A C TA Obstetricia et Gynecologica

AOGS M A I N R E SE A RC H A R TI C LE

The efficacy of moderate-to-vigorous resistance exercise

during pregnancy: a randomized controlled trial
KAROLINA PETROV FIERIL1, ANNA GLANTZ2 & MONIKA FAGEVIK OLSEN1
1

Institute of Neuroscience and Physiology, University of Gothenburg, and 2Antenatal Care, Primary Health Care,
Gothenburg, Sweden

Key words
Exercise, pregnancy, public health,
randomized controlled trial
Correspondence
Karolina Petrov Fieril, N
arh
alsan,
Rehabmottagning, Olskroken, 416 65
Gothenburg, Sweden.
E-mail: karolina.fieril@vgregion.se
Conflict of interest
The authors have stated explicitly that there
are no conflicts of interest in connection with
this article.
Please cite this article as: Petrov Fieril K,
Glantz A, Fagevik Olsen M. The efficacy of
moderate-to-vigorous resistance exercise
during pregnancy: a randomized controlled
trial. Acta Obstet Gynecol Scand 2015; 94:
3542.
Received: 14 April 2014
Accepted: 29 September 2014
DOI: 10.1111/aogs.12525

Abstract
Objectives. To assess the effect and safety of moderate-to-vigorous resistance
exercise during pregnancy. Design. Randomized controlled study. Setting. Two
antenatal clinics in Gothenburg, Sweden. Population. Ninety-two healthy pregnant women. Methods. The intervention was administered during gestational
weeks 1425. The intervention group received supervised resistance exercise
twice a week, performed at an activity level equivalent to within moderate-tovigorous (n = 51). The control group received generalized exercise recommendation, a home-based training program and a telephone follow up (n = 41).
Main outcome measures. Health-related quality of life, physical strength, pain,
weight, blood pressure, functional status, activity level, and perinatal data.
Results. Functional status deteriorated during the intervention in both groups
and pain increased. Significant differences between the groups were obtained
only for birthweight. Newborns delivered by women who underwent resistance
exercise during pregnancy were significantly heavier than those born to control
women; 3561 (452) g vs. 3251 (437) g (p = 0.02), a difference that disappeared when adjustment was made for gestational age (p = 0.059). Both groups
showed normal health-related quality of life, blood pressure, and perinatal data.
Conclusions. These findings indicate that supervised, moderate-to-vigorous
resistance exercise does not jeopardize the health status of healthy pregnant
women or the fetus during pregnancy, but instead appears to be an appropriate
form of exercise in healthy pregnancy.
BP, blood pressure; DRI, disability rating index; GDM,
gestational diabetes mellitus; HRQoL, health-related quality of life; RCT,
randomized controlled trials; SF-36, Short Form-36 Health Survey.

Abbreviations:

Introduction
Maintaining a physically active lifestyle is associated with
many benefits, including lower risk of cardiovascular disease, diabetes, hypertension, some types of cancer, and
depression (1). Exercise is defined as a planned, structured, and repetitive subset of physical activity that
improves or maintains physical fitness, overall health or
well-being as an intended intermediate or final objective
(2). Pregnant, healthy women are recommended to do
30 min or more of light to moderate exercise a day on

most, if not all, days of the week (3,4). Exercise during

pregnancy is associated with reduced back pain (5),
improved health perception (6), and weight gain control

Key Message
Supervised regular, moderate-to-vigorous resistance
exercise has no adverse effect on childbirth outcome,
pain, or blood pressure. Further investigation into the
use of resistance exercise during pregnancy is needed.

2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 3542

35

Resistance exercise during pregnancy

(7). In the literature investigations have reported on the

effect of aerobic exercise when adopted in pregnancy.
Only a few randomized controlled trials (RCT) have,
however, examined the efficacy and safety of resistance
exercise during pregnancy (810). One study found resistance exercise performed with an elastic band effective in
improving glycaemic control in women with gestation
diabetes mellitus (GDM) (9). No adverse impact on the
delivery (10), or the newborn has been seen (8). Hence,
in their review Nascimento et al. (11) suggested adding
resistance exercise to the exercise recommendations.
Although the exercise recommendations do not provide
specific guidance for vigorous intensity exercise (3,4), Nascimento et al. (11) suggested that their results supported
the promotion of moderate-to-vigorous prenatal exercise.
Ruchat et al. (12) concluded that a walking program of
vigorous intensity is safe and beneficial to both the
mother and fetus, and also promotes decline in glucose
concentrations among women at risk of GDM (13). In a
prospective study Jukic et al. found an association
between first-trimester vigorous exercise and longer gestation, and reduced risk of preterm births (14). To the best
of our knowledge, no RCT has been conducted that studies prenatal resistance exercise at moderate-to-vigorous
intensity.
The aim of this study was to evaluate the health effect
and safety of moderate-to-vigorous intensity resistance
exercise when free weights are used by healthy women
during pregnancy, with regard to health-related quality of
life (HRQoL), pain location, physical strength, body
weight gain, blood pressure (BP), functional status, activity level, and childbirth outcomes.

Material and methods

Participants for this study were recruited from February
2006 through November 2006, and from September 2008
through April 2009, all from two antenatal clinics in
Gothenburg, Sweden. Background variables did not significantly differ in between the two study periods. The
participants were verbally informed about the study by
midwives or they received written information available
at the antenatal clinic. Those interested in participating
contacted the research coordinator. The criteria of inclusion were: (i) Pregnancy <14 weeks of gestation; (ii) single pregnancy; (iii) absence of medical or obstetric
diseases; (iv) ability to understand verbal and written
Swedish. Criteria of exclusion followed the recommendation regarding contraindications according to the American College of Obstetricians and Gynecologists (4).
Approximately 1500 pregnant women had been registered
at the antenatal clinics at that time (99% of Swedish
women receiving combined obstetric and midwifery

36

K. Petrov Fieril et al.

care have their deliveries in the public health system,

via antenatal clinics) (15). Of 116 women willing to participate, 24 were excluded for either twin pregnancy or
being 14 weeks of gestation. Hence, 92 women were
included (Figure 1). The study was approved by the
Regional Ethical Review Board at the University of Gothenburg (D No. 353-05) and registered in the Research
and Development Center in Sweden (registration number
VGFOUGSB-4388). Written informed consent for participation was obtained from each participant. The CONSORT guidelines were followed while conducting the
study.
The women were enrolled at gestational week 13, at
which time the research coordinator (physiotherapist)
met with each and provided them with general exercise
recommendations and a home training program. Participants were randomly assigned to either the intervention
group or the control group (allocation ratio 1:1). The
research coordinator performed the randomization by
using opaque sealed envelopes, which were randomly
picked out before the meeting with each participant. All
data were collected at a primary health care location by
an investigator (physiotherapist) who was blinded to participant group status. The intervention group practised
high-repetition, resistance training twice a week for
12 weeks (pregnancy weeks 1425), performed using light
barbells [110 lbs (0.454.5 kg)] and weight plates [2.5
10 lbs (1.14.5 kg)], which was carried out while listening
to music in a supervised (by the research coordinator)
group exercise setting (16). The exercises were selfadjusted to each womans condition of pregnancy and
performed at a self-estimated, moderate to vigorous
intensity (17). Each session was 60 min long, including
warm-up and wind-down. All major muscle groups were
trained repeatedly (5080 repetitions for each muscle
group) during 35 min, including shorter breaks. The
training was inspired by BODYPUMPTM (16) but adjusted
to pregnant women: warm-up and relaxation periods
were extended a few more minutes, squat jumps were
exchanged for heel raises, the squats were less deep and
the abdominal training was exchanged for pelvic-lift and
static-abdominal training. All such training was performed with good form for trunk- and pelvic-floor muscle control and these were supervised by the research
coordinator. Besides this training, additional exercises
were recommended to the participants, including walking,
bicycling, water-gymnastics, Pilates, yoga and resistance
exercises. Compliance was defined as participation in at
least two-thirds of all training sessions.
Control group participants received general exercise
recommendations during pregnancy and were informed
of appropriate exercise and exercise frequency. Additionally, they were given written guidance and instruction on

2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 3542

K. Petrov Fieril et al.

Resistance exercise during pregnancy

Assessed for eligibility (n = 116)

Excluded (n = 24)
Not meeting inclusion
criteria (n = 24)

Enrollment
Randomized (n = 92)

Allocation
Allocated to intervention group (n = 51)
Received allocated intervention (n = 51)

Allocated to control group (n = 41)

Received allocated intervention (n = 41)

Lost to follow up (n = 13)

Lost to follow up (n = 7)
Discontinued intervention (timeconstraints)(n = 5)
Change of work (n = 2)
Personal reasons (n = 1)
Moving from town (= 1)
Dislocated placenta (n = 1)
Discomfort during exercise (n = 1)
Pelvic girdle pain (n = 1)
Miscarriage (n = 1)

Follow up

Not motivated (n = 3)
Personal reasons (n = 2)
Moving from town (n = 1)
Miscarriage (n = 1)

Analysis

Analysed (n = 38)
Excluded from analysis (n = 0)

Analysed (n = 34)
Excluded from analysis (n = 0)

Figure 1. Flow diagram summarizing the study design.

a general training program containing home exercises

suitable for pregnancy, including pelvic-floor muscle
training. They were offered a free visit to a physiotherapist if desired. Exercises were recommended to the
control participants, including walking, bicycling, watergymnastics, Pilates, yoga and resistance exercises. In
pregnancy week-18 the research coordinator contacted
the controls by telephone for follow up. Before and after
the intervention the participants filled in questionnaires
and performed the following tests: HRQoL was measured
using the Short Form-36 Health Survey (SF-36; Swedish
Acute Version 1.0) (18) SF-36 comprises 36 items, 35 of
which are arranged in eight physical and mental health
scales, and one being a self report of health change.
Scores may be obtained ranging from 0 to 100. Higher
scores positively correlate with higher levels of functioning. The eight sub-scales are: (i) physical functioning; (ii)
role, physical; (iii) bodily pain; (iv) general health; (v)
vitality; (vi) social functioning; (vii) role, emotional; and
(viii) mental health. Pain was measured using a graphic
(drawings) depiction of body locations, upon which the
participant would localize the area of pain. Scores were
assigned to indicate the presence or absence of pain in

each of 45 body areas (19). Five areas located to the

lower back and pelvis were selected for analysis.
Hand-grip isometric strength was defined as the peak,
voluntary, hand-grip force applied using the Grippit
electronic hand-grip strength detector (GrippitAB,
Gothenburg, Sweden), administered in accordance with
standard laboratory protocol (20). Grip strength correlates with upper extremity strength (21). Weight gain and
BP were obtained from medical records at the perinatal
clinic, Primary Health Care, Gothenburg, Sweden. Weight
gain was measured in kilograms, wearing clothes but with
no shoes. Functional status was measured by the Disability Rating Index (DRI) and recorded on a visual analogue
scale, i.e. a self-estimation scale from 0 to 100, where 0
indicated no restricted activity and 100 indicated inability
to perform the activity. The DRI includes 12 items that
measure functions, including: dressing, outdoor walks,
climbing stairs, sitting for a longer time, standing bent
over a sink, carrying a bag, making bed, running, light
physical activity, heavy physical activity, lifting heavy
objects and participating in exercises/sports. During the
intervention period all of the participants kept a structured diary of daily physical activity, according to the

2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 3542

37

Resistance exercise during pregnancy

K. Petrov Fieril et al.

Table 1. Baseline demographics and clinical characteristics; mean

values  SD or n (%).
Baseline
demographics
Maternal age,
mean (SD)
Education, years
at school,
mean (SD)
Prepregnancy
body mass
index,
mean (SD)
Activity level pregnancy
week 13
(min/day), mean (SD)
Walking
Moderate
Vigorous
Primipara, n (%)
Marital status, n (%)
Married/
cohabiting, n (%)
Smoking, n (%)
Taking snuff, n (%)

Intervention
group (n = 38)

Control group
(n = 34)

p-value

30.8 (3.6)

30.6 (3.4)

0.77

15.4 (1.79)

16.3 (1.8)

0.07

The participants estimated the number of minutes per

day that they had performed the different activities.
Perinatal data, including birthweight, birth length, gestational age at time of delivery and cesarean section rates
were obtained from the Sahlgrenska University Hospitals
perinatal records.

Statistical analysis
22.6 (2.5)

23.0 (2.6)

0.50

52
11.7
1.1
28

47
18.3
1.2
28

0.68
0.12
0.89
0.52

(47)
(14.8)
(3.2)
(74)

38 (100)
1 (2.5)
1 (2.5)

(58)
(20.7)
(4.3)
(82)

33 (97)

0.47
0.52
0.52

short form of International Physical Activity Questionnaire (22). Each activity was divided into vigorous intensity, moderate intensity, walking and sedentary.

The sample size calculation was calculated on a difference

in HRQoL measured by SF-36. To detect a clinically significant difference between groups with 80% power and
at the 5% significance level, and a difference between
groups of 10 units, 40 participants were needed in each
group. Group-mean differences in physical strength, body
mass index, BP, activity level, birthweight, birth length,
and gestational age were analyzed by the Students t-test
or chi-squared test using statistical software SPSS version
22.0 (IBM Corp, Armonk, NY, USA). Subgroup scores in
SF-36 and DRI were analyzed using the MannWhitney
U-test. Birthweights adjusted for gestational week were
converted to Z-scores. A p-value <0.05 (two-tailed) was
defined as significant. Only participants who fully completed the trial according to the protocol were considered
compliant and analyzed.
Ninety-two women met the inclusion criteria and were
enrolled (Figure 1). No significant differences in background characteristics were found between the group of
women who dropped out and those for whom complete

Figure 2. Group differences in Quality of Life (SF-36) between gestational weeks 13 and 25, respectively, Intervention group (n = 38) and
Control group (n = 34). Abbreviations: PF, Physical Functioning; RP, Role Physical; BP, Bodily Pain; GH, General Health; VT, Vitality; SF, Social
Functioning; RE, Role Emotional; MH, Mental Health.

38

2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 3542

K. Petrov Fieril et al.

data were obtained, up to and including gestational week

25. Sixty percent of the women in the intervention group
estimated their own resistance exercise as vigorous and
40% rated their exercise as moderate intensity. The
mean attendance rate in the intervention group was 80%
(67100%).

Results
The group means for the intervention group and control
group did not significantly differ on multiple variables,
including: age, education, parity, pre-pregnancy body
mass index, physical activity, marital status, and tobacco
status (Table 1). HRQoL did not differ between the intervention group and controls (Figure 2), neither number of
women with back pain nor those with pelvic pain
(Table 2). Group-means scores for peak voluntary
strength, weight gain, BP, and activity level did not differ
significantly (Table 2). As shown in Figure 3, no significant differences were found between the groups in physical functioning, measured by the DRI. Birthweights were
significantly higher in the intervention (x
I = 3561 
452 g) compared with the control group (x
c = 3251 
437 g; p = 0.02). However, when adjusted for gestational
age, this difference did not remain (p = 0.059). The mean
birth length was 50.7 (2.1) cm in the intervention
group and 49.4 (2.6) in controls (p = 0.10), and gestational age was 280.1 (12.5) days in the intervention
group and 276.7 (7.7) among controls (p = 0.16). There
were no differences in cesarean section rates. In each
group, five women had a cesarean section: 14% and 15%
in the intervention group and the control group,
respectively.

Discussion
Benefits of resistance exercise for adults are well-known
(23), but in pregnancy women are recommended to proceed with caution, particularly when exercise is performed
at moderate or vigorous levels (3,4). The present study
indicates that supervised regular, moderate-to-vigorous
resistance exercise performed twice a week does not
adversely impact childbirth outcome, pain, or BP. However, it is important to note that physical and emotional
status changes accompany pregnancy, including a
decrease in functional status and an increase in pain,
whether one does resistance exercise or not. The
intervention did not have any significant impact on
HRQoL. Previous studies were inconclusive. Barakat et al.
reported improved health self-perception, a component of
HRQoL, among previously sedentary pregnant women
(6). However, other studies failed to show a significant
increase in HRQoL among exercising, overweight/obese

Resistance exercise during pregnancy

Table 2. Pain, peak voluntary strength, weight, systolic blood

pressure, diastolic blood pressure.

Outcome

Intervention
group
(n = 38)

Control
group
(n = 34)

Pain, n (%)
Gw 13
12 (31%)
12 (36%)
Gw 25
22 (58%)
21 (52%)
Peak voluntary strength, mean (SD)
Left hand
Gw 13
311 (47)
309 (58)
Gw 25
317 (52)
311 (55)
Right hand
Gw13
338 (46)
342 (58)
Gw25
344 (54)
248 (67)
Weight
Gw13
66.5 (9.3)
65.0 (10.3)
Gw25
72.7 (9.2)
70.5 (11.0)
Systolic blood pressure
Gw13
109 (18.8)
111 (10.5)
Gw25
112 (8.8)
112 (9.7)
Diastolic blood pressure
Gw13
66.2 (8.3)
63.7 (7.7)
Gw25
65.7 (8.2)
63.4 (7.8)
Activity level
Walking
Gw13
52 (47)
47 (58)
Gw25
118 (109)
79 (76)
Moderate
Gw13
11.7 (14.8) 18.3 (20.7)
Gw25
15.8 (12.9) 16.8 (15.4)
Vigorous
Gw13
1.1 (3.2)
1.2 (4.3)
Gw25
11.2 (26.9)
4.6 (7.1)
Sedentary
Gw13
316 (196)
366 (170)
Gw25
372 (171)
384 (171)

p-value

CI

0.40
0.52

0.92
0.65

25.8 to 23.2
31.2 to 19.4

0.73
0.69

20.7 to 28.1
24.3 to 32.8

0.61
0.80

6.1 to 3.1
6.7 to 2.6

0.39
0.56

5.1 to 9.2
4.7 to 4.0

0.35
0.56

6.23 to 1.28
6.02 to 1.52

0.68
0.08
0.12
0.76

29.6 to 19.4
83.6 to 5.1
1.73 to 14.99
5.60 to 7.61

0.89
0.15

1.88 to 1.64
15.9 to 2.78

0.25
0.77

35.9 to 136.2
68.8 to 92.7

Mean values  SD and confidence interval (CI) or n (%).

Gw, gestational week.

women (24), or pregnant women performing water gymnastic training (25).

The participants self-rate the intensity of their resistance exercise as moderate-to-vigorous; few RCTs with
pregnant women have exercised to such a vigorous level
of intensity. Remarkably, these results show no adverse
effects on the course of pregnancy or the health status of
offspring (1214). In our study, birthweight in the intervention group was higher than that of those born to control women, but when adjusted for gestational age this
was not significant. In the body of literature we found
inconsistent results on exercise and birthweight. Exercise
may reduce the risk of low birthweight outcome (26)
leading to a hypothesis that exercise enhances growth in
the fetoplacental unit and reduces the risk of preterm

2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 3542

39

Resistance exercise during pregnancy

K. Petrov Fieril et al.

Figure 3. Group differences in Disability Rating Index between gestational weeks 13 and 25, respectively, Intervention group (n = 38) and
Control group (n = 34).

birth (14). Additionally, though in contrast, Jukic et al.

reported that women who performed exercise tended to
have lighter babies (14).
A few RCTs have studied resistance training during
pregnancy. Light-to-moderate resistance training seems to
be effective in improving glycaemic control in women
with GDM (9), and does not adversely impact the type of
delivery (10) or the health status of offspring (8). The
present study corroborates this, supporting the finding
that higher intensity resistance training is appropriate as a
prenatal exercise. Back and pelvic pain are common during pregnancy. Pennick and Liddle concluded from their
review that more than two-thirds of pregnant women
experience back pain and almost one-fifth experience pelvic pain (27). One might be apprehensive about performing weight-bearing exercise with barbell and weight-plates
because this could negatively impact pelvic girdle pain
and lumbar pain. However, the present study shows that
women from both intervention and control groups
reported back and pelvic pain equally as often. In a large
RCT, Stafne et al. (28) concluded that prenatal exercise
does not modify the risk of low back pelvic pain,
although the women they studied who regularly exercised
seemed to handle the disorders in a better way.
Pregnancy in itself is dynamic, of course, in many
respects. This presents a methodological challenge, and it
is hard to determine a baseline for many of the variables
under study. The SF-36 measures physical and mental
health functioning along eight dimensions, but these are

40

conditions that change naturally as pregnancy progresses

(29). This underscores the benefit of carrying out RCTs.
A limitation in the present study may be the small
sample size: though our power analysis led us to choose
80 participants, the effect size in our instruments may
have been underestimated, which is a possible explanation
for not finding significant differences in most of the
obstetric and perinatal outcomes (type 2 error). Another
limitation is that both groups exhibited a relatively high
level of physical activity, including that both groups were
physically active at baseline, which may explain why no
significant difference was found between the groups. For
instance, Price et al. (30) showed that in comparison with
pregnant women who remain sedentary during the gestation period, active pregnant women improve muscular
strength and fitness. An alternative approach might have
been to study sedentary women, or women with some
kind of disability, such as back pain, obesity, GDM or
reduced HRQoL, to examine group differences. Future
studies might examine the efficacy of regular resistance
training among pregnant women with poorer HRQoL,
back pain, GDM or women sedentary at baseline.
Another limitation is the potential bias associated with
the high drop-out rate, as 20 of 92 participants did not
complete the intervention. During pregnancy unforeseen
things do occur, including miscarriage, as occurred once
in each of the groups in this study. Another woman in
the intervention group dropped out due to discomfort
during exercise, in her case while doing squats, a lower

2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 3542

K. Petrov Fieril et al.

body resistance movement. Good trunk- and pelvic-floor

muscle control is very important during moderate-to-vigorous exercise in pregnancy, especially during exercises
when the hip is in flexion and a heavier load is placed on
pelvic floor muscles and cervix (for example squats or
cycling in a forward leaning position).
Since the study comprised women who were volunteers
and motivated to participate in an exercise program during pregnancy, the result may not be generalizable to
other populations. Additionally, the women were used to
doing exercise, ranging from regular walks to vigorous
exercise. In comparison with the background population,
these women were also highly educated and had a low
body mass index.
We consider that supervised, self-rated moderate-tovigorous resistance training does not jeopardize the pregnant woman or the fetus in healthy pregnancy, although
pregnant women should follow the exercise recommendations and start at an exercise level corresponding to lightto-moderate (3,4). Within our knowledge, this is the first
study to examine moderate to vigorous resistance training. In a review, Nascimento et al. (11) recommend moderate-to-high-intensity exercise for active women. Noting
that no upper level of safe exercise intensity has been
established (3, 4), this study warrants further investigation
into the use of resistance exercise during pregnancy, to
advance arguments toward new recommendations regarding appropriate exercise activity and intensity in healthy
pregnancy.

Conclusion
The results of this study indicate that supervised, moderate-to-vigorous resistance training does not jeopardize the
pregnant women or the fetus during pregnancy, but
instead appears to be an appropriate form of exercise in
healthy pregnancy.

Resistance exercise during pregnancy

3.
4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

Funding
14.

This study was financially supported by the Wilhelm and

Martina Lundgrens Research Foundation, IRIS Stipendiet, the Renee Eander fund, the local Research and Development Center of Gothenburg and South Bohuslan, and
from Research and Development Primary health Care of
Gothenburg (clinical trial registration number 2021).

15.

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