Assessment of Knowledge,Attitude,and Practice Toward Physical Activity and It’s Associated Factor Among Women Attending Antenatal Care at Public Health Institutions in Debre Berhan Town,North Eastern Ethiopia

Abstract

Physical inactivity is linked to pregnancy-related complications. Exercise participation during pregnancy is restricted in low-middle income nations, including Ethiopia. Therefore, this study aimed to assess factors associated with physical activity practice among pregnant women attending antenatal care at public health institutions in Debre Berhan Town Northeastern Ethiopia. Institutional based cross-sectional study was conducted from March 22, 2021 to May 22, 2021 in Debre Berhan Town. The systematic random sampling technique was used to obtain the 418 participants. Data were collected by using standardized questionnaires. Data were entered, cleaned by Epi data version 3.1 and analyzed by SPSS version 25. The variables which had p-value < .05 and with 95% confidence interval were declared as determine factors of antenatal physical exercise. According to this study, 222 (53.1%, CI [48.3, 57.7]), 220 (52.6% [47.8, 57.2]), and 218 (52.2% [CI 47.6, 56.7]) of respondents had good knowledge, favorable attitude, and good practice of physical exercise respectively. Age group of 30 to 34 years (AOR: 2.15, 95% CI [1.08, 4.29]), housewife (AOR: 7.81, 95% CI [1.48, 41.21]), cultural recommendation (AOR: 2.16, 95% CI [1.37, 3.39]), exercise before pregnancy (AOR: 2.69, 95% CI [1.72, 4.19]), and gestational age >24 weeks (AOR: 2.538, 95% CI [1.02, 6.29]) were factors associated with practice of physical exercise during pregnancy. Physical activity during pregnancy was more common in the current study than in the national average. During an ANC visit, health care providers should improve and strengthen physical activity counseling sessions.

Keywords

knowledge attitude practice antenatal exercise pregnant women

Introduction

Antenatal care (ANC) can be defined as the care provided to pregnant women by qualified health care professionals to ensure the best health conditions for both mother and baby during pregnancy (WHO, 2016). World Health Organization (WHO) describes the physical activity as any movement of the body created by skeletal muscles requiring energy expenditure. It refers to all movement including during leisure time, for transport to get to and from places, or as part of a person’s work. Both moderate and vigorous-intensity physical activity improve health (WHO, 2020).

According to the American College of obstetrics and gynecology (ACOG) for healthy pregnant and postpartum women, at least 150 min per week a moderate intensity of aerobic exercise, is recommended (ACOG Committee Opinion No. 804, 2021). Pregnant women who are regularly engaging in a vigorous-intensity aerobic activity or who highly active can continue physical activity during pregnancy, and their health care provider should better counsel how and when physical exercise will be done over time (Obstetricians ACo, Gynecologists, 2015).

Globally maternal mortality ratio (MMR) is 216 per 100,000 and Sub-Saharan Africa has a very high MMR of 546 (WHO, 2015). According to Ethiopia demographic survey (EDHS), 2016 Ethiopia is one of sub-Saharan country with a high MMR, 412. Physical inactivity is the fourth leading factor for early mortality worldwide (ACOG Committee Opinion No. 804, 2021). A sedentary lifestyle before or during pregnancy is frequently associated with negative maternal health impact include increased risk for gestational diabetes, macrosomia, and cesarean section (Yin, et al., 2019), hypertensive disorder and excessive gestational weight gain (Fazzi et al, 2017), complications during labor and birth, postpartum weight retention, and poor neonatal outcomes (WHO, 2015).

Reduced Physical Activity is rising across many countries in the world with major health implications including increased non-communicable diseases (NCDs) such as cardiovascular disease, diabetes, and cancer and their shared common risk factors like raised blood pressure, raised blood sugar, and overweight, and it has been identified as a risk factor for 6% of all deaths, worldwide (Hailemariam et al., 2020).

Studies report that most of the pregnant women living in low middle income countries (LMICs) are not sufficiently active and did not meet the present exercise guidelines during their pregnancy (Janakiraman et al., 2020). A systematic review study conducted in Africa about Physical activity in pregnant women showed that low levels of physical exercise in pregnancy are prevalent in developing and developed countries (Mukona et al., 2016).

The prevalence of sedentary activity is high among Ethiopian pregnant women (76, 79%) and the majority of them are below American College of Obstetrician and Gynecologists (ACOG) recommendation (Janakiraman et al., 2020). In another study conducted in Tigray, Ethiopia 79.3% of the study participants were classified as sedentary (Hailemariam et al., 2020). Some factories that affect pregnant women’s exercise practice that is not studied in Ethiopia include that, husband habit of exercise (Adeniyi et al., 2014), cultural background (Merkx et al., 2017).

There is no study conducted in our country especially in the study area concerning knowledge, attitude, and practice toward regular physical exercise during pregnancy among pregnant women. Therefore, this study aimed to assess knowledge, attitude, practice toward physical activity, and its associated factor of pregnant women attending antenatal care at health institutions in Debre Berhan town.

Methods and Materials

Study Area and Period

The study was conducted at public health institutions found, in Debre Berhan town, North Shoa zone, Amhara region, Ethiopia. Debre Berhan town is located 130 km far from Addis Ababa, and 695 km far from Bahir Dar capital city of Amhara Regional state. It has 1 referral hospital, 1 private hospital, 3 health centers, and 14 private clinics. Its total area or size is around 18,000 km². The total population of the town was estimated to be 120,399. Of these 54,442 Males and 65,957 are Females. The study was conducted from March 22, 2021 GC to May 22, 2021 GC.

Study Design

Institutional-based cross sectional study was conducted.

Population

The study population was pregnant women attending ANC at Debre Berhan town public health institution who were sampled from the source population during the study period.

Eligible Criteria

Pregnant women attending antenatal care at public health institutions were included. Whereas, pregnant women’s who attending ante natal care and was presented or diagnosed with medical or obstetric complications and not gave a response during the study period were excluded.

Sample Size Determination

The sample size (n) required for the study was calculated using the formula to estimate a single population proportion. Prevalence on knowledge of pregnant women on antenatal exercise during pregnancy from previous study was 55.3% (Janakiraman et al., 2020), with a 95% level of confidence and a 5% margin of error. By including a 10% non-response rate, the total sample size increased to 418.

Sampling Procedure

Debre Berhan had one public hospital and three health centers. However, Tebase Health Centre was a Covid-19 isolation center and was therefore omitted from the study. The study population was sampled using systematic random sampling using the lottery method. The total number of pregnant women attending the ANC clinic throughout the study period was 984, according to information from the ANC clinic’s registry, and the Kth interval (K = 2) was computed. Similarly, lists of study subjects were then proportionally distributed among the randomly selected health institutions. The first sample was chosen at random between 1 and Kth, followed by taking every Kth participant thereafter, where Kth was a sampling interval based on the day’s register list. The procedure was repeated until the study period reached the estimated eligible Sample size.

Data Collection Tool and Procedure

A structured questionnaire was used to determine knowledge, attitude, and its associated factor, which was adapted and modified from the study conducted in on a similar topic (Adeniyi et al., 2014; Nkhata et al., 2014).

The questionnaire had six sections. Section 1: Socio-demographic characteristics of participants and it have 7 items. Section 2: Obstetric and health-related history and it has 5 items. Section 3: Exercise-related characteristics and source of information about different types of antenatal exercise. It has 7 items. Section 4: Knowledge toward benefit and contraindication of antenatal physical activity and it had 14 items. Section 5: Attitude toward physical exercise during pregnancy and it had 10 items. Section 6: Practice toward physical activity during pregnancy and it has 25 items. International Physical Activity Questionnaire (IPAQ) long version was used to determine the practice of physical exercise during pregnancy across a variety of different domains including leisure-time, domestic, work, and transport-related physical activity. The Cronbach alpha test was > .7, indicating that the instrument was reliable.

Operational Definitions

Good knowledge: Participants answered correctly to knowledge assessing questions, scored greater than, and equal to the mean value; and poor knowledge: Participants answered correctly to knowledge assessing questions and scored less than the mean value (Adeniyi et al., 2014; Nkhata et al., 2014).

Favorable attitude: It refers to those who answered attitude questions correctly and scored greater than and equal to the mean value; and unfavorable attitude: Those who answered attitudes assessment questions correctly and scored less than the mean value (Adeniyi et al., 2014; Nkhata et al., 2014).

Practice: A pregnant woman who participates in or do any type of antenatal exercise in the current pregnancy, that recommended by the American College of Obstetricians and Gynecologists (ACOG; Adeniyi et al., 2014; Nkhata et al., 2014).

Data Quality Management and Analysis

The questionnaire was prepared in English language and translated to Amharic by language expert profession for ease of data collection. Three BSC holder nurses and two midwives were recruited for the data collection process and training was given for 3 day on the objective and relevance of the study. Five percent Pretest was conducted in one health center before the actual data collection outside of the study area. The confidentiality of the information was maintained by placing a strong emphasis on the “no name, no blame” principle.

Data was entered using EPI data version 3.1 and transported to SPSS version 25 software for statistical analysis. Descriptive statistics was performed to describe variables. The effect of predictor variables on the dependent variable was evaluated using binary logistic regression analysis. After performing bivariable logistic regression analysis, variables with a p-value of less than .25 were considered significant and were transferred to multivariable binary logistic regression analysis. The final model test was performed by Hosmer-Leme to demonstrate goodness of fit. When the p-value was less than .05, significance was declared, and if it was greater, it was assumed to be confounding variables. A collinearity test was determined after analyzing the VIF results of each variable, which were between 1 and 3.

Result

Socio-Economic Characteristics of Among Women Attending Antenatal Care

Most of the respondents age group was found 25 to 29 years (44.7%) and 377 (90.2%) of participants were married. Above three fourth (77.8%) of the respondents were Orthodox in religion. (Table 1).

Table 1.

Socio-Economic Characteristics of Among Pregnant Women Attending Antenatal Care at Public Health Institution in Debre Birhan Town 2021 (n = 418).

Variables	Categories	Frequency	Percent
Age of women	20–24	104	24.9
	25–29	187	44.7
	30–34	88	21.1
	35–39	39	9.3
Education level of participants	Illiterate	11	2.6
	Read	38	9.1
	Elementary	37	8.9
	High school	144	34.4
	College or university	188	45.0
Marital status of participants	Single	17	4.1
	Married	377	90.2
	Divorced	24	5.7
Occupation of participants	Government	150	35.9
	Housewife	161	38.5
	Private	52	12.4
	NGO	44	10.5
	Farmer	11	2.6
Monthly income	<2,000	158	37.8
Monthly income	≥2,000	260	62.2
Cultural recommendation for doing physical exercise during pregnancy	No	157	37.6
	Yes	261	62.4

Obstetrical and Health-Related History Among Women Attending Antenatal Care

Majority of the respondents, 290 (69.4%) were multigravida and 264 (63.2%) were Premiparas. About 272 (65.1%) of respondents had >24 weeks’ gestational age and half of the participants (51.2%) had 1–2 children. On the other hand, only 87 (20.8%) of participants had history of miscarriage (Table 2).

Table 2.

Obstetrical and Health-Related History of Among Women Attending Antenatal Care at Public Health Institution in Debre Birhan Town 2021 (n = 418).

Variables	Categories	Frequency	Percent
Number of pregnancies (gravida)	Primi-gravida	128	30.6
Number of pregnancies (gravida)	Multigravida	290	69.4
Number of birth (para)	Premi-para	264	63.2
Number of birth (para)	Multi-para	154	36.8
Gestational age	<16 weeks	29	6.9
	16–24 weeks	117	28.0
	>24 weeks	272	65.1
Number of children	No child	158	37.8
	1–2 child	214	51.2
	More 2 children	46	11.0
History of miscarriage	No	331	79.2
History of miscarriage	Yes	87	20.8

Physical Exercise-Related Characteristics and Source of Information Among Pregnant Women

Based on this study, 218 (52.2%, CI [47.6, 56.7]) of pregnant women did practice of physical exercise during pregnancy. Two hundred sixty-seven (63.9%) of the participants hadn’t got exercise advice from a medical professional and 242 (57.9%) of respondents did physical exercise before becoming pregnant. According to Figure 1 shows that, Concerning the reason not doing exercise currently during this pregnancy, afraid that harmful to fetus and fell uncomfortable by 136 (38.9%) and 78 (22.3%) of respondents respectively. Two hundred sixty-seven (63.9%) had ever heard about antenatal physical activity.

Figure 1.

Reason not doing exercise currently during this pregnancy among pregnant women attending antenatal care in Debre Berhan town, Amhara region, Ethiopia 2021 (n = 418).

About types of antenatal physical activity, 186 (46.5%) of participants were heard about walking and 96 (24.0%) of respondents were heard about relaxation/breathing. Based on this study, 212 (50.7%) and 119 (28.5%) of participants were mentioned health care provider and family as source of information about physical exercise, respectively (Table 3).

Table 3.

Physical Exercise-Related Characteristics and Source of Information About the Different Types of Antenatal Exercise Among Pregnant Women at Public Health Institution in Debre Birhan Town, 2021 (n = 418).

Variables	Categories	Frequency	Percent
Got exercise advice from a medical professional	No	267	63.9
Got exercise advice from a medical professional	Yes	151	36.1
Ever done physical exercise before becoming pregnant	No	176	42.1
Ever done physical exercise before becoming pregnant	Yes	242	57.9
Ever done physical exercise during pregnant (practice)	No	200	47.8
Ever done physical exercise during pregnant (practice)	Yes	218	52.2
Ever heard about antenatal physical activity	No	151	36.1
Ever heard about antenatal physical activity	Yes	267	63.9
Types of antenatal physical activity you heard	Heard about walking	186	46.5
	Heard about aerobics	18	4.5
	Relaxation/breathing	96	24.0
	Pelvic floor exercise	16	4.0
	Back care exercise	30	7.5
	Ankle and toe exercise	24	6.0
	Heard about swimming	30	7.5
Source of information about physical exercise	Health care provider	212	50.7
	Mass media	75	17.9
	Family	119	28.5
	Internet	12	2.9

Prevalence on Knowledge, Attitude, and Practice of Pregnant Women on Ante Natal Exercise During Pregnancy

According to this study, 222 (53.1%, CI [48.3, 57.7]), 220 (52.6% [47.8, 57.2]), and 218 (52.2% [47.6, 56.7]) of respondents had good knowledge, favorable attitude, and practiced of physical exercise. Two hundred twenty-two (53.1%, CI [48.3–57.7]) of respondents had good knowledge and of which 237 (56.7%), 268 (64.1%), and 211 (50.5%) were correctly identified as antenatal exercise can decrease back pain, prevent excessive weight gain, and can decrease cesarean delivery, respectively.

Of 220 (52.6% [47.8, 57.2]) respondents who had a favorable attitude toward antenatal exercise, 280 (67%) of the respondents were strongly agree that physical exercise during pregnancy is necessary, 151 (36.1%) of respondents were strongly agreed that physical activity helps to prevent pregnancy related complications, 123 (36.6%) of participants were strongly agree that physical activity during pregnancy helps for post-delivery recovery and 184 (44%) of respondents were strongly agree that Antenatal physical activity should be done based on health professional advice.

Of 218 (52.2%) practiced of physical exercise, 254 (60.8%) of women had a job or do any unpaid work outside your home, 303 (73%) of respondent women used motor vehicles as means of transportation, 228 (54.5%) of respondents did not perform vigorous physical activities in house like heavy lifting, chopping wood, or digging in the garden or yard in last 7 days and 329 (78.7%) of pregnant women walked at least 10 min in their leisure time in last 7 days (Figure 2).

Figure 2.

Knowledge, attitude, and practice of physical activity during pregnancy among pregnant women attending antenatal care in Debre Berhan town, Amhara region, Ethiopia 2021 (n = 418).

Factors Associated with Practice of Women of Antenatal Physical Activity

Pregnant women in the age group of 30 to 34 years were 2.2 times more likely to practice physical exercise (AOR: 2.15, 95% CI [1.08, 4.29]) compared with those in the age group of 20 to 24 years. Pregnant women who had housewife were 8 times more likely to practice physical exercise (AOR: 7.81, 95% CI [1.48, 41.21]) compared to those who were unemployed pregnant women.

Pregnant women who got cultural recommendation for physical activities were 2 times more likely to practice physical exercise (AOR: 2.16, 95% CI [1.37, 3.39]) compared to those who were not got cultural recommendation about physical activities.

Pregnant women who did exercise before pregnancy were 3 times more likely to practice physical exercise (AOR: 2.69, 95% CI [1.72, 4.19]) compared to those who did not exercise before pregnancy. Pregnant women who had >24 weeks gestational age were practice physical exercise 2.5 times more likely to practice physical exercise (AOR: 2.538, 95% CI [1.02, 6.29]) compared to those who had <16 weeks gestational age (Table 4).

Table 4.

Factors Associated With Practice of Women of Antenatal Physical Activity at Public Health Institution in Debre Birhan Town 2021 (n = 418).

Variable		Exercise during pregnancy		COR [95% CI]	p-value	AOR [95% CI]
Variable		No	Yes	COR [95% CI]	p-value	AOR [95% CI]
Age group	20–24	57	47	1		1
	25–29	100	87	1.015 [0.63, 1.64]	.655	0.88 (0.51, 1.53)
	30–34	31	57	2.15 [1.197, 3.84]	.029	2.15 [1.08, 4.29]*
	35–39	13	26	2.33 [1.08, 5.04]	.163	1.84 [0.78, 4.33]
Occupational Status of women	Government	77	73	4.27 [0.89, 20.41]	.055	5.17 [0.97, 27.68]
	Housewife	63	98	7.00 [1.46, 33.46]	.015	7.81 [1.48, 41.21]*
	Private	28	24	3.86 [0.76, 19.61]	.420	7.93 [0.39, 45.27]
	NGO	23	21	4.11 [0.79, 21.23]	.055	5.49 [0.96, 31.36]
	Unemployed	9	2	1		1
Monthly income	<2,000 ETB	90	68	1		1
Monthly income	≥2,000 ETB	110	150	1.81 [1.21, 2.69]	.110	1.435 [0.92, 2.23]
Cultural recommendation	No	93	64	1		1
Cultural recommendation	Yes	107	54	2.09 [1.39, 3.13]	.001	2.16 [1.37, 3.39]*
Exercise before pregnancy	No	107	69	1		1
Exercise before pregnancy	Yes	93	149	2.48 [1.67, 3.70]	.001	2.69 [1.72, 4.19]*
New gestational age category	<16 weeks	21	8	1		1
	16–24 weeks	60	57	2.49 [1.02, 6.08]	.058	2.54 [0.97, 6.64]
	>24 weeks	119	153	3.38 [1.44, 7.89]	.044	2.538 [1.02, 6.29]*

and bold faced stands for p < .05 in multivariate (backward stepwise log-regression).

Discussion

According to this study, 222 (53.1%, CI [48.3–57.7]) of respondents had knowledge about the importance physical activities during pregnancy. The finding of this study was higher than the studies done in India (Mukona et al., 2016), Pakistan (Merkx et al., 2017), Zambia (Nkhata et al., 2014), Nigeria (Mbada et al., 2014), and Gondar in Ethiopia (Janakiraman et al., 2020). This may be due the increment of social media and internet used among the participants. Or the difference may be due to the difference of culture, study design, behavioral difference, and study areas difference.

Concerning about the physical exercise during pregnancy, 218 (52.2%, CI [47.6, 56.7]) of pregnant women who did practice. The finding of this study was higher than the studies done in Nigeria (Ojukwu et al., 2018). This discrepancy may be due to the cultural difference, the study design difference and the given health education about the importance physical exercise during pregnancy.

Pregnant women in the age group of 30 to 34 years were 2.2 times more likely to practice physical exercise (AOR: 2.15, 95% CI [1.08, 4.29]). This study was aligned with the study conducted in Tigray, Ethiopia showed that maternal age was the variable that showed statistical association with physical activity during pregnancy (Hailemariam et al., 2020).

Pregnant women who got cultural recommendation for physical activities were 2 times more likely to practice physical exercise (AOR: 2.16, 95% CI [1.37, 3.39]). This study was supported by studies done in Luska (Nkhata et al., 2014) and Ethiopia (Hailemariam et al., 2020).

Pregnant women who did exercise before pregnancy were 3 times more likely to practice physical exercise (AOR: 2.69, 95% CI [1.72, 4.19]). This finding was supported by studies done in African countries (Hailemariam et al., 2020; Nkhata et al., 2014, 2016). This may be due to doing exercise before pregnancy, which may give knowledge about doing exercise during pregnancy.

Pregnant women who had >24 weeks gestational age were 2.5 times more likely to practice physical exercise (AOR: 2.538, 95% CI [1.02, 6.29]). As evidenced through different research, physical exercise during pregnancy is advised by societies, especially when the gestational age increases (Merkx et al., 2017; Nkhata et al., 2014; Sheth et al., 2019; Wijesiriwardana & Gunawardena, 2016).

Strength and Limitation of the Study

Since the study is new in the area, it will serve as a source of information for further intervention and was used as a standard tool to assess ANC. The disadvantage of cross-sectional study design has its drawback, this does not show which one is the first effect or cause and there were also shortages of literatures (studies) for discussion.

Conclusion and Recommendation

In this study, physical activity was higher than the national average. Age groups 30 to 34 years, occupation (housewife), cultural recommendation, exercise before pregnancy, >24 weeks gestational had significant association with practice physical exercise. During an ANC visit, health care providers should improve and strengthen physical activity counseling sessions. Academic institution should work on the awareness of their students and health care providers about physical exercise during pregnancy time by including it in their curriculum. Finally, researcher should study perception and experiences in pregnant women about antenatal exercise by qualitative study in order to get detailed information.

Footnotes

Acknowledgements

We are grateful to Ethical Review Board of Debre Birhan University for giving ethical clearance. We also thank to all staffs in Debre Birhan health centers to support our study.

Data Availability Statement included at the end of the article

Abbreviations and Acronyms

ACOG: American College of Obstetrician and Gynecologists.

ANC: Ante Natal Care.

ANEx: Ante Natal Exercise.

BSC: Bachelor of Science.

EDHS: Ethiopia Demographic and Health Survey.

GDM: Gestational Diabetes Mellitus.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis, and interpretation, or in all these areas; took part in drafting, revising, or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted, and agree to be accountable for all aspects of the work. All authors read and approved the final manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethics Approval

Ethical approval for this study was obtained from the ethical review board of Debre Berhan University.

Informed Consent

Written informed consent was obtained from legally authorized representatives before the study.

Trial Registration

Not applicable.

ORCID iDs

Molla Kassa Hailu

Ayele Mammo Abebe

Data Availability

The original data for this study is available from the corresponding author.

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