Patterns, facilitators and barriers to physical activity among Nigerian pregnant women

Introduction pregnancy is associated with sedentary behaviors and/or low levels of physical activity (PA). This study aimed to assess patterns, barriers, and facilitators of PA among pregnant women. Methods a convergent parallel mixed method design study involving a concurrent collection of quantitative (n=198) and qualitative (n=36) data was carried out. Respondents were drawn from five selected health care facilities in Ile-Ife, Osun state, South-West, Nigeria. Physical activity was assessed using the pregnancy physical activity questionnaire. Focus group discussions were used to qualitatively explore barriers and facilitators of PA. Quantitative data were analyzed using descriptive and inferential statistics, while qualitative data were analyzed using thematic content analysis. Results the mean total PA score for the population was 118.663±81.522 mets-min/wk. While it was 118.743±92.062 mets-min/wk, 113.861±72.854 mets-min/wk, and 25.429±87.766 mets-min/wk for the first, second, and third trimester respectively. The respondents engaged more in moderate (44.27±37.07) than vigorous (13.89±18.87) intensity PA. Respondents in the third trimester had the highest and the least scores for household-related PA (45.7±33.0) and vigorous-intensity PA (10.0±14.0) respectively. Major themes that emerged on enablers and barriers of PA engagement during pregnancy were related to intrapersonal, interpersonal, availability of specialized health personnel and policy for PA, good built environment/neighborhood factors, and pervading cultural beliefs and myths about pregnancy. Conclusion moderate intensity and household-related PA were most common among Nigerian pregnant women. Contextual facilitators and barriers to PA during pregnancy were largely related to intrapersonal, interpersonal, environmental or organizational, policy, and cultural factors.


Introduction
Pregnancy is a significant stage in a woman´s life [1] that is associated with considerable physiological and psychological changes that often predispose her to sedentary behaviors and/or low levels of physical activity (PA) [2]. Sedentariness or lack of PA during pregnancy, in turn, precipitates negative effects on the physical, psychological and psychosocial health of the woman [3,4]. On the other hand, being physically active during pregnancy is associated with a reduced risk of adverse pregnancy and birth outcomes; including preeclampsia, gestational diabetes, and preterm births [5]. Consequently, studies have recommended that women should initiate or continue exercise in most pregnancies [6,7] as it is safe for the mother and not harmful to the fetus [8,9]. While, only a few engage in exercises or sports activities during pregnancy, a substantial proportion of women stop exercising after they discover they are pregnant, thus leading to decrease levels of PA among them [10]. The causes of reduced PA in pregnancy are multifarious. Hormonal changes, [11] social, [12] physiological, [13] and psychological [12,14] factors have been implicated in many studies. In addition, factors not limited to beliefs and attitudes about PA [7,15] levels of knowledge and education, [16] phobia or safety concern of the pregnant woman and her physician, [17] race/ethnicity [18], and experience from previous involvement in PA [19] were reported to influence PA in pregnancy. Apart from certain factors that seem to be common as facilitators and barriers to PA in pregnancy, most of the factors that influence PA are contextspecific [20]. However, the context-specific facilitators and barriers of PA among pregnant women seem to have been explored less in sub-Sahara Africa, compared with Western countries. Therefore, the objective of this study was to assess patterns, facilitators, and barriers to PA among Nigerian pregnant women.
Where n= desired sample size, Z= 95% confidence level, it is 1.96, p= expected proportion in population and d= absolute error or precision. A sample size of 196 was calculated, however, 216 was estimated to allow for 10% non-response or invalid data. A total of 198 purposive respondents participated in the study. Also, a sample size of 30 is adjudged large enough for a qualitative study to allow the unfolding of a 'new and richly textured understanding´ of the phenomenon under study [22]. A total of 36 pregnant women responded in the qualitative phase of the study.
Data collection: the following questionnaires were used to collect data 1. Pregnancy physical activity questionnaire (PPAQ). The PPAQ developed by Chasan-Taber et al. [23] was used to quantitatively assess PA among pregnant women. The PPAQ consists of 33 items that aim at assessing different day-to-day activities (including household/ caregiving, occupational, sports/exercise, transportation, and inactivity) and how much time is spent doing each of the activities. To score the questionnaire, the total duration is multiplied by 7. The intensity was then calculated using field-based measurements and metabolic equivalent of task ((MET) values [23,24]. The PPAQ score is expressed in mets-minutes/week). Focus group discussion (FGD) interview guide. A FGD guide adapted from the Carolina Population Center´s PA and weight gain in pregnancy study [25] was used in this study. The FGD guide was subjected to face and content validity by experts in women´s health and PA studies at the Obafemi Awolowo University, Ile-Ife, Nigeria. In order to explore PA patterns, enablers, and barriers, the guide was adapted around the key issues in order to explore the depth of opinions on the subject. The moderator used the guide to elicit information that is relevant to the inquiry by asking questions and exploring answers as they arise. A full report of the discussion was obtained by notetaking and tape recording. A total of five FGDs were conducted, one in each of the facilities. Each FGD was composed of between 6 and 10 pregnant women. Table 1 shows the FGD guide used in the study. Furthermore, the FGD guide sought information on the practice and predictors of PA among women.
Statistical analysis: descriptive statistics of mean, standard deviation, and frequency distribution were used to summarize the sociodemographic variables of respondents. IBM SPSS (statistical package for social sciences) was used for statistical analysis. Verbatim transcription of the qualitative data collected from the focus group discussions was carried out. The interview transcripts were indexed and mapped according to recurring themes, and were analyzed using thematic content analysis. Physical activity was computed based on the PPAQ score. Average weekly energy expenditure (MET-h´week 1) was calculated by multiplying the duration of time spent in each activity by its intensity, following the computation guide described by Chasan-Taber et al. [23].
Ethical consideration: ethical approval for the study was obtained from the Health Research and Ethics Review Committee of the Institute of public health, Obafemi Awolowo University Ile-Ife, Nigeria (IPHOAU/12/945). All participants were informed of the purposes and procedures of the study and all provided both verbal and written consent.

Results
General characteristics: a total of 198 and 36 respondents participated in the quantitative and qualitative aspects of the study. The sociodemographic, obstetrics, and clinical characteristics of the respondents are presented in Table 2. The mean age of respondents in this study was 29.04±3.74 years. The respondents were mostly civil/public servants (39.4%) and of the Christian religion (73.7%). About half of the respondents (48.0%) were in their second trimester and 88.9% still engaging in active work during their pregnancy. The majority of the respondents had no known pathological condition (91.4%) and were multiparous (45.5%).
Quantitative data: Table 3 shows the mean, percentile, and type of PA among the respondents (across the three trimesters). Mostly performed by the respondents were household PA (39.825±33.222) and sports (41.945±33.039) PA. The PA type with the highest and lowest mean score was moderate (44.27±37.07) and vigorous (13.89±18.87) intensity PA. The mean PA score was highest in the third trimester (125.4±87.8). While household-related PA was highest in the third trimester (45.7±33.0), the lowest mean PA score for vigorous-intensity PA (10.0±14.0) was also observed ( Table 4).

Qualitative data
What is physical activity: the concept of PA seems to be understood by a majority (73%) of pregnant women. "To the best of my knowledge, it (PA) means doing our daily activities, you wake up in the morning, doing house chores, go to work," (MKD). Although, some of these respondents misconstrue PA to be synonymous with exercise and physical fitness. "Physical activity is normal daily works like house chores and work (occupation) and exercise" (SDG).In addition, respondents submit that taking care of children is essentially a major part of PA. "at least we have to prepare for children in the morning is part of physical activity" (PKT). Respondents mostly attribute PA to household chores; involving cooking food, sweeping the floor, washing plates, bathing, and dressing children (61%). However, PA was rarely associated with leisure among women ( Table 5).
What are the ways women can be physically active: the respondents submit that involvement in household chores will suffice for a pregnant woman. "The things we (pregnant women) can do as part of PA include washing clothes, washing plates then if you have other kids in the house take care of them, move from one area to the other" (MKT). Nonetheless, some of the respondents, in addition to doing household chores submit that active working (occupation) and exercise are ways of improving PA in pregnancy. "There are different types of exercise, walking for like 30 minutes down the street, maybe every day is good for the pregnant women also " (SKT). Nonetheless, there were some misconceptions about how to improve PA among pregnant women. For example, some said "eating energy giving food" (MKO), and "use your drugs appropriately and eat different fruits" (MKY).
Types of prenatal physical activity: most of the respondents revealed that they were involved in rigorous household activities involving lifting or carrying heavy loads, fetching water from the well water, and backing babies. "Lifting of heavy loads, like a pail of water to flush by the time you´re gaining weight (because of pregnancy) you´ll discover you cannot carry many loads" (MKD). Other common outdoor activities reported include trekking long distances and occupational activity participation in exercises "I work, to the extent, I can trek anywhere but now, we can work well before but now, we cannot work well again"(SDG). For some of the respondents, leisure time activity was more of going to religious programs, while few still will engage in leisure walking "I was also active with church activities and all. I still do most of these things" (RSV).
Perceived meaning and types of physical activity: the types of PA identified were leisure-time PA, work/occupation, household, active transportation, and outdoor with household PA being the most mentioned type of PA. The perceptions about PA, sources of information, and perceived changes/factors in PA during pregnancy ( Table 5).
Changes and factors affecting physical activity since pregnancy: the general consensus among the respondent was that PA was markedly reduced since being pregnant. "My physical activity level has reduced definitely because the level of energy is lower. So everything is slower you know you are carrying a baby. It takes a lot from you" (MKD). Some of the women assert that there is strength sharing between the mother and fetus leading to fatigue and the attendant drop in PA. "You know, another person is inside, for some it may be one or two (twin), part of the energy we have before is what the baby has taken" (RMD).
Advice on participating in physical activity during pregnancy: common advice given were on being active, avoiding or relieving stress, posture management, nutrition and respect for myths. On being active a respondent reported: "It is recommended for us to sweep using standing broom if we cannot bend down, we are told other ways to do these things that will make it easier"(PRD). On avoiding stress, some of the respondents stated "We heard the advice that we should not engage in strenuous work, that our legs must not be swollen more than necessary, they said we must not see blood on our body," (SRT). On nutrition, some of the respondents submit "my brother-in-law used to advise me not to eat plantain, a friend told me to drink pawpaw water because it prevents jaundice" (SMD). "My sister-inlaw used to tell me not to take cold drinks, because it makes the baby´s head grow big ... I follow the advice once in a while. I still take a cold drink when I feel like it, especially when they are not at home" (MRD). Others forms of food to be avoided as reported by the women were bitter yam, snail, okra, and plantain. On posture and body ergonomics in pregnancy, the advice given was expressed thus: "I am told not to bend down too much to sweep or wash clothes. I was told to sit down often so that my baby will not aspirate blood" (MDG). "They say bending down may cause blood to enter the baby´s eyes," (NSD). The pregnant women in this study were advised also to adhere to certain cultural tenets, as revealed by some of the excerpts "I have been advised not to go out in the afternoon sun around 1-3 pm, and that I should always attach a pin to my cloth before going to the market" (PRD)."We are advised to add a pin to our clothes before going out in order to scare evil spirits away. I don´t want anything to harm my child, so I adhere to this advice" (RPD). "They used to say if we mistakenly find ourselves outside around 1 pm we can take a small stone, put it in our ear and continue going, it was given by mothers before us, I follow them, they are good" (SDG). However, not all pregnant women believe in the cultural tenets. I am a Muslim, I don´t have taboos but they used to say pregnant women should not walk in the sun around 1 o´clock. I don´t really follow them "(SKD).
Perceptions about post-partum engagement in physical activity: various perceptions on postdelivery PA participation were expressed; "When one gives birth, one should not be lazy, one should just do house chores and the stress of taking care of the baby is enough to make somebody to lose weight" (MRD). "After one delivers the weight sheds by itself, one does not have to do anything or use any drugs, it happened like that after my first baby" (NSB).
Facilitators of physical activity: some respondents believe that having good health is an important factor in PA engagement. "I think good health is a facilitator, When you are healthy you will be able to do a lot of things" (MKY). Some believe that self or getting motivation by others to engage in PA is important (  (PGS). Having money and availability of good food were also reported as facilitators of PA in pregnancy. "Money gingers somebody to be very active, when things are going well with the family one is happy and doing everything is easy" (MSB). Availability of good built environment or neighborhood was another facilitator of PA in pregnancy. "Good roads is necessary, almost all the roads are bad and is not suitable for walking for a pregnant woman" (MKY). Availability of specialized health personnel and policy for PA in pregnancy. "Workplace should be mandated to give a day off for antenatal where physical activity program will be carried out without having to rush back to work"(RSV).
Barriers to physical activity in pregnancy: ill health or co-morbid conditions in pregnancy and financial challenges were considered as barriers; "health challenges and weakness affects one from being physically active" (MKY). "Money is a stumbling block because if there is no money to take care of oneself, eat good food, one may not be able to do anything, because the body will be weak"(MYB). Personal factors such as pregnancy-related physiological changes, mood and depression, and having wrong advisers were implicated as barriers ( Table 6); "when there is nobody to exercise with, like walking now, it is boring to walk" (SRT)."When you are told that exercising or stressing the body can result in miscarriages or other complications, you will be careful"(SRT). "Some people are still fighting with their past and it will affect their present, causing depression which will render them physically inactive" (PDG). Some cultural beliefs is reported as an impediment to PA in pregnancy "our culture and what our elders tell us is one thing that can be a barrier, for example in some families they say their pregnant women must not work least they have a miscarriage so the woman is not allowed to work until she give birth" (MKT).

Discussion
The PA scores obtained in this study varied according to pregnancy trimester. Women in the third trimester had the highest PA score. Contrary to this finding, previous studies found high levels of PA during the second trimester of pregnancy [26,27]. However, the finding of this study may be attributed to anecdotal evidence in the study setting where women in the advanced stage of pregnancy usually want to be physically active, as it is believed to aid, especially, spontaneous vagina delivery process, owing to palpable aversion for cesarean section [28]. A study in the context where this study was conducted found that cesarean section among the Yoruba of Western Nigeria is treated with suspicion, aversion, misconceptions, fear, guilt, misery, and anger [29]. Anecdotally, full-term women in the study context are often encouraged to engage in more than usual activities such as rigorous walking, pounding yam to make iyan (a staple yam meal in the study location), or making cassava flour meals, which are laborious household chores. Based on PA types, pregnant women in the third trimester had the highest overall mean in household-related PA. This finding is supported by the report of Florindo et al. [30] who reported that the highest of all reviewed PA types among pregnant women was household intensity PA. Adeniyi et al. [31] explain that the third trimester is a period where pregnant women, usually embark on maternity leave which may make them spend more time at home than at work. From this study, vigorous intensity and occupational PA were comparable across trimesters. A possible reason may be that many women once they discovered they are pregnant, reduce engaging in occupational activities and may feel more comfortable and safer doing household activities irrespective of trimesters [32].
From this study, pregnant women in the third trimester have the least mean score for vigorousintensity PA. This finding is generally consistent with previous research indicating a significant decline in time spent in total and vigorous leisure PA and stable levels of moderate leisure PA from pre-pregnancy to pregnancy [33,34]. It was also observed that there was no significant association between PA levels and the sociodemographics of pregnant women. Findings on the association between PA and sociodemographics of pregnant women have been somewhat inconsistent [35,36]. In the qualitative results in this study, a large proportion of the women seem to exhibit some knowledge of PA, however, the knowledge was generally within the context of household PA. Kader and Naim-Shuchana [37] in a review reported that there is limited knowledge, even about participation in elite sports in pregnancy even though exercise during pregnancy does not increase any risk of adverse pregnancy or birth outcomes, not even for elite athlete women. Nigerian pregnant women in this study, have limited understanding of the different domains of PA, other than engagement in household chores. Some of the women, in addition to engaging in household chores, submit that active working (occupation) and exercise are ways of improving PA in pregnancy. Most of the women in this study stated that they were involved in rigorous household activities involving lifting or carrying heavy loads, fetching water from the well, etc. This finding buttress the quantitative result that household PA is the most common type of PA among Nigerian pregnant women. This is probably due to norms of the ethnic groups in Nigeria that make household chores mandatory for the female gender. This finding support previous reports about West Africa that women usually work longer hours a day than males in similar circumstances. Specifically, that women's working week is longer than 64 hours, whereas for men it is only about 32 hours. About half of women's time is spent on domestic tasks, but even then women spend more time on agriculture than men do (26 hours/week compared with only 12 hours/week for men) [38]. Sumra and Schillaci [39] submit that multiple role engagement in women, even at a relatively high level as experienced by "superwomen", is not associated with significantly higher stress, or reduced life satisfaction.
Most of the women in this study acknowledged that their PA became markedly reduced since being pregnant, which is in line with previous reports [40]. Some of the women rehearsed fatigue as a major factor influencing change in PA. Other studies have noted the impact of fatigue on women´s level of PA [9,41]. Advice/information, myths, and misconceptions about PA were mostly gotten from family and friends. This study´s finding is in agreement with a previous study by Prochaska et al. [42]. From a practical perspective, the summary of factors that facilitated women´s engagement in PA during pregnancy includes social support; personal factors (such as motivation, selfdetermination, and time consciousness); availability of money and good food; availability of a good built environment or neighborhood, as well as, availability of specialized health personnel and policy for PA participation in pregnancy. Some of these factors have been identified by other studies [43,44]. Women in this study identified a number of factors that hindered their capacity to be physically active. Consistent with reports from other studies, many of these were health or practical issues, including pregnancy-related symptoms like feeling tired or weak and decreased motivation and time, which are factors that are often associated with working and family commitments. Some barriers are transient, but some were present throughout the entire period of pregnancy. Perceived barriers arose from women´s concern about the risks of being physically active for either themselves or their fetus. Other barriers include; time constraints; perception of already being active, dearth of money; lack of motivation and company; wrong advice; mood, and depression. Some of these are supported by the literature [33,45,46]. A systematic review of a qualitative and quantitative approache to perceived barriers to leisure-time physical activity during pregnancy concludes that mother-child safety concerns, lack of advice/information, and lack of social support were also importantly emphasized in pregnancy-related barriers to be targeted in future interventions [46]. The responding pregnant women in this study based on sociodemographic characteristics were relatively young and were only recruited from selected hospitals from only one region in Nigeria. Therefore, the findings of this study can only be generalized to similar contexts, as an extrapolation of findings to developed settings may be challenging.
Clinical implications: there is a need for programmatic actions aimed at promoting PA among pregnant women by dispelling myths and eliminating barriers that limit participation in PA. Therefore, education and training on PA should be part of the continuum of care at antenatal care setting.

Conclusion
Moderate intensity household physical activity is preponderant among Nigerian pregnant women, especially in the third trimester of pregnancy. Major themes that emerged on enablers of PA engagement during pregnancy were related to intrapersonal (absence of pregnancy-related symptoms, time availability and selfdetermination), interpersonal (availability of social support and financial stability), availability of specialized health personnel and policy for PA, and good built environment/neighborhood factors. While the barriers were mostly related to intrapersonal (having a sense of impaired health requiring PA engagement, time constraints, lack of motivation, perception on usefulness of PA and safety concerns), and interpersonal (lack of advice/information and social support) factors, and pervading cultural beliefs and myths about pregnancy.

What is known about this topic
 Physical activity participation in pregnancy is associated with better outcomes for mother and fetus, including controlled weight and reduced predilection for obesity;  Physical activity is generally considered safe for both the pregnant woman and the fetus;  Women face significant barriers to participating in require physical activity needed for the healthy pregnancy.

Competing interests
The authors declare no competing interests.

Authors' contributions
Chidozie Emmanuel Mbada designed the study, analysed and critically reviewed the manuscript; Olabisi Aderonke Akinwande, Okechukwu Ernest Orji, Adebanjo Babalola Adeyemi, Esther Kikelomo Afolabi and Kikelomo Aboyowa Mbada designed the study, and participated in writing of the manuscript; Dolapo Adeola Ojo participated in data collection and analysis, and in writing of the manuscript. All authors have read and agreed to the final manuscript.

Acknowledgments
We gratefully acknowledge all the pregnant mothers that volunteered for this study. We thank the administrative and nursing staff at the selected hospitals for the support. Table 1: pregnancy, physical activity study focus group guide Table 2: social-demographic, obstetrics and clinical characteristics of the respondents Table 3: mean, percentile and physical activity types among pregnant women (for first, second, third trimesters, and combined data) Table 4: frequency distribution of physical activity level of pregnant women based on demographic factors Table 5: perceptions about physical activity, sources of information and perceived changes/factors in physical activity during pregnancy Table 6