This study showed that women in the intervention group received PA counseling more frequently during pregnancy and that all women who received PA counseling positively modified their PA behaviors.
Overall, the low proportion (35.8%) of pregnant women who reported receiving PA counseling throughout pregnancy is alarming. We found no longitudinal studies to date assessing PA counseling received throughout pregnancy, but our result is low compared to the cross-sectional studies in the literature [11, 12]. This observation adds to the concerns about the rise in maternal obesity and the related complications .
Our study supported the findings that (1) pregnant women who benefit from PA counseling by trained health professionals are more likely to report it  and (2) this counseling tends to be in line with the recommendations. Similar results were found for the overweight pregnant women whose obstetric care counseling has been suboptimal up to now . However, these overweight pregnant women did not receive PA counseling in line with the recommendations. Efforts should be made for women with weight problems since the advice has beneficial effects on gestational weight gain .
Counseling and PA behaviors
The purpose of this secondary analysis was to investigate the impact of counseling in a routine care setting on prenatal PA behavior. Our results showed that the women who received counseling throughout pregnancy improved their PA behaviors more than the other women. Indeed, a smaller decrease in vigorous and sports activity was reported. These results highlight the reduced perceived barriers reported in the literature and increasing physical activity behavior . As observed by others [18, 19], PA declined over the course of pregnancy overall, but our results nevertheless show the efficacy of the intervention. We cannot, however, exclude the possibility that differences between the dichotomized subgroups in educational level and marital status contributed to the differences in received counseling , PA behaviors changes [21, 22] or both.
Although the intervention did not lead to a significant effect on total activity, all women who received PA counseling in the intervention group were more likely to improve their behavior, with a smaller PA decrease in the third trimester (p=0.053 result not shown).
Our results are in line with recent findings, notably the intervention effect in prenatal care and goal setting as favorable to physical activity behaviors in overweight women [23, 24]. A significant difference in sedentary physical activity was observed in the pre-pregnancy overweight women. Based on the assumption that women who were overweight before pregnancy would be less likely to comply with the recommendations [25, 26], the explanation for the non-significant difference for the other types and intensities remains plausible. However, moderate-intensity PA remains the aim throughout pregnancy .
The report in the literature of the low rate of pregnant women who reach the recommended PA levels  also gives meaning to our results. Indeed, we observed no difference in the PA behaviors of the women who received counseling in accordance with the recommendations. Of the women who have received PA counseling throughout pregnancy in this study, a little more than half received pooled information on FID in accordance with the recommendations.
We assumed that the women would be able to meet the PA recommendations if health professionals delivered the right recommendations, in line with Connelly et al. . Our study has convinced us that discussions and counseling on PA in line with the recommendations should be systematic. Moreover, our results provide additional justification for strengthening health policies, educational interventions and the training of healthcare providers on the PA recommendations during pregnancy , especially for pregnant women with weight problems.
It should be kept in mind that despite the ACOG update , the hypothesis that health professionals take into account pre-pregnancy physical activity and then progressively help their patients reach the recommendations [30, 31] can be retained. This especially may concern those women who were sedentary before pregnancy [8, 32]. Besides providing the recommendations, health professionals are also responsible for working in concert with their patients to make PA decisions appropriate for each one.
Overall, our results on the distribution of PA counseling were similar to those of other studies. In one study, health professionals reported that they offered counseling to all patients early in pregnancy . This can explain the general effect of trimester on the distribution of PA counseling showing no significant difference. The clinical workload of health professionals who deal with pregnant women is such that they often lack time, which in turn reduces the time allocated to PA counseling [34, 35]. Addressing the time pressure on healthcare providers, who nevertheless need to promote health during antenatal care, is a complex challenge .
Overall, the effect on PA behaviors observed in late-pregnancy compared to early-pregnancy counseling suggests that appropriate counseling for women both before conception and during pregnancy would be beneficial .
Strengths and limitations
Our study has several limitations. Although structured and based on the ACOG recommendations, our questionnaire has not been validated and thus might constitute a methodological bias. As it was self-administered after delivery, misclassification on the counseling received throughout pregnancy may have been prevalent due to, for example, recall bias and social desirability [38, 39]. Our study did not examine the knowledge and counseling provided by the health professionals throughout pregnancy, and thus we were unable to investigate the low rate of counseling as per the ACOG recommendations. The training for the intervention health professionals may also have been too short for them to fully develop skills in prescribing PA. The strengths of this study are the following: it responds to the barriers that pregnant women often report that force them to limit their physical activity, and it presents an intervention that opens perspectives on promoting physical activity because, as it is integrated into primary care, it does not require significant resources.