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SYSTEMATIC / NARRATIVE REVIEW ARTICLE

Impact of structured physical exercise during pregnancy on

maternal health and fetal outcomes: A systematic review

Farah Hanani Mohd Nor, MMed (Fam Med)1, Nurjasmine Aida Jamani, MMed (Fam Med)2, Karimah Hanim Abd
Aziz, DrPH3

1
Klinik Kesihatan Simpang Renggam, Jalan Rambutan Simpang Renggam Kluang Johor, 2Department of Family Medicine,
Kulliyyah of Medicine, International Islamic University Malaysia Jalan Sultan Ahmad Shah, Kuantan Pahang Malaysia,
3
Department of Community Medicine, Kulliyyah of Medicine, International Islamic University Malaysia, Jalan Sultan Ahmad
Shah, Kuantan Pahang Malaysia

ABSTRACT exercise program with better reporting of adherence and

Introduction: Current guidelines recommend that pregnant outcomes.
women engage in physical activity. Exercise during
pregnancy has been shown to positively impact both KEYWORDS:
maternal and fetal outcomes. Therefore, we conducted a Physical activity, lumbopelvic pain, pre-eclampsia, gestational
systematic review to evaluate the impact of structured diabetes, preterm, birthweight, pregnancy
physical activity during pregnancy on maternal health and
fetal outcomes.
INTRODUCTION
Materials and Methods: A systematic search was conducted Physical activity is beneficial and vital in preventing non-
on relevant articles published between 2015 and 2020 using communicable diseases, cancer, and other health conditions
PubMed, Google Scholar, ScienceDirect, Scopus, and the and improving overall well-being, including that of pregnant
Cochrane Library. Studies on pregnant women, comparative women. Despite its benefits, an estimated 1.4 billion adults
study designs with concurrent controls, structured physical are physically inactive. It is reported that inactive people
intervention and health outcomes for both maternal and fetal have a 20% to 30% increased risk of death than those who
were targeted. Maternal outcomes include gestational are sufficiently active.1
weight gain, lumbopelvic pain, gestational diabetes and pre-
eclampsia, while fetal outcomes include prematurity and Pregnancy represents a critical window for both maternal
birth weight. Only original studies with published data were and fetal health, with physiological and metabolic changes
included. This review was reported in accordance with the that can significantly influence long-term outcomes. Among
Preferred Reporting Items for Systematic Reviews and Meta- the most concerning complications during pregnancy are
Analysis. gestational diabetes mellitus (GDM), excessive gestational
weight gain (GWG), pre-eclampsia and lumbopelvic pain, all
Results: A total of 3441 published articles were retrieved of which are associated with adverse perinatal and
from different databases. After assessing the obtained postpartum outcomes.2
papers, studies that did not meet the inclusion criteria were
excluded. Twenty studies involving 5188 populations that Physical activity has emerged as a promising, non-
met the inclusion criteria were included in this review. pharmacological intervention to mitigate pregnancy-related
However, due to the heterogeneity of the studies, meta- risks. Current international guidelines, including those from
analysis was not done. Structured physical activity the World Health Organization (WHO, 2022) and the
significantly reduced the risk of gestational diabetes (OR: American College of Obstetricians and Gynecologists (ACOG,
0.57; 95% CI: 0.40–0.81; p = 0.002), but had no statistically 2020), recommend that pregnant women without
significant effect on lumbopelvic pain (OR 0.98 (95% CI: 0.49 contraindications engage in at least 150 minutes of
to 1.93) p=0.95), gestational weight gain (OR 0.88 95% CI: moderate-intensity physical activity per week before, during
(0.44, 1.76) p=0.71), pre-eclampsia (OR 0.78, 95% CI: 0.41, and after pregnancy.3 The benefits of regular prenatal
1.49, p=0.46) causing preterm delivery (OR 0.91, 95% CI exercise may extend beyond physical fitness, potentially
(0.69, 1.20), p=0.50) or affecting fetal birth weight (mean reducing the risk of GDM, managing weight gain within
difference 0.93, 95% CI (-42.67, 44.53), p=0.97) recommended limits, alleviating musculoskeletal discomfort,
and enhancing mental well-being.2
Conclusion: Structured physical activity during pregnancy,
three times a week, 30 minutes per day of moderate Structured physical exercise refers to planned, organised, and
intensity, is safe and benefits pregnant women and the fetus. repetitive physical activities designed to improve or maintain
Our findings challenge the view that physical exercise specific aspects of physical fitness, such as strength,
during pregnancy is not helpful and can be harmful. To endurance, flexibility, or cardiovascular health.4 Unlike
generate further evidence, there is a need for high-quality, general physical activity, which includes any bodily
standardised trials that assess specific types of structured movement that increases energy expenditure (e.g., walking

This article was accepted: 08 July 2025

Corresponding Author: Nurjasmine Aida Jamani
Email: [email protected]

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Impact of structured physical exercise during pregnancy on maternal health and fetal outcomes: A systematic review

to work or household chores), structured exercise follows a program during pregnancy on maternal and fetal health
defined regimen with set goals, intensity levels, and outcomes. We conducted the search in May 2021.
durations.
Box I. Search strategy for impact of exercise on maternal and
For example, structured physical exercise may include fetal health
supervised training programs, aerobic workouts, resistance
training, or high-intensity interval training (HIIT), often 1. Effect OR Impact
tailored to individual needs or health objectives. Research 2. Structured OR Supervised
highlights its effectiveness in improving physical fitness and 3. Physical exercise OR exercise
health outcomes, particularly when systematically prescribed 4. Pregnancy OR pregnant women OR gestation
based on factors like frequency, duration, and type of 5. #1 AND #2 AND #3 AND #4
exercise.3
Inclusion criteria
Previous studies have shown a positive impact of physical We selected all Randomized Controlled Trials (RCTs)
exercise on maternal health and fetal development. For worldwide involving a structured plan on physical activity
example, exercise intervention has been proven to prevent that reported the effect of structured physical exercise on
excessive weight gain 5,7 , reduce the incidence of gestational maternal and fetal health outcomes and fulfilled the
diabetes 5,7 and pregnancy-induced hypertension 8, and following criteria. The criteria included English peer review
decrease the intensity of lower back pain and pelvic girdle articles published from January 2015 to December 2020 due
pain.9,10 Furthermore, exercise also helps reduce the total to the establishment of ACOG guidelines on physical activity
duration of labour,11 and decrease the incidence of and exercise, which was published in 2015, studies involving
instrumental delivery.12 In addition, more studies have shown pregnant women with singleton pregnancies and low-risk
that physical activity during pregnancy does not cause and uncomplicated pregnancy. Articles for which the full text
preterm birth or low birth weight.7 could not be obtained after two email contacts from the
principal investigator and quasi-experimental studies were
Studies have shown that most pregnant women are not excluded. In addition, conference abstracts and grey
physically active during pregnancy due to several factors, literature were excluded because they may not be subjected to
such as lack of energy or sickness due to pregnancy, lack of the same peer review rigour.
motivation, lack of time or busyness due to work and myths
regarding exercise can cause miscarriage.13 Nevertheless, the Study selection
forms of exercise during pregnancy that benefit pregnancy, We imported relevant articles identified through the
and maternal outcomes are still debatable. databases into a Microsoft Excel Spreadsheet and removed
duplicate publications. Two reviewers independently
Although several studies have investigated exercise during performed the screening using the titles and abstracts to
pregnancy, there is a lack of a comprehensive review that search for potentially eligible articles based on the inclusion
synthesizes the evidence on the impact and effect of and exclusion criteria mentioned above. Discussions were
structured physical activity on maternal and fetal outcomes. held to resolve any disagreement with a final consensus
Hence, this systematic review aims to evaluate the effect and before reviewing the full text of each relevant article.
impact of structured physical activity on maternal health
and fetal outcomes, particularly gestational diabetes, pre- Data Extraction
eclampsia, gestational weight gain, lumbopelvic pain, birth Two review authors (FHMN and NAJ) screened the titles and
weight, and preterm delivery. This review focuses on articles abstracts independently to identify potentially relevant
from 2015 onwards based on the establishment of ACOG citations. These review authors retrieved the full texts of all
guidelines on physical activity and exercise, which was potentially relevant articles and independently assessed the
published in 2015. eligibility of the studies using predefined inclusion criteria.
We extracted data from all the articles found to be relevant.
The authors of the primary studies were contacted by email
MATERIALS AND METHODS in case more complete information was needed. Any
Protocol and Registration disagreements or discrepancies between reviewers were
The present review was registered with the International resolved by discussion and, if necessary, consulting a third
Prospective Register of Systematic Reviews (PROSPERO) with author (KHAA). In addition to the electronic search, we
clinical trial CRD42021229914 and conducted according to searched for reference lists of the articles identified.
the Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA). Quality assessment
We evaluated the quality of the studies using the risk of bias
Search strategy by the Cochrane Collaboration tool.14 It covers six domains of
All authors developed and reviewed a search strategy (Box 1). bias: selection bias, performance bias, detection bias,
Medical Subject Headings terms and keywords were used in attrition bias, reporting bias, and other biases. Within each
various combinations. We searched published literature from domain, assessments are made for one or more items, which
five online databases: PubMed, Google Scholar, Science may cover different aspects of the domain or different
Direct, Scopus, and Cochrane Library databases to identify outcomes.
studies examining the effect of the type of structured exercise

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Systematic / Narrative Review Article

Data synthesis Type of structured physical exercise

We analyzed the maternal and fetal outcomes among The types of exercise varied among the studies. Most studies
pregnant women who participated in a structured exercise have conducted aerobic exercises 15,16,30,32,33,17,19,20,22–24,28,29, three
program compared to those in the control groups. Statistical studies performed aquatic exercises 18,21,26, and each one
analysis was conducted using Review Manager (RevMan) conducted yoga 31, Pilates 34, and resistance exercises.25
software version 5.4. Only published data were used. No Meanwhile, Cordero et al., 2015 18 conducted mixed land-
attempts were made to retrieve raw data from the original based and aquatic activities. Most of the intensity levels were
study authors. moderate, except for three studies that had light to moderate
intensity.17,20,27 and there were two studies on vigorous
Odd ratios (OR) or mean differences (MDs) were calculated intensity.25,29 These categories were established according to
with 95% confidence intervals using the Mantel-Haenszel the Borg scale.21,23,28,32 with the scoring of perceived exertion,
method. A fixed effects model was applied. Heterogeneity was heart rate 17,22,29, the combination of the Borg scale and heart
assessed with I2 statistics, and a random effects model would rate 15–20,30,33, and a questionnaire to assess metabolic
have been used if significant heterogeneity was detected equivalents of task (METs).24 Five studies did not mention the
(I2>50%). indications of the intensity of the exercise.25–27,31,34 The exercise
groups were done at least twice to three times per week,
The ORs were reported for dichotomous data (excessive ranging from 45 to 65 min. Most of these studies were
gestational weight gain, gestational diabetes, pre-eclampsia, conducted in the first or second trimester until delivery,
lumbopelvic pain intensity, and preterm delivery). In except for a study by Sklempekokic et al. 30, which started in
contrast, MDs were reported for the continuous outcome of the third trimester.
birth weight.
Risk of bias
A meta-analysis was not conducted due to substantial Risk of bias was assessed using the Cochrane Risk of Bias
clinical and methodological heterogeneity across the Tool, as implemented in Review Manager (RevMan). Two
included studies, notably variations in participants’ independent reviewers (FHMN, NAJ) performed the
gestational age, differences in study quality and varying risk assessment. Disagreements were resolved through discussion
of bias. or consulting a third reviewer (KHAA).

The following seven domains were evaluated: random

RESULTS sequence generation (selection bias), allocation concealment
Characteristics of the studies (selection bias), blinding of participants and personnel
A total of 3441 studies were retrieved from different (performance bias), blinding of outcome assessment
databases. After removing the duplicate articles (n =814) and (detection bias), incomplete outcome data (attrition bias),
reading the titles and abstracts, articles not fulfilling the selective reporting (reporting bias), and other sources of bias.
inclusion criteria were excluded. A total of 33 full-text articles Based on the information reported in the individual studies,
were downloaded, and their eligibility was assessed. Of these each domain was judged as having a ‘low risk,’ ‘high risk,’ or
articles, 13 were excluded because they did not meet the ‘unclear risk’ of bias. Figures II and III present a graphical
inclusion criteria (among the ten papers, the outcome of summary of the risk of bias across all included studies
interest was not reported, and the other three papers were not (generated via RevMan). Figure II illustrates the quality
primary studies). Finally, 20 articles were used for this assessment regarding random sequence generation. Nine
systematic review. The detailed selection procedure, as studies lacked sufficient data on the randomised process, so
outlined in the PRISMA guidelines, is illustrated in Figure I. we assessed the risk of bias as unclear.15,18,20,23,25–27,30,32 One study
randomised participants based on volunteerism, which we
The summary characteristic of the included studies is listed in evaluated as a high risk of bias.25
Table I. Fourteen (14) studies were conducted in Europe; nine
were in Spain 15-22, two in Norway 23-24, and each one in Sweden Most studies used numbered, opaque, and sealed envelopes
25
, Denmark 26, and France.27 The rest of the studies were to conceal the allocation, which we considered to be a low
conducted: one in Brazil 28, Colombia 29, Slovenia 30, Iran 31, risk of bias. However, nine studies were assessed as having an
Nigeria 32, and Australia 33. A total of 5,179 participants were unclear risk of bias due to insufficient methodological details
involved in the studies, comprising 2,378 pregnant women in on allocation concealment. 18, 19, 21, 22, 27, 29, 30, 32, 33 All twenty studies
the exercise group and 2,801 participants in the control reported that participants were blinded; therefore, the risk of
group. The majority of the exercise took place in hospitals or bias was assessed as low. However, eleven studies did not
medical centre 15,16,31,32,34,17,19,20,22,23,27,29,30, three in universities, 18,26,28 specify whether the outcome assessors were blinded. Despite
two at public facilities 21,24 and one at the clinic.25 For the attempts to confirm this with the authors, we concluded these
studies, the exercise sessions were conducted by a studies as having an unclear risk of bias.18-20,22,26,27,29,31-34 One
physiotherapist-supervised exercise session17,22,25,30,32,33, an study was judged to be at high risk of bias because the
exercise instructor16,19,23,24,26,28,31,34, fitness instructors15,18,20, researchers were not blinded.21
gynaecologist 27 or dietician29. All women in the control group
were given standard antenatal care. Approximately 65% of the studies analysed all enrolled
participants, resulting in a low risk of bias. Seven studies were

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Impact of structured physical exercise during pregnancy on maternal health and fetal outcomes: A systematic review

Fig. 1: PRISMA flow diagram of literature search for the effects of structured physical exercise during pregnancy

judged to have a high risk of bias due to inadequate reporting Regarding other biases, three studies were assessed as having
of missing data and the inclusion of participants who an unclear risk of bias. In one study 21, although an intention-
dropped out of the intervention group.17,20,22,25,28,29,32 One study to-treat analysis was stated to have been used, not all
had an unclear risk of bias because it presented findings participants were included in the analysis. Two studies did
without providing absolute values for pregnant women in the not report the participants' baseline characteristics.18,22
exercise and control groups.26

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 Table I: Characteristics of included studies on structured physical activity and the outcome
Authors/ year Subject Intervention description Outcomes

512
IG CG Type of Duration Intensity Frequency Gestational Maternal Fetal
exercise (min) (times/week) period
(weeks)
Daniel 2015 35 35 Aerobic 45-60 Moderate 2 From 16 Exercise programs in pregnant No statistical difference in birth weight
weeks until women did not increase the risk of (EG 3.37kg; CG 3.31kg; MD 60.00; 95%
the week of preterm labour. However, the CI -252.28,372.28; p=0.72).
delivery gestation duration was significantly
longer in the exercise group than in
the control t (68) = 2.315; p = 0.026).

Cordero 2015 122 220 Aquatic 50-60 Moderate 3 From 10-14 Maternal exercise using aerobic and No statistical difference in birth weight
water-based weeks until muscular conditioning on land and (mean difference EG 3324.1 ± 433.1; CG
activity 36 weeks in the water with high compliance 3250.1± 425.01; MD 74.00, 95% CI -
Systematic / Narrative Review Article

reduced the incidence of GDM (OR 33.62,181.62; p=0.177).

0.10; 95% CI 0.013,0.803;
p=0.009). It was associated with a
decrease in gestational weight gain
(OR 0.56; 95% CI 0.31,0.99; p=0.04).

Haakstad 2015 52 53 Aerobic 60 Moderate At least 2 From 24 There were no statistical differences
weeks between the exercisers and controls
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to 36 weeks in numbers reporting low back pain

after the intervention (OR = 1.10; CI
0.47–2.60; p=0.83).

Fieril 2015 51 41 Resistance 60 Moderate- 2 From 14 Birth weight

vigorous weeks Newborns delivered by women who
until 28 underwent resistance exercise during
weeks pregnancy were significantly heavier
than those born to control women (EG
3561±452g; CG 3251±437g; MD 310.00;
95%CI 104.50, 515.50; p= 0.02), a
difference that disappeared when
gestational age was adjusted (p =
0.059).

Barakat 2016 420 420 Aerobic 40 Moderate 3 From 9- Pre-eclampsia Birth weight
11weeks until The exercise intervention reduced Pregnant women who do not exercise
38-39 weeks the incidence of pre-eclampsia (0.5% were 2.5 times more likely to give birth
vs 2.3%; OR 0.22; 95% CI 0.05, 1.02; to a macrosomic infant (OR, 2.53; 95%
p=0.03). CI 1.03, 6.20; p=0.04).

Gestational weight gain

Pregnant women who did not
exercise were 1.5 times more likely
to gain excessive weight (OR 1.47;
95% CI 1.06, 2.03; p= 0.02).

Gestational diabetes
Exercise reduced the incidence of
GDM (2.4% vs 5.5%; OR 2.05; 95% CI

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0.91, 4.6; p=0.03).
 Table I: Characteristics of included studies on structured physical activity and the outcome (Continued)
Authors/ year Subject Intervention description Outcomes
IG CG Type of Duration Intensity Frequency Gestational Maternal Fetal
exercise (min) (times/week) period
(weeks)
Guelfi 2016 85 87 Pedalling 60 Moderate 3 From 14 The supervised home-based exercise No statistical difference in the:
cycling weeks until started at 14 weeks of gestation did - Preterm delivery (OR 0.75; 95% CI
delivery not prevent the recurrence of GDM 0.16, 3.46; p=1.000)
(OR 1.02; 95% CI 0.55, 1.89; p=0.95). - Birth weight (EG 3552 ± 469g; CG
No statistical difference in the: 3419± 518g; MD 133.00; 95% CI; -
- Pre-eclampsia (OR 2.05; 95% 16.04,282.04; p=0.82)

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CI 0.18, 23.03; p=1.000)

Jahdi 2016 30 30 Supervised 60 Moderate 3 From 26 No statistical differences in birth

yoga weeks weight (EG 3005.6 ± 176.5g; CG 3156.6
until 37 ± 469.1g; MD -151.00; 95% CI -330.35,
weeks 28.35; p=1.0).

Perales 2016 122 117 Aerobic 55-60 Light- 3 From 9-11 The groups did not differ in The groups did not differ in
moderate weeks until - Total gestational weight gain - Birth weight (EG 3183.6 ± 446.8g; CG
39- (OR 0.47; 9 5% CI 0.22, 0.99; 3232.1 ± 383.2g; MD -48.50; 95% CI-
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40 weeks p=0.06) 175.13, 78.13; p=0.46)

Ramirez- Velez 24 26 Aerobic, 60 Moderate- 3 From 16-20 Lumbopelvic pain There was no significant difference
2017 resistance vigorous weeks until Low back pain intensity was 0.38 between the exercise and control
28- (95% CI 0.02-0.74); p=0.04) lower in groups regarding mean birth weight
34 weeks the water exercise group. (EG 3133 ± 406g; CG 3013 ± 494g; MD
120.00; 95% CI -129.88, 369.88; p=0.34).

Backhausen 258 258 Water 45 Moderate 2 From 20 There was no difference in: There was no difference in:
2017 exercises weeks Pre-eclampsia (OR 0.83; 95% CI 0.30, - Preterm delivery (OR 0.56; 95% CI
until 32 2.34; p=0.57) 0.20, 1.58; p=0.34)
weeks - gestational diabetes (OR 0.96; - Birth weight (EG 3549 ± 531g ; CG
95% CI 0.06, 15.41) 3540 ± 531g; MD 9.00 ; 95% CI -
87.03, 105.03; p=0.66)

Rodriguez- 50 53 Pilates 40-45 Moderate 2 From 26-28 Eight weeks of the Pilates program did
Diaz method weeks until not cause an adverse effect on birth
2017 34-36 weeks weight (EG 336.23 ± 361.88; CG 3417.6
± 473.54; MD -55.37; 95%CI -221.57,
108.83; p=0.005).

Sklempekokic 22 23 Aerobic, 50-55 Moderate 2 From 30 The exercise program had a

2017 resistance weeks until beneficial effect on the severity of
36 weeks lumbopelvic pain in pregnancy as it
reduced the intensity of the pain
(the numeric rating scale PGQ
(p=0.017) and RMDQ score (p=0.005)
in the 36th week of pregnancy.

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Impact of structured physical exercise during pregnancy on maternal health and fetal outcomes: A systematic review
 Table I: Characteristics of included studies on structured physical activity and the outcome (Continued)

514
Authors/ year Subject Intervention description Outcomes
IG CG Type of Duration Intensity Frequency Gestational Maternal Fetal
exercise (min) (times/ period (weeks)
week)
Watelain 2017 45 45 Muscle 60 Light- 2 From 24 weeks Strengthening exercises centred on
strengthening moderate until 36 weeks the trunk reduce low back pain
intensity (p<0.0001).

Sanda 2018 303 303 Cardiovascular 60 Moderate 2 From mean No statistical differences in
gestational - Preterm delivery (OR 1.00; 95% CI
week 17.6 ±2.6) 0.50, 1.99; p=0.83)
until delivery - Birth weight (EG 3410.6 ± 486.2g; CG
(mean 3449.7 ± 539.3g; MD -39.10; 95% CI -
Systematic / Narrative Review Article

gestational 122.04, 43.84; p=0.36)

week
39.9 ±1.8)

Brik 2019 42 43 Cardiovascular 60 Light- 3 From 9 weeks Gestational weight gain No significant difference in the
moderate until 38 weeks No difference in maternal weight - Preterm birth (OR 0.50; 95% CI 0.04,
was measured at 20, 28, 36, and 38 5.73; p=0.66)
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weeks gestation or in weight gain at - Birth weight (EG 3161 ± 564.4g;

38 weeks between women who CG 3477.11 ± 414.51g; MD -40.00;
followed the exercise program and 95% CI -242.68, 162.68; p=0.36)
those who did not (OR 0.86 95%; CI
0.26, 2.80; p=0.51).

Barakat 2019 260 260 Aerobic 55- Moderate 3 From 8-10 Gestational weight gain Birth weight
60 weeks until 38- Exercise throughout pregnancy can No differences were found in birth
39 weeks reduce the risk of excessive maternal weight between study groups (p=0.6).
weight gain (OR 0.60; 95% CI 0.39, The ratio of neonate macrosomic was
0.92; p=0.018). slightly higher in the control group
than in the intervention group (7.2% vs
Gestational diabetes 3.4%; OR 0.456; 95% CI, 0.191,1.087).
the prevalence of gestational
diabetes was significantly higher in
the CG than the EG (6.8% vs 2.6%
respectively; OR 0.363; 95% CI
0.138,0.953; p = 0.033).

Rodriguez 65 64 Aquatic 60 Moderate 3 From 20 weeks The median birth weight was 3259g in
2019 aerobic until 37 weeks EG and 3477 grams in IG, and the
exercises difference was statistically significant
(MD -218.1; 95% CI - 388.81, -47.41;
p=0.011).

Roldan- Reoyo 64 67 Aerobic 60 Moderate From 10-12 No statistical difference in birth weight
2019 3 weeks until 36- (EG 3139 ±451.52g; CG 3222.41 ±
40 weeks 416.62g; MD - 83.41; 95% CI -273.65,
106.83; p>0.005).

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 Table I: Characteristics of included studies on structured physical activity and the outcome (Continued)
Authors/ year Subject Intervention description Outcomes
IG CG Type of Duration Intensity Frequency Gestational Maternal Fetal
exercise (min) (times/ period (weeks)
week)
Pelaez 2019 115 230 Aerobic, 60- Moderate 3 From 12 weeks Supervised moderate to vigorous
resistance 65 until 36 weeks exercise performed throughout
gestation was influential in
preventing EGW gain (22 [22.0%] vs
69 [34.3%]; OR 0.54; 95% CI 0.31,
0.04; p=.03).

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It also prevented gestational
diabetes (OR 0.45; 95% CI 0.12, 1.61;
p=0.03)

Da Silva 2017 213 426 Aerobic 60 Moderate 3 From 16-20 No differences between the two No differences between the two groups
weeks groups in in
32-36 weeks - mean gestational weight gain (OR - birth weight (EG 3234 ± 511g; CG
1.03; 95% CI 0.70, 1.52; p=0.10) 3254 ± 467g; MD -20.00; 95% CI -
- pre-eclampsia (OR 0.99; 95% CI 103.52, 63.52; p=0.63).
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0.47, 2.09; p=1.0) The exercise program did not cause

- gestational diabetes (OR 1.03; 95% adverse impacts on preterm birth (OR
CI 0.55, 1.92; p=1.0) 1.10; 95% CI 0.66, 1.83; p=1.1)

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Systematic / Narrative Review Article

Maternal Health Outcomes lower risk of GDM in the exercise group than in controls.
Gestational weight gain Heterogeneity among the studies was low (Chi² = 8.53, df = 6,
Seven randomised controlled trials were analysed to evaluate p = 0.20; I² = 30%), indicating consistency across the included
the effect of maternal exercise on gestational weight gain, as trials. Several studies, including those by Barakat (2016,
shown in Figure IV. The pooled analysis included 2,218 2019) and Cordero (2015), reported significant protective
participants, with 961 in the exercise group and 1,257 in the effects of exercise.15,16,18 The results support the role of prenatal
control group. The overall odds ratio (OR) for excessive exercise as an effective intervention for reducing the
gestational weight gain in the exercise group compared to incidence of GDM, reinforcing current public health
the control group was 0.88 (95% CI: 0.44 to 1.76), indicating recommendations promoting physical activity during
a non-significant risk reduction (Z = 0.37, p = 0.71). While pregnancy.
several studies demonstrated a favorable trend toward
reduced weight gain with exercise, the confidence intervals Pre-eclampsia
often overlapped the line of no effect. Notably, substantial Figure VII shows the analysis that explores the impact of
heterogeneity was observed across studies (Tau² = 0.76; Chi² exercise on the risk of pre-eclampsia, synthesising data from
= 62.12, df = 6, p < 0.00001; I² = 90%), likely reflecting four studies published between 2016 and 2017. The included
differences in study populations, exercise protocols, and studies span a total of 2,062 participants, comparing exercise
outcome definitions. Despite the lack of statistical interventions to control groups. The cumulative analysis
significance in the pooled estimate, the direction of effect revealed an odds ratio (OR) of 0.78 (95% CI: 0.46–1.32),
suggests a potential benefit of maternal exercise, warranting suggesting a potential reduction in pre-eclampsia risk among
further investigation through well-designed, homogeneous individuals who engage in exercise, although the result did
trials. not achieve statistical significance (P = 0.35). The
heterogeneity among the studies was low (I² = 19%, P = 0.30),
Lumbopelvic pain indicating consistency across findings. The most pronounced
Four studies were identified that reported on lumbopelvic benefit was observed in the study by Barakat et al. (2016)15,
pain (LBP), measuring pain intensity level 26,27,30 and which reported an OR of 0.22 (95% CI: 0.05–1.02). Despite
prevalence of LBP pain among pregnant women.23 Out of these promising trends, the results highlight the need for
these studies, one study reported no statistically significant further large-scale, randomised controlled trials to confirm
results.23 Three randomised controlled trials were analysed to the protective effects of exercise on pre-eclampsia,
assess the effectiveness of exercise in reducing lumbopelvic particularly in diverse populations.
pain during pregnancy, as shown in Figure V. The analysis
included a total of 753 participants (375 in the exercise group Fetal health Outcome
and 378 in the control group). The pooled odds ratio (OR) was Premature delivery
0.98 (95% CI: 0.49 to 1.93), indicating no statistically Figure VIII shows the analysis that evaluates the impact of
significant difference in the odds of experiencing lumbopelvic exercise on preterm delivery, incorporating data from seven
pain between the exercise and control groups (Z = 0.06, p = studies conducted between 2016 and 2019.15,16,24,26,28,29,32,33 The
0.95). The test for heterogeneity revealed no significant pooled analysis included 2,648 participants, comparing
variation across studies (Χ² = 0.63, df = 2, p = 0.73; I² = 0%), preterm delivery outcomes between exercise intervention
indicating consistent findings. While individual study groups and control groups. While the overall odds ratio (OR)
estimates varied, none demonstrated a significant benefit of of 0.80 (95% CI: 0.56–1.12) indicates a trend toward reduced
exercise. One study could not be included in the meta- risk with exercise, the association was not statistically
analysis due to non-estimable data.27 Overall, the findings significant (P = 0.19). The analysis demonstrated low
suggest that exercise may not significantly impact the heterogeneity (I² = 0%, P = 0.94), suggesting consistency
prevention or reduction of lumbopelvic pain in pregnancy. across studies. The study by Barakat et al. (2016)15 contributed
However, the wide confidence intervals and limited number the most weight (46.4%) to the analysis, with an OR of 0.87
of studies indicate that further high-quality trials are (95% CI: 0.46–1.28). These results underscore the potential
warranted. benefits of exercise in reducing preterm delivery, but
highlight the necessity for further high-quality, randomised
Gestational Diabetes controlled trials to confirm these effects and elucidate the
Seven randomised controlled trials were analysed to evaluate mechanisms.
the effect of maternal exercise during pregnancy on the risk
of developing gestational diabetes mellitus (GDM), as shown Birthweight
in Figure VI. Two studies used the American Diabetes Analysis from 16 studies conducted between 2015 and 2019
Association (ADA) criteria, 18,19, and one study was based on investigates the effect of exercise during pregnancy on infant
the International Association of Diabetes and Pregnancy birthweight as shown in Figure IX. The pooled analysis,
Study Groups (IADPSP), 33. Four other studies did not specify encompassing a total of 3,681 participants, compared birth
their diagnostic criteria.15,16,26,28 Four studies reported weight outcomes between the exercise and control groups.
statistically significant results.16,18,19,35 The overall mean difference (MD) of 7.84 grams (95% CI: -
The pooled data comprised 2,887 participants, consisting of 22.69 to 38.36) suggests a negligible effect of exercise on
1,222 women in the exercise group and 1,665 in the control birthweight, with statistical insignificance (P = 0.61).
group. The analysis yielded a statistically significant Moderate heterogeneity (I² = 49%, P = 0.02) is observed,
reduction in the odds of GDM among women who engaged indicating variation across study findings. The most
in exercise, with a pooled odds ratio (OR) of 0.57 (95% CI: significant contribution to the analysis was observed in the
0.40 to 0.81; Z = 3.10, p = 0.002). The findings suggest a 43% study by Ramirez-Velez et al. (2017), which reported a MD of

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Impact of structured physical exercise during pregnancy on maternal health and fetal outcomes: A systematic review

-340.60 grams (95% CI: -544.00 to -137.20). These results Structured physical activity has been associated with reduced
suggest that while exercise during pregnancy does not risk of developing pre-eclampsia. Our review found that
substantially influence birth weight, further research is structured antenatal exercise lowered the risk of developing
warranted to examine specific contexts and subpopulations pre-eclampsia by 22% even though it was not statistically
where exercise may have significant impacts. significant. Davenport et al. (2018) in their meta-analysis
evaluated the effect of structured physical activity on 273,182
pregnant women in 106 studies and found that exercise
DISCUSSION reduced the risk of gestational hypertension by 39% and pre-
This systematic review evaluated the impact of structured eclampsia by 41%. The authors suggest following ACOG
exercise on gestational outcomes among pregnant women, recommendations to achieve at least a 25% reduction in the
mainly gestational diabetes mellitus (GDM), gestational odds of developing pre-eclampsia.12 However, a descriptive
weight gain (GWG), lumbopelvic pain, pre-eclampsia, study by Babili et al., (2021) reported that moderate to
preterm delivery, and fetal birth weight. The exercise vigorous antenatal exercise did not reduce the incidence of
programs in the intervention group combined aerobic pre-eclampsia.41 Exercise performed during pregnancy was
exercise, dance, resistance training, aquatic workouts, hypothesised to suppress peripheral insulin resistance, reduce
cardiovascular workouts, and Pilates, which were easily oxidative stress, and promote placental growth and vascular
incorporated into the structured exercise regimen. Most of the development.42-44 This mechanism reduces blood glucose and
studies were liked by pregnant women, as indicated by the controls blood pressure.
high adherence rate.
Our systematic review also found that structured physical
Our findings suggest that structured physical activity during activity during antenatal did not reduce lumbopelvic pain
pregnancy significantly reduced the incidence of gestational (LBP) intensity or prevalence. Despite this, our review
diabetes by 40% compared to the control group. These suggests that antenatal exercise improves the quality of life
findings are aligned with a meta-analysis by Sanabria- and disability caused by LBP. Shiri et al. (2018) evaluated the
Martinez et al.36 A meta-analysis involving 2,873 pregnant association between physical activity during pregnancy and
women from 13 studies found that structured physical LBP, which found that exercise intervention had no
exercise during pregnancy reduced the incidence of protective effect on LBP or pelvic girdle pain. However, they
gestational diabetes by 31%. The impact was seen as greater found that pregnant women taking sick leave due to LBP
when the exercise program was initiated during early were less compared to the control group.9 This could be
pregnancy. Nasiri-Amiri et al. (2019), evaluated the effect of explained by the fact that exercise improves muscle strength,
exercise on 1441 pregnant women in eight studies.54 They lowers stress on the spine, and increases joint stabilization.10
reviewed that exercise decreased the risk of GDM in obese and In contrast, a protective effect of exercise against LBP was
overweight pregnant women. However, Davenport et al., seen in a few studies. A meta-analysis by Kinser et al. (2017)
(2018) found that antenatal exercise was ineffective in demonstrated that exercise during pregnancy reduced LBP,
reducing the incidence of GDM.40 This could be because discomfort, and related symptoms.55 Furthermore, a meta-
unsupervised exercise leads to poor compliance with the analysis by Davenport et al. (2018) also found that exercise
exercise protocol, which in turn influences the results. performed during pregnancy and the early postpartum
Nevertheless, this finding may support that a healthy lifestyle period did reduce the severity of LBP compared to those who
initiated pre-conception and in the early trimester may be a did not exercise.12
fundamental method in preventing chronic disease risk in
pregnant women. Our review also found that exercise during pregnancy does
not affect birth weight and gestational length. Women with
Our review found that exercise intervention during low-risk a higher exercise energy expenditure during pregnancy
pregnancy did not significantly impact the prevention of delivered infants with appropriate gestational age (AGA)
excessive weight gain. Still, considering the OR, exercise had birth weight without evidence of an increased risk for small
a 25% protective effect in preventing excessive weight gain. or large gestational age (SGA/LGA). Betham et al., (2019) in
Our findings aligned with a review and meta-analysis study their review examining the effect of vigorous physical activity
by Shieh et al. (2018) concluded that physical exercise is on 32080 pregnant women in 13 studies, found that the
ineffective in preventing excessive weight gain during exercise program did not increase the risk of delivering an
pregnancy.37 In addition, Kunath et al. (2019) demonstrated SGA infant and reduced the risk of prematurity.45 Moreover,
that combining physical exercise and diet was ineffective in our study and others suggest a reduction in the risk of
avoiding excessive weight gain.38 delivering LGA infants with antenatal exercise.46-48 In
contrast, a case-control study by Mahmoodi et al., (2013)
In contrast, Wang et al., (2019) in a meta-analysis study found that sports participation was linked to a greater risk of
found that active pregnant women in all BMI categories LBW infants.49
significantly gained less weight than the control group.39
Furthermore, another review by Sui et al. (2012), which We also found no relationship between structured physical
examined the effects of exercise among 276 overweight and activity during pregnancy and the risk of prematurity. In
obese pregnant women, found that supervised antenatal contrast to a review by Aune et al. (2017), 20 RCTs and 20
exercise lowered the risk of excessive weight gain. The cohort studies found that a high intensity of physical exercise
authors also concluded that the impact of limiting during antenatal care decreased the risk of preterm birth by
gestational weight gain is more significant in the 14%.50 Similarly, Di Mascio et al., (2016) showed that
combination of exercise and diet groups.6 pregnant women can safely perform aerobic exercise as it

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Systematic / Narrative Review Article

was not related to an increased risk of preterm birth.51 Exercise However, most studies were based on various types,
increases insulin sensitivity and decreases the inflammatory intensities, or durations of exercise and were inconsistent in
process which may contribute to reducing the risk of preterm quality. Hence, more trials are needed to find the effect of
birth.52 However, previous studies showed inconsistent structured physical activity during pregnancy on gestational
findings, as they reported inverse associations between outcomes. As this review only includes randomised controlled
physical activity during pregnancy and preterm birth.52-53 trials, further study must be conducted to arrive at a complete
Takami et al. (2018) conducted a cohort study that showed conclusion on the impact of structured physical activity on
physical activity during pregnancy increased the risk of pregnancy outcomes.
preterm birth.

The findings of this review have important implications for SOURCE OF FUNDING
clinical practice, particularly in the context of routine This research did not receive funding from any external
antenatal care. Given the observed reduction in the risk of sources.
gestational diabetes mellitus (GDM) among women who
engaged in prenatal structured exercise, healthcare providers
should proactively promote physical activity as a standard ACKNOWLEDGEMENT
component of pregnancy care. Clinical guidelines The authors also thank the International Islamic University
recommend at least 150 minutes of moderate-intensity Malaysia and the Ministry of Health Malaysia for their
exercise per week during pregnancy for women without approval and publication of our research.
contraindications.3

Providers—obstetricians, family physicians, and midwives— CONFLICT OF INTEREST

should offer individualized exercise counselling, considering There is no conflict of interest.
gestational age, medical history, and physical limitations.
Structured programs, such as supervised group sessions or
home-based regimens with follow-up, may improve ETHICAL APPROVAL
adherence and outcomes.12 Although the evidence for This study was approved by the Research and Ethical
reducing lumbopelvic pain, gestational weight gain, pre- Committee of researchers’ institution (IREC 2021-189)
eclampsia, premature delivery and low birth weight remains
inconclusive, the overall maternal benefits—ranging from
improved glycemic control to enhanced psychological well- AUTHOR’S CONTRIBUTION
being—support the broader integration of exercise into NAJ and KHAA conceived and designed the study. FHMN and
antenatal pathways. Integrating exercise promotion into NAJ conducted the literature search, provided research
routine antenatal visits, supported by patient education and materials, and collected and organized data. FHMN, NAJ,
local resources, could improve pregnancy outcomes and and KHAA analyzed and interpreted the data. FHMN, NAJ,
long-term maternal health. and KHAA wrote the initial and final drafts of the article and
provided logistic support. All authors have critically reviewed
The limitations of our study include the fact that only and approved the final draft and are responsible for the
randomized controlled studies, and English articles were content and similarity index of the manuscript.
included in our review. We excluded quasi-experimental
studies or literature reviews. Additionally, we were unable to
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