Questioning restrictions on physical activity for those at risk of preterm birth

Restrictions on physical activity and even complete bedrest are frequently prescribed for pregnant patients by doctors or suggested by others to prevent preterm birth, even though both practices have been proven ineffective and in some cases even harmful.

Beth Leong Pineles, a maternal-medicine doctor at Pennsylvania Hospitaland an assistant professor of obstetrics and gynecology at thePerelman School of Medicine, is conducting a study of activity restriction during pregnancy with the goal of "deimplementation" in the Penn Medicinesystem and ultimately nationwide. The long-term goal is to use exercise as a tool to reduce preterm birth and improve the overall health of pregnant women.

Penn undergraduates Ellie Mayers and Gladys Smith were involved in the first stage of the study's research with Pineles during the summer. The goal is to determine the prevalence of bedrest and activity restriction, starting with the patient population at Penn Med, through an in-person survey of pregnant patients.

Smith, a second-year from Williamsburg, Virginia, is a student in the College of Arts and Scienceswho plans to go to medical school. Mayers, a third-year from Beachwood, Ohio, is in the School of Nursingwith plans to become a midwife and is also pursuing a minor in the history of health and humanities, a collaboration between Nursing and the College.

The research opportunity, which provides a $5,000 award for each student, is through the Penn Undergraduate Research Mentoring Program, a 10-week summer program supported by the Center for Undergraduate Research and Fellowships(CURF).

In-person research

Mayers and Smith were assigned to work at Penn Maternal Fetal Medicine Washington Square and the Hospital of the University of Pennsylvania in Philadelphia. They read patient charts to determine who was considered at high risk for preterm labor, including those who previously delivered preterm, are pregnant with more than one baby, have certain conditions affecting their cervix, or who have had preterm contractions.

They then asked those patients to complete the survey. For the best response rate, face-to-face is better than phone calls, texts, or emails, Pineles says, noting that her goal is to get at least 300 survey responses. "It's a better experience for the students. It's more engaging. They like to talk to the patients and be involved in the clinic, and they get some exposure to medicine," she says. "And they're helping. They're doing a great job getting a lot of survey responses."

Mayers and Smith are planning to continue the research next semester and into the future, invited by Pineles to stay with the project. Pineles says she expects the entire deimplementation project to take about three more years.

"There's a wealth of data that we can look at in a multitude of different ways," Pineles says. "So, if Ellie and Gladys want to continue to be involved, that would be great. We can continue to work together, answer new questions, and publish more papers."

Mayers says she's seen a "different view of health care" doing research versus clinical work as a nursing student. "It's been super interesting to see a snapshot of time when the ultimate goal of the research is to solve these problems," informing actions "that nurses and doctors are going to implement," she says. "And I love science. I love talking to people. I'm very social, and I just want to help people. I feel like that all culminated in my interest in nursing."

Smith says asking the research questions and being in the clinic has steered her towards pursuing a "more social science-based way of thinking regarding medicine." She says working with Pineles "has cemented my desire to go to medical school. Being in the clinic with her has made it seem more immediate and achievable."

Understanding activity restrictions

The survey asks patients to describe their high-risk conditions, what advice they were given about physical activity during their pregnancy, and who gave that advice, among other questions about their health. "We don't know what women are being told. We don't know who's telling them. And I think it's important to know that if we're going tackle the problem and understand it better," Pineles says.

Physical activity restriction can include limits on walking, working, sexual activity, exercising. Bedrest can mean the patient doesn't even get up to go to the bathroom. Some negative complications can include muscle atrophy, deep vein thrombosis, mental and emotional stress, boredom and loss of social connections, and potential financial losses.

Studies have shown that pregnant women who were given activity restrictions "actually had worse outcomes in their pregnancy and were more likely to deliver prematurely," Pineles says. "We really don't see any benefit of activity restriction. We have several national guidelines about exercise and physical activity and pregnancy, and all recommend against bedrest and recommend against routine activity restriction."

Pineles is deploying her study survey nationally "to get a national prevalence of activity restriction during pregnancy, which has not been done," she says. They received the expected 1,500 responses on the national survey, distributed by a marketing service through social media, she says.

Mayers and Smith used the national survey data for the research posters they will present at the CURF Research Expo on Sept. 16, and for abstracts they each submitted to the Society of Maternal-Fetal Medicinenational conference.

Interest in medical care

Mayers says she wanted to be a nurse as long as she can remember, coming from a long line of nurses, including her grandmother and great-grandmothers. Also, Mayers spent much of her early years in hospitals surrounded by medical professionals because her younger sister needed treatment as an infant. "Doctors are amazing, but it was always nurses that were with my family constantly and are the ones that I really have memories of," Mayers says, adding that her sister will be a first-year at Penn this fall.

Mayers says she previously wasn't interested in research, but at Penn she learned about various possibilities, including a Ph.D. in nursing. "I've been lucky in that the Nursing School has prepared me really well to do a lot of aspects of this research. I am very comfortable interacting with patients in a variety of ways," Mayers says, noting that she was on an OB/GYN rotation last semester. "I was quick in understanding different conditions and in understanding how to read the chart and look at the overall patient profile."

Specifically, Mayers says she is interested in reproductive health, both the clinical and political aspects. She's the co-president of Penn's chapter of Nurses for Sexual and Reproductive Healthand also is a member of Penn Hilleland the Kite and Key Society. Ultimately Mayers says she wants a career as a midwife or a women's health nurse practitioner.

The research is interesting to Smith because she may want to pursue OB/GYN in her medical career. She once visited her mother's friend when she was pregnant on bed rest, who lost her baby shortly thereafter. "That specific memory was jarring to me and is what made me particularly interested in this research opportunity," Smith says, "because every mom is trying their hardest to maximize the chances that their baby will be healthy."

She also wanted a summer experience that would allow her to directly interact with patients, seeking a position in which she could "understand what providers are doing, actually get to see the influence of the research being done."

Smith also works at the Center for Autism Researchat the Roberts Center for Pediatric Researchat the Children's Hospital of Philadelphia.

Smith says that conducting the patient survey was "extremely daunting" initially; she worried that the way she was speaking with the patients was inhibiting them from participating, and so she adjusted her script and her approach throughout the summer.

"Ellie is outspoken and very comfortable working with patients. Using her as a role model during the first few weeks was really helpful because I could model my attitude and my body language to be more like hers," Smith says.

Pineles started her own research when she was an undergraduate at University of California, Irvine, so she wanted to provide the opportunity for Penn undergraduates. Mayers and Smith are the first undergraduate research assistants she has recruited since joining Penn Medicine two years ago from University of Texas Health Science Center in Houston. Pineles was at the University of Maryland for residency and the University of Southern California for her M.D. and Ph.D.

"The young students are so eager and interested, and it's a good way to get them involved and get started on something of their own," Pineles says. "I always ask them to come up with their own project. What question can you ask with the data that we have that seems interesting? What do you want to know?"

Personal research interests

Mayers' project is focused on who is giving the advice and how likely it is that patients will follow the advice depending on who is giving it. "Are we seeing a statistical difference in the wellbeing of the patient if it's a health care professional who prescribed it or if it's someone else?" Mayers says.

Smith's project is looking into health equity, specifically regarding variance between different racial and ethnic groups' agreement with and adherence to their prescribed activity recommendations. "My question is also social science-based," Smith says. "I'm curious as to why these disparities might exist and how we might go about eliminating them."

Both Mayers and Smith also have shadowed Pineles during her workday in the hospital, which has had an impact on them both. "I can't imagine a more formative experience after my freshman year of college," Smith says. "I've learned so much, especially shadowing and actually seeing patients in Labor and Delivery," Smith says.

Mayers says that Pineles has been a "really excellent mentor" as an attending physician at Penn Med. "That's a connection that I hope I'm going to have for a really long time, and I hope to continue to build on," Mayers says, "She's someone that when I enter the workforce will look out for me and already is providing me with professional development opportunities."