Physical activity level among pregnant women attending maternal healthcare services in rural Karnataka; findings of a cross-sectional study

Background

Physical activity is any bodily movement produced by skeletal muscles that requires energy expenditure, it includes domestic, work-related, transportation and recreational activities.¹ It plays a significant role in improving maternal and child health and prevention of chronic non-communicable diseases.² Physical activity during pregnancy has a significant role in preparation for labor effort and reduction of the duration of the labor.³ It is also important to prevent pregnancy-related complications such as gestational diabetes mellitus, preeclampsia, gestational weight gain and improved maternal fitness and well-being, mood stability, decreased musculoskeletal discomfort and lower limb edema.^4–11 Not only for mothers it also benefits the fetus including decreased resting fetal heart rate, increased amniotic fluid level, improvement to the viability of the placenta, early neurobehavioral maturation and stress tolerance.^4,11,12 Additionally, it lowers the incidence of operative delivery and prematurity.⁴

Pregnancy is a time of biological, social, psychological and behavioral changes associated with the decline of physical activity and exercise habits in pregnant women because of this most pregnant women especially in low and middle-income countries perceive rest and relaxation as being significantly more important than having regular exercise or being active during pregnancy.¹³ The World Health Organization’s guideline on physical activity recommends that pregnant women engage in at least 150 minutes of moderate-intensity physical activity on most days/weeks in the absence of medical/obstetrical complications. But, high-risk activities like vigorous exercise and contact sports should be avoided.¹ Several developed countries like the United States, the United Kingdom, Canada, Australia, Denmark, and Japan have their physical activity guidelines for pregnant women.^14–18 In contrast, in developing countries like India the evidence base on implementing national physical activity guidelines is sparse.

Sustainable Development Goals for global development by 2030 have listed 17 goals with more than 100 indicators. Ensuring healthy lives and promoting well-being for all at all ages is the third goal listed under Sustainable Development Goals. In this goal, strategies to reduce global maternal mortality ratio < 70/100,000 live births, and to increase access to reproductive healthcare services by 2030 were recommended to national policymakers worldwide by the World Health Organization. Despite the standardized healthcare facilities and substantial progress made in contributing to Sustainable Development Goal 3 (SDG target 3.1) through a record decline in mortality rate from 26/1000 live births in 2019 to 21/1000 live births in 2020, the state of Karnataka is still facing challenges as least performer among the five southern states of India towards maternal mortality rate. According to a report by the president of the Karnataka State Obstetrics and Gynecological Association in 2022, the main reasons considered for the high maternal mortality rate are irregular medical checkups and non-adherence to medical advice.^19–21

Though the American College of Obstetricians and Gynecologists committee opinion number 804 recommends continuing physical activity during pregnancy and the postpartum period, globally, about 60% of women become inactive during pregnancy.¹⁴ In India, the prevalence of physically active women during pregnancy ranges from 2.8% to 10.2% respectively.^22,23 Evidence in the literature insists on the necessity of physical activity for normal anatomic and physiologic changes in the growing fetus, the physical activity practice is commonly lacking in the general population. The physical activity dosages recommended based on obstetric evaluation have many positive effects on maternal and fetal health. However evidence reports that the majority of pregnant women tend to decrease their physical activity during pregnancy due to different factors.^{13,19,20,24,25} Also sedentary lifestyle is reported as a major risk factor for 50% of Caesarean deliveries in Mangalore town, Karnataka. Therefore, the aim of this study is to assess the prevalence and associated factors of self-reported physical activity during pregnancy among pregnant women in Dakshina Kannada District of Karnataka.

Methods

Sample size and sampling technique

The study sample size was determined by using the single population proportion formula; by assuming a 5% level of significance, confidence interval of 95%, and 50% prevalence of physical inactivity less than the recommended guidelines by the pregnant women in the study area (non-availability of regional data). The derived power calculated sample was 384, the final sample size was n = 424 after accommodating for 15 % contingency plan. On average 30 to 35 pregnant women visit these maternal healthcare facilities (MHF) on average. To improve sample and time representativeness the data collection was limited to a maximum of ‘5’ in a single day for a single MHF. A multistage sampling technique was designed to attain the required power-calculated sample for this study.

The Dakshina Kannada district has 2 revenue sub-divisions and nine taluks; Mangalore, Moodbidri, Mulki, Ullala, Bantawal, Puttur Belthangadi, Sullia, and Kadaba. We conveniently selected 4 taluks from where the Antenatal care clinics of outpatient Obstetrics and gynecology department of Alvas Health Center (Moodbidri), and the out-patient women’s health care department of Alvas Physiotherapy Clinic (Moodbidri) receive the majority of the clients. The MHF stationed at PHCs and Anganwadi centres were visited and that serves the majority of the women of that taluks were selected. Based on the previous year’s registry data, the required sample for each selected centre was proportionally allocated. So, during every data collection day, the Kath number was calculated by dividing the number of mothers who visited the center the previous working day by ‘5’ (maximum slab allowed). Data was collected until the proportional sample for the center was achieved Figure 1.

Figure 1. Sampling flow.

Results

Discussion

The purpose of this cross-sectional study is to determine the level of physical activity and determinants of the sedentary lifestyle during pregnancy among women attending antenatal health care centers in Dakshina Kannada district of Karnataka, India. The study findings revealed that 40.33% of women were physically inactive and 59.7% self-reported to practice the recommended level of physical activity. Overall, a moderate proportion of pregnant mothers reported below-par physical levels in the study area.

The prevalence of physical inactivity found in this study is higher than the prevalence reported in the Bangalore (India) study 7.2% in 2021,²⁷ Zonal hospitals of Tigray (Ethiopia) 21.9% in 2019,²⁸ Serbia 27.2% in 2020,²⁹ Northern Sweden 27.3% in 2021,³⁰ and Riyadh (Saudi Arabia) 41.62% in 2020.³¹ At the same time, the prevalence is lesser than the reported prevalence among the Western pregnant women population (75%) in 2016,³² pregnant women attending the Institutional antenatal care facility of Tigray (Ethiopia) (79.3%) in 2020,²⁸ Middle eastern pregnant women (84%) in 2016,³⁰ and pregnant women in South Asia (86%) in 2016.³² The differences in the level of literacy, economic background, awareness and accessibility towards antenatal health education and care, socio-cultural practices and beliefs, lifestyle practices and development in advanced technologies could be contributing factors for the varying range of prevalence worldwide. The second objective of this study is to identify the factors associated with a sedentary lifestyle during pregnancy. Type of employment, family income, number of children, stage of trimester, regular exercise before pregnancy and lack of time were the factors identified as significantly associated with physical inactivity among pregnant women attending antenatal care in Dakshina Kannada, Karnataka. Pregnant women involved in occupations such as merchants or businesses lack physical activity seven times compared to women involved in civil services and household activities. Women occupied as merchants or owned self-business were involved in prolonged sitting. They were lacking both occupational and leisure time physical activity. Involvement in sedentary occupation could also predispose pregnant women to adverse effects such as gestational diabetes, gestational hypertension, gestational weight gain and so on.³³ At the same time excessive physical exertion at any occupation such as trunk forward bending, rotation, reaching and lifting could increase intra-abdominal pressure and can result in miscarriage or spontaneous abortion.³⁴ This insists on the need for educating pregnant women about the safer level of physical exertion that could be accomplished in the workplace. In the present study, the pregnant women with low family income were three times physically inactive compared to average and high family income categories. Previous studies^35–37 in the literature have reported that pregnant women with low family income were physically active compared to average and high income. The population included in those studies differs from the present study by socio-cultural aspects, financial background and lifestyle practices. Both state and central governments of India have implemented antenatal care and nutritional schemes such as Mathrushree, Mathrupoorna, Accredited Social Health Activist - ASHA package, Samagra Mathru Arogya Palana and so on for pregnant women below the poverty line. Though these schemes provide nutritional and financial assistance for antenatal care, there is no clear data to identify the reach of the American College of Obstetricians and Gynecologists’ recommended guidelines for physical activity in pregnant women from low family income. Lack of awareness on physical activity guidelines could be a contributing factor for physical inactivity among pregnant women with low family income. This necessitates the need for the promotion and implementation of physical activity in pregnant women with low family income living in south India.

The study findings identified that pregnant women with one child were five times physically active compared to 2 children and no children. The study finding is inconsistent with the previous reports from Ethiopia^28,38 and Nigeria.³⁹ In those studies,^28,38,39 moderate physical activity is reported in pregnant women parenting two or more children. The higher rate of fertility and high magnitude of multiparity exists among the Ethiopian and Nigerian populations and which is average or low among the population included in this study. This could be a contributing reason for differences in physical activity patterns of parenting pregnant women. The parenting responsibilities differ in pregnant women with younger and elder children; and in primiparous and multiparous situations. Pregnant women with one young child are in need to deliver more parental responsibilities compared to pregnant women with two or three elder children and hence lack time for participating in physical activities. Probably the nulliparous pregnant women could able to find time to perform physical activity and hence they are not sedentary compared to pregnant women with one child. In this study, it is observed that physical activity declines in each trimester. Pregnant women in the second trimester were two times physically inactive compared to the first trimester. Lack of adequate knowledge and practice towards programming physical activity in each trimester is prevailing commonly in pregnant women. Additionally, fear of falling, miscarriage/spontaneous abortion, and anxiety refrains them from participating in physical activity programs during pregnancy. This is attributed to the trend of declining physical activity in advanced trimesters among pregnant women in Dakshina Kannada district. This study also revealed that pregnant women lacking schedules were two times physically inactive compared to those who were able to manage their time. More time spent in household or family activities and occupation could have compromised the time spent involvement in physical activity programs.

There were a few limitations in this present cross-sectional study. Firstly the collected data were self-reported and hence might have been affected by potential reporting bias. Secondly, there could be varied perceptions towards physical activity programming guidelines among the participants and lastly, the collected data lacking objective measurements. Nevertheless, these power-calculated sampled study reports valuable insights into the variables that are determinants of the physical activity levels among pregnant mothers in the study area. Further, the sampling procedure used and data collection strategy to limit the recording to five respondents per day per center would have enhanced the time and sample representation in this study.

Conclusion

This study found that a moderate proportion of pregnant mothers were not engaged in physical activity to the levels recommended by the ACOG guidelines. The determinants that negatively influenced physical activity were low family income, sedentary occupation, being primiparous, mothers in their second trimester, and reporting of lack of time as the reason.

Though the national policies and schemes are favorably implemented towards the promotion of safer antenatal care, there still exists a deficiency in knowledge and practice towards the recommended level of physical activity guidelines in pregnancy. Strategies towards the target population are warranted to improve the physical activity status and to sensitize the benefits of being active during pregnancy.

Ethics and consent

The study protocol was approved by the institutional ethical review committee of the Alvas College of Physiotherapy and Research Centre (ref no; ACP/OP/CL/20230323/03) dated 22-03-2023. All the participants provided written informed consent, and they adhered to the principles outlined in the Declaration of Helsinki.