weeks, the most common reason women gave for reducing their activity was physical limitations, and this was mostly nausea and vomiting and maternal fatigue; interestingly Downs and Hausenblas (2004) found that women's beliefs about exercise were that it improves mood but that physical limitations restrict exercise. Thus, physical limitations may operate both at the level of beliefs about appropriate behaviours as well as making it actually difcult to persist with physical exercise or activity. If women suffered from physical symptoms, their strategy was to try to use their available energy to sustain their working week, often at the expense of their routine home and leisure activities: 'm less active, I'm too tired. I can't go out at weekends sometimes I struggle to get dressed in the morning I'm so tired'. However, as well as the limitations induced by their physical symptoms, the women had clearly also made a conscious decision to reduce their general activity level. The rationale for both avoiding specic tasks and modifying more general activity was similar: 'm not socialising so much. I've slowed down. It's common sense really, isn't it'.

The physical symptoms of pregnancy, in particular the profound tiredness of early pregnancy, also appear to provide women with a legitimate justication for changing behaviour or at least avoiding activities later in pregnancy. This is facilitated by the identication of tiredness as a symptom of pregnancy and one that can be avoided or reduced by resting, as we highlighted in the section on advice above. Women are therefore able to 109 recruit tiredness as an explanation for their behaviour or lack of behaviour in describing the changes to us and to others, without having recourse to any other justication: a commonly recurring response was that they would have liked to do morebut have been too tired'. It is also irrefutable, since it is the case that simply being pregnant can make women tired, without even the extra weight of effort of exercising. Thus, women are free from blame and permitted to be inactive, at the same time as fullling their responsibility as carer/container in the maternal role.

Moreover, the importance that women in the study attributed to rest during pregnancy was found to be comparable to the importance that they attributed to other well-established health behaviours, such as not smoking or abstaining from alcohol, and to be signicantly higher than the importance accorded to regular exercise or an active lifestyle. Whereas advice to cut down on cigarettes or alcohol (or other substances) highlights the potential and invisible risks of continuing, rest and sleep tend to be seen only as benecial to both mother and baby, whatever else might be happening. Once at home, it is also easy to accomplish, especially in an environment where others are concerned for your wellbeing. As far as the importance of sleep and rest during pregnancy is concerned, this may partially reect an expectation of a disrupted sleep pattern after the birth but also the prevalence of advice on resting, which is endorsed by friends and family. The visibility of some areas of advice and information is high, certainly in the early stages of pregnancy. The lower importance a.s.signed to exercise and activity may be in part a feature of its lower visibility compared to rest or relaxation.

In addition to tiredness and physical limitations, another 'legitimate'

barrier was the direct or indirect risks arising from activity. Women described how they believed that there was an unnecessary degree of risk a.s.sociated with many of the activities that they had routinely undertaken prior to becoming pregnant and the advice on exercise to avoid makes clear that they are right. Direct risks arose from various aspects of occupational, domestic and recreational activity and usually occurred wherever a particular task was a.s.sumed to be too strenuous or too dangerous to perform. Many women, however, left the precise nature of the perceived risk unspecied although almost all of the women in the study believed that an aspect of their former behaviour could directly jeopardise the progress of the pregnancy: haven't done any DIY, I won't lift the heavy toolbox. I just don't want to overdo it'.

It should be mentioned again here that none of the women had jobs that required heavy lifting or that might be considered inherently dangerous in health and safety terms. Signicantly, when asked about strenuous physical activity the women discussed the possibility of it leading to unwanted acci-dents, falls or muscular strain, in relation to their own welfare rather than that of the baby. In the few cases where the baby's health or development 110 was considered to be at risk, the women described themselves as consciously tailoring their activity to place the perceived needs of their unborn child above their own. A partic.i.p.ant, who considered herself previously as an active person, said that she did not 'rush around so much or carry heavy things or go dancing. It's my choice, something growing in me needs as much help as it can get'.

Women also felt that it was necessary to make changes in order to avoid indirect risks. Indirect risks arose from the notion that, while the performance of an activity in itself might not be dangerous, there were a.s.sociated with it other potential hazards that may threaten health. The vast majority of indirect risks arose from recreational pursuits. Within this context, three specic limitations to activity were cited. These occurred in roughly equal proportion and referred to the potential harm that could be caused by activities commonly a.s.sociated with pa.s.sive smoking, overcrowded loca-tions and alcohol consumption. Two of these have risks a.s.sociated with them at any time, while the danger of crowds was something specic to pregnancy. The overriding effect of these concerns was to discourage women from engaging in social activities outside the home and for some this included physical activities. For example, one woman had not only limited her social activities but also had limited her swimming to times when only adults would be present: always have to try to protect myself in crowded rooms, so I don't want to go out. I like swimming but I can only go when it's adults only. I went before and got kicked by the children'. Particularly in later pregnancy when they had often given up work, the women spoke of the isolation that can follow from the limiting of their social activities and not only their own limitations. The pressure from others to reduce activity contributed signicantly to their feelings of bore-dom and social isolation. While women felt they had to full their maternal role, there was also some resistance to this external pressure: 'My friends don't think I should be going out, so they don't bother phoning me.

I haven't seen anyone for ages. I feel like I've given everything up, my job, my life'. Another woman explained how frustrating it could be to be prevented from doing what she wanted at home: 'm not allowed to do things like gardening or housework. My partner stops me so I try to rest more but then I get very frustrated. I know when to stop but he won't believe me. It's so boring just sitting'.

Alongside the perceived risks to health, a further and important issue that the women raised with us was an increased anxiety over their new body shape. This contributed to their feeling unwilling or uncertain about partic.i.p.ating in recreational activity. The issue of body image has not been addressed elsewhere in this chapter and it is perhaps worth exploring it a little further at this point before coming back to the topic of how and what advice the women in our study had received about physical activity during pregnancy.

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Body image as a barrier Even quite early in pregnancy, women often described themselves as 'feeling fat', 'feeling heavy' and 'feeling awkward' and this affected their behaviour: 'm going out less. I feel fat, very body-conscious . . . I feel like people are looking at me a lot. Maybe I'm just paranoid'. This is not unusual in the sense that women's bodies do undergo signicant changes in a short period of time and within a few months they may have changed shape dramatically. Earle (2003) argues that concerns with fatness and physical appearance are signicant factors in women's lives during pregnancy. The experience of embodiment clearly represented by pregnancy can be a frightening one. It is thus not surprising that even in the earliest stages of pregnancy concerns over body image may inuence women's activity levels, in part because of their ambivalence towards the physical changes that accompany pregnancy. It has been suggested that anxiety over physique or bodily appearance may be responsible for a lower rate of partic.i.p.ation in recreational and social activities by women, especially those who perceive themselves to be overweight (Spink, 1992; Wiles, 1994). One of the reasons given for taking exercise is to keep t; another is to improve body image (e.g. Choi, 2000; Grogan, 2000). Women in indus-trialised societies are immersed in issues of weight control and appearance, neither of which may be acceptable to them during pregnancy and there is increasing pressure on women to return quickly to their pre-pregnancy appearance, often prompted by the coverage of celebrity pregnancies (see Chapters 5 and 7). One study of pregnant women found that only a small minority responded positively to their new gure (Zajicek, 1979) and there is earlier research evidence of dissatisfaction with body during later pregnancy in particular (Harris, 1979; McConnell and Datson, 1961; Mercer, 1986). It is also possible that women who are less positive about being pregnant or who are anxious in the rst instance may also respond more negatively to their bodily changes and pregnancy more generally.

However, the response is by no means universal. For some women pregnancy can represent a welcome period during which they feel temporarily free from cultural demands to be slim (Unger and Crawford, 1996; Wiles, 1994). Baker et al. (1999) found that weight and shape satisfaction were higher in pregnancy than at four months post partum.

Similarly, Clark and Ogden (1999) found that the pregnant women in their study of health behaviours were less dissatised with their body shape than non-pregnant women. Boscaglia et al. (2003) reported that women who exercised regularly were happier with their changed body image when they became pregnant. Clearly, women will differ in their responses to exercise or activity during pregnancy itself and to some extent this may be determined by their pre-pregnancy att.i.tudes both to exercise and to their body image (Devine et al., 2000; Downs and Hausenblas, 2003).

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The women's various concerns and experiences, which contributed to what we have described as barriers to activity, may not only affect women's willingness to partic.i.p.ate in the recommended exercise activities but also in routine activities and therefore contribute to the changes in behaviour we identied in the study. The physical symptoms of pregnancy and the concept of risky activities provide women with a form of control over their choices of behaviours. However, concerns over body image may in part reect women's feelings of being out of control, which they do not wish to be visible to others. Although recourse to physical limitations and risk may offer women control over their activity, these concepts also allow others to comment on and determine how women should behave. The balancing and negotiation of their own needs and requirements in respect of activity have to take account of what others may expect.

Taking advice?

In the longitudinal study we asked the women partic.i.p.ating whether they had received any advice regarding their physical activity behaviour in the four weeks prior to each of the ve interview points. Nearly all of the women indicated that they had received advice or information at least once during the course of their pregnancy about exercise and activity more generally. The primary sources of information changed over pregnancy, with books or magazines being the main source at the start and least used towards the end. A consistent source of advice across pregnancy was that from friends and family.

Written sources of advice that were mentioned included a variety of the professional and lay self-care books, pregnancy and parenting magazines and The Pregnancy Book that we referred to above. They also mentioned leaets and newspapers. The inclusion of newspaper items may have provided them with up-to-date information, but as we have already seen in regard to dietary advice, the information can be misleading

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