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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 19
| Issue : 2 | Page : 113-119 |
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Perceptions of exercise interventions in pregnancy; A cross sectional survey of health care workers in Kaduna State
Amina Mohammed-Durosinlorun1, Fatima Sani2, Rukayya Abubakar2, Funmi Egwu2, C Mohammed1, M Taingson1
1 Department of Obstetrics and Gynaecology, College of Medicine, Kaduna State University/BarauDikko Teaching Hospital, Kaduna, Nigeria
2 Department of Physiotherapy, BarauDikko Teaching Hospital, Kaduna, Nigeria
| Date of Submission | 17-Mar-2021 |
| Date of Decision | 04-Sep-2022 |
| Date of Acceptance | 15-Sep-2022 |
| Date of Web Publication | 23-Nov-2022 |
Correspondence Address:
Amina Mohammed-Durosinlorun
Department of Obstetrics and Gynaecology, College of Medicine, Kaduna State University/BarauDikko Teaching Hospital, Kaduna, 1 TafaBalewa Way, Kaduna, Kaduna State
Nigeria
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/njbcs.njbcs_11_21
Context: The potential benefits of exercise to pregnant women and their unborn children are immense, yet regular exercise prescription may not be the norm. Aims: Our study aimed to investigate the perceptions and practices of obstetric care providers regarding exercise in pregnancy. Materials and Methods: The study was a cross-sectional survey done in Kaduna state between July and December 2020. A pretested questionnaire was given to obstetric care providers and information was obtained about demographics, professional and facility characteristics of respondents, their perceptions, and practices related to exercise in pregnancy, and information they routinely give pregnant women regarding exercise. Descriptive analysis was done using frequencies, percentages, mean, and standard deviation. Results: There were 265 respondents with a mean age of 34.23 ± 9.29 years. They were mostly females (215, 82.1%), married (171, 65.3%), Muslim (137, 52.3%), and Hausa (107, 40.8%). There were more nurses (153, 58.4%) from the public (212, 80.9%) and tertiary (133, 50.8%) health facilities. Almost all respondents agreed that exercise during pregnancy was beneficial (258, 98.5%). The commonest indication for exercise was cited as obesity and diabetes, whereas it was mostly contraindicated with bleeding while pregnant. The commonest barriers to exercise in pregnancy were the fear of pregnancy complications, inadequate knowledge, and high workload. Conclusion: Healthcare workers in this study generally had positive perceptions and practices toward exercise during pregnancy, except for the fact that they feel pregnant women should avoid strength-building exercises, and do not usually recommend individualized programs. Local guidelines need to be developed for EIP and providers better trained.
Keywords: Exercise, health care providers, Kaduna, perception, practice, pregnancy
How to cite this article:
Mohammed-Durosinlorun A, Sani F, Abubakar R, Egwu F, Mohammed C, Taingson M. Perceptions of exercise interventions in pregnancy; A cross sectional survey of health care workers in Kaduna State. Niger J Basic Clin Sci 2022;19:113-9 |
How to cite this URL:
Mohammed-Durosinlorun A, Sani F, Abubakar R, Egwu F, Mohammed C, Taingson M. Perceptions of exercise interventions in pregnancy; A cross sectional survey of health care workers in Kaduna State. Niger J Basic Clin Sci [serial online] 2022 [cited 2023 Jun 8];19:113-9. Available from: https://www.njbcs.net/text.asp?2022/19/2/113/361885 |
| Background | |  |
Physical inactivity is the leading cause of morbidity, disability, and premature mortality.[1] Yet so many people still lead sedentary lifestyles[2],[3] even though the adoption of a healthy lifestyle, which includes a healthy diet and exercise, is a simple health promotion strategy that can help prevent a wide range of diseases.
Exercise in pregnancy has been proven to be beneficial for both mother and baby.[3],[4],[5],[6],[7] However, for maximal benefits, exercise must be done regularly throughout pregnancy, for 30 min on most, if not all, days of the week.[8] Some benefits of exercise in pregnancy include improved self-esteem and mental state, cardiovascular fitness, less somatic pain, limited weight gain, few pregnancy complications including gestational diabetes mellitus and hypertensive disorders in pregnancy, and faster postnatal recovery.[3],[4],[5],[6],[7]
Unfortunately, less than half of pregnant women meet recommendations for exercise during pregnancy.[3],[4],[5],[6],[7] Pregnant women are more likely to be sedentary or have shorter and less intensive exercise regimens than non-pregnant women and other adults, and activity levels decrease as pregnancy progresses.[3],[4],[5],[6],[7] A few pregnant women meet recommended guidelines for exercise during pregnancy.[3],[4],[5],[6],[7]
A study found that most women are unsure about exercise during pregnancy or do not know what to do during pregnancy.[3],[4],[5],[6],[7] This has been attributed to several barriers including myths derived from sources other than their health care providers (HCPs) and exaggerated fears of miscarriages, preterm deliveries, and intrauterine growth retardation.[8],[9]
In rural or low-income settings, the pregnancy period may be the only time a woman visits the hospital. This makes it an ideal time for HCPs to give them information on exercise and other health interventions.[2],[9] Women may be more likely to exercise during pregnancy if this is discussed by their obstetric care providers.[3],[4],[5],[6],[7] Pregnant women may become more aware and take better care of their health knowing it has an impact on their baby.[9]
A previous study of overweight pregnant women showed most women felt their HCP did not give adequate information about exercise during pregnancy.[10] Although exercise is beneficial in pregnancy, not all categories of pregnant women are eligible to have all forms/intensity of exercise, hence the HCP needs to be fully informed on this subject.
There is a dearth of research into this area in this environment. This study was therefore designed to investigate the perceptions and practices of HCPs toward exercise in pregnancy.
| Materials and Methods | | |
Ethics: Permission for the study was obtained from the Ethics and Research Committee of Kaduna State Ministry of Health (No. MOH/ADM/VOL. 1/502, May 21, 2018). Informed consent was also obtained from participants.
Study setting: The study was done in Kaduna state between July and December 2020. Kaduna is an urban/semi-urban town situated in the northwestern region of Nigeria. The population is diverse in its culture, religion, and ethnicity. The State has several federal, state, Local Government, and private health facilities spread across its 23 local government areas. State-owned facilities offer free maternal care services.
Study design: The study was descriptive with a cross-sectional design.
Study participants and eligibility criteria: The study participants were HCPs currently working in Kaduna state and recruited from both government-owned and private facilities, offering care to pregnant women at primary, secondary, or tertiary levels of care throughout the state. Only HCP attending to pregnant women and currently offering antenatal care (doctors, nurses, and community health care providers), and willing to participate were included in the study. Healthcare workers not offering antenatal care services were excluded (such as pharmacists, medical laboratory scientists, and radiographers).
Sample size calculation: Using the G*Power3 software (version 3.1),[11] a priori power analysis was done with an effect size of 0.3, alpha error of 0.05, and power of 0.95, and the minimum required sample size was 220. More questionnaires were given to cover attrition and improperly filled questionnaires.
Sampling technique: Non-probability convenience sampling was used.
Data collection: Data were collected using a pretested, self-administered, semi-structured questionnaire adapted and modified from previous studies.[12],[13] Face validation was done by authors (obstetricians and physiotherapists). The questionnaire had sections eliciting information on demographics, professional and facility characteristics of respondents, their perceptions, and practices related to exercise in pregnancy, and information they routinely give pregnant women regarding exercise.
Data analysis: Data were analyzed using the SPSS computer software program for windows, version 20.0 (SPSS Inc, Chicago, IL). Descriptive analysis was done using frequencies, percentages, mean, and standard deviation. Chi-square or likelihood ratio was used as a test of association and a P value of <0.05 was considered significant.
| Results | | |
Demographic characteristics of the HCPs
Three hundred twenty questionnaires were administered but only 265 participants responded (82.8% response rate). Participants' ages ranged from 20 to 60 years (mean 34.23 ± 9.29). Majority were females (215, 82.1%), married (171, 65.3%), Muslim (137, 52.3%), and Hausa (107, 40.8%) respondents as shown in [Table 1]. Their average income is also shown with the majority earning 30,000 nairas or more (152, 58.0%).
The personnel and facility characteristics of participants are shown in [Table 2]. Most participants were nurses (153, 58.4%) from the public (212, 80.9%) and tertiary (133, 50.8%) health facilities. Respondents had varying years of experience, the majority had worked for 1–5 years (87, 33.2%). | Table 2: Personnel and facility characteristics of health care providers
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Perceptions and practices of HCPs
The perceptions and practices of HCPs relating to exercise in pregnancy (EIP) are shown in [Table 3]. The majority of respondents agreed that EIP is a major component of antenatal care (159, 60.7%). Most respondents felt that a lot of women in this environment usually ask questions relating to EIP during their antenatal visits (219, 83.6%). When taking history, respondents routinely asked about EIP (193, 73.7%). | Table 3: Perceptions of healthcare providers relating to exercise in pregnancy (EIP)
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Almost all respondents felt EIP was beneficial (258, 98.5%) and possible benefits noted by respondents are shown in [Figure 1]. Respondents felt exercise in pregnancy may be indicated especially in certain situations, most commonly in overweight/obese pregnant women and diabetics [Figure 2]. The majority felt that EIP was not associated with low birth weight (LBW) (207, 77.1%) and that EIP poses minimal or no risks at all to the fetus (196, 74.8%) [Table 3]. Most also felt that sedentary women with uncomplicated pregnancies should be allowed to start EIP (171, 65,3%), whereas those who were already exercising before they got pregnant should continue with EIP (149, 56.9%). Respondents felt EIP may be contraindicated in certain situations or extra caution required, most especially in cases of threatened/recurrent miscarriage, antepartum hemorrhage, cardiac disease, cervical incompetence, and severe hypertension in pregnancy [Figure 3]. | Figure 1: Benefits of exercise. Note: Respondents gave multiple responses
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 | Figure 2: Special groups of women who require EIP. Note: Respondents gave multiple responses
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 | Figure 3: Groups where EIP is contraindicated or extra caution is required. Note: Respondents gave multiple responses
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However, 188 respondents (71.8%) felt pregnant women should not participate in strength training exercise programs. More than half of the respondents would not include individual recommendations regarding EIP [Table 3]. About 139 respondents (53.1%) would recommend only moderate intensity exercise programs for pregnant women. [Figure 4] shows the various types of exercises prescribed and it was most commonly walking and aerobics. Advice on EIP was usually given during the second and third trimesters of pregnancy, and it took respondents less than 20 min to give this advice (117, 44.7%) [Table 3] and [Table 4]. | Figure 4: Types of exercises recommended to pregnant clients. Note: Respondents gave multiple responses
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 | Table 4: More views and practices of healthcare providers related to exercise during pregnancy (EIP)
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A significant number of respondents were unaware of any professional guidelines on EIP (124, 47.3%) and even fewer (4 respondents) were able to name any specific guideline [Table 4]. A lot of reasons were given as barriers to HCPs offering advice to pregnant women on EIP; however, the commonest reasons were the fear of pregnancy complications, inadequate knowledge, and high workload [Figure 5]. The majority of the HCPs also exercised themselves (217, 82.8%) [Table 4]. | Figure 5: Barriers to counseling women on EIP. Note: Respondents gave multiple responses
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HIP who felt EIP should be a major component of antenatal care and those who did not were compared [Table 5], and income was the only significant factor (P value <0.05).
| Discussion | | |
The potential benefits of exercise to pregnant women and their unborn children are immense, yet regular exercise prescription is not the norm for pregnant women in this environment as provided for in guidelines for EIP.[14],[15] A previous study investigating why pregnant women do not exercise optimally opined that lack of exercise information or incorrect information may be a reason for this.[16] Our study aimed to investigate the perceptions of HCPs involved in the care of pregnant women regarding EIP. Our findings from this study provide a useful insight into possible reasons why exercise had not been a routine part of pregnant women's care in this environment.
Our study showed that the majority of respondents agreed that EIP was indeed a major component of antenatal care (60.7%), they routinely asked about exercise history (73.7%), and that a lot of pregnant women made inquiries about exercise during their clinic visits. This is something positive and one study concluded that when women discussed exercise with their obstetric providers, they were more likely to “maintain or increase exercise” during pregnancy than those who did not.[8]
The result of our study showed that HCPs in this environment are knowledgeable as to the benefits of EIP as agreed by almost all respondents (98.5%). This is similar to another study where 99% of respondents believed that exercise during pregnancy is beneficial.[16] Respondents were able to identify the benefits of EIP as shown by various studies [Figure 1], such as improved cardiovascular fitness and sense of self, less postpartum depression, anxiety, sleep disorders, prevention, and urinary incontinence.[13],[17],[18]
These benefits extend to the postpartum period and beyond.[17],[18] Other benefits include less weight gain during pregnancy and risk of diabetes, among others.[17],[18] Similarly, respondents were able to recognize that EIP causes little or no risk to the fetus and may even have a positive effect on fetal growth adaptation.[13] Respondents could identify that EIP posed minimal or no risks to the fetus (74.8%), much lower than in another study where 89% of respondents believed the same.[12] About 77.1% of respondents in this study felt EIP was not associated with low birth weight (LBW), which is comparable to another study where 93% of respondents felt the risk of LBW was not increased by EIP.[12]
Being overweight/obese or diabetic was one of the most cited indications for exercise by respondents. Another study of overweight and obese pregnant women revealed they did not get adequate information about exercise during pregnancy.[10] It is however pertinent to note that both obese and non-obese women will derive benefits from exercise.
Respondents felt that sedentary women with uncomplicated pregnancies should be allowed to start EIP (65.3%), whereas 56.9% of those already exercising before pregnancy should be allowed to continue. Although others agree, women may, however, need to change their exercise intensity and frequency over the course of pregnancy.[13],[19]
Although exercise is generally safe in pregnancy, there may be some relative or absolute contraindications,[13] and respondents gave several reasons they felt EIP may be contraindicated or require extra caution [Figure 3]. These reasons could be one of the reasons why HCPs in this environment did not give specific exercises to pregnant women or ed them to exercise experts such as physiotherapists. The reasons given are also similar to other studies, but if pregnancies are uncomplicated, then these concerns are really not substantiated.[20],[21],[22] EIP guidelines in several countries also state similar possible contraindications.[23] Further studies are, however, required to clarify the safety of EIP in pregnant women with chronic diseases.[13] Respondents cited conditions requiring “bed rest,” though this is not effective for the prevention of preterm birth and should not be routinely recommended, more so it may predispose to thromboembolism.
Some types of exercise are certainly dangerous and should be avoided in pregnancy such as contact sports.[2],[3],[4],[13],[24] Exercise entailing prolonged periods in the supine position should also be avoided to prevent hypotension.[13] Exercise with risks of falls, trauma, or collisions[23] should also be avoided. This again emphasizes the reason why HCPs should be properly trained to guide pregnant women, and why exercise programs should be individualized.
However, 71.8% of respondents felt pregnant women should not participate in strength training exercise programs unlike other studies, where 76% of respondents believed women should participate in strength training programs during pregnancy.[12] Unlike this study, it is recommended that pregnant women be encouraged to participate in strength training as part of their exercise routines.[13] Some guidelines warn against high loads during strengthening exercises due to the risk of pressure reflex, recommended a seated position during strength training, and using lighter weights with more repetition.[23] However, only a few studies have investigated the safety and efficacy of strength training during pregnancy.[20],[23],[25]
Most respondents (53.1%) would recommend only moderate-intensity exercise programs for pregnant women, with less than 2% recommending vigorous exercise. This is similar to other studies where most obstetric providers did not agree that vigorous exercise was beneficial during pregnancy.[8],[14] One study showed that pregnant women were less likely to meet vigorous or moderate EIP recommendations.[26] Most EIP guidelines support moderate-intensity programs.[17],[19],[23],[27],[28],[29] For as long as a pregnant woman can carry on a conversation while exercising, she is unlikely to overexert herself.[30] This can be used as a simple guide to gauge what strength of exercise the pregnant woman can cope with.
The most common form of exercise prescribed by respondents in this study was walking and aerobics. This is similar to other studies where walking was the most popular form of exercise in both pregnant and non-pregnant women,[1],[26] probable because it is simple to do. Walking is also convenient, requires no sophisticated gadgets or extra cost, and can be easily sustained.
More respondents generally spent less than 20 min to counseling the women about EIP (44.7%) and they were mainly nurses. These results are similar to other studies, nurses had more personal contact with patients and spent more time counseling for EIP. Nurses spent an average of 49.3 min, as compared to doctors who spent an average of 29.8 min.[12],[31] In other studies, providers spent 10 min or less advising patients on exercise.[12],[32],[33] Adequate time may be required for qualitative counseling, but this is not always possible, especially in hospitals with a high volume of patients.
Due to these varied recommendations, it is wise to individualize EIP recommendations, and women need to consult their obstetric care provider about this,[19] although 52% of respondents do not include this in their discussions. Some studies found that certain exercises were taught in general, rather than with individual instruction, they were not remarkably effective probably due to poor adherence.[34]
Guidelines can help providers advise on general and individualized exercise programs. In our study, 47.3% of respondents were unaware of any EIP guidelines, probably because local ones have not been developed. Elsewhere, even when guidelines exist, providers may still be unaware of them or possess adequate knowledge about the outcomes associated with EIP.[8],[12],[13],[14]
One of the common barriers to EIP cited by respondents was the fear of pregnancy complications, which is probably why 80% of pregnant women are physically inactive, especially in the last trimester of pregnancy.[29],[35] Lack of knowledge/training was also cited in this study, which was also noted in other studies,[33] as well as lack of insurance, reimbursements, and guidelines. Local myths about EIP may also impact negatively counseling. In one study, for example, African American women believed raising their arms above their head could potentially cause cord entanglements and harm their babies.[36] Myths about EIP were noted in this study as a barrier but were not explored further.
Better training of obstetric providers and counseling tools, the presence of low-cost neighborhood accessible exercise facilities, and community-based exercise programs will make EIP easier exercise.[8],[37]
The fact that 82.8% of respondents exercise may be why a lot of them have positive attitudes toward EIP. Previous studies have shown that health workers who exercise themselves, tend to have more positive attitudes about physical activity and promote it.[1],[38]
Further studies are, however, suggested to further explore study findings, especially myths surrounding EIP.
| Conclusion and Recommendation | | |
Healthcare workers in this study had positive perceptions toward EIP, except for the fact that they feel pregnant women should avoid strength-building exercises, and do not recommend individualized EIP programs. Local guidelines need to be developed for EIP and HCPs should be better trained to maximize clinical benefits to pregnant women.
Strengths and limitations
A few studies have researched this area of interest; so, this can serve as a basis for further studies. The non-randomization of the sample is a limitation of the study and can introduce selection bias; thus, results should be interpreted with caution.
Ethical approval
Permission for the study was obtained from the Ethics and Research Committee of Kaduna State Ministry of Health (No. MOH/ADM/VOL. 1/502).
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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