PREVALENCE OF DIETARY SUPPLEMENTS CONSUMPTION AND EXERCISE AMONG PREGNANT WOMEN IN AL MADINAH AND THEIR EFFECT ON MODE OF DELIVERY.

Objective: To assess prevalence of dietary supplements consumption and exercise among pregnant women in AL Madinah and their effect on mode of delivery. Methods: Retrospective study was conducted in AL included who were randomly selected and different ages, social levels and education levels. the was electronic questionnaire, the questionnaire consisted of three sections, the included questions about socio-demographic characteristics, while the second included questions to assess some potential risk factors, and third section included questions to (39) Diabetes risk‖ of GDM‖ those who do not have healthy lifestyles should be encouraged to view the preconception period and pregnancy as opportunities to embrace healthier routines (1) . This study conducted to assess the effect of exercise, supplement and herbs during pregnancy in Al-Madinah Al-Monwarah 2016. There was a low prevalence of chronic diseases among participants at this study by 28.1%. our finding closes to the results of an American study which reported that 27% of pregnant women suffered from a chronic disease (41) . This similarity in the results due to the convergence of life conditions and medical care between KSA and USA. The most common chronic diseases at our study was Iron deficiency with 11.90%. In recent study Prevalence of anemia (Hb<11gm/dl) on pregnant women in Pakistan was found to be 96% (42) . This difference prevalence of anemia between the two countries naturally because of the different economic levels and types of food between the two countries. Also, pressure was one of the common chronic diseases among our participants with 3.33%.‏ This percentage is much lower than the rates in other countries, (17 %) in Nigeria (43) , (17.2%)in Finland (44) . This difference is due to the difference in the nature of life, the level of economic, quality of food, and the pressure faced by women between Saudi Arabia and those countries. Nulliparous and grand multiparous women had been reported in previous studies to be at increased risk of hypertensive disorders of pregnancy, especially Pregnancy induced hypertension (PIH) and Pre-eclamptic toxemia (PET) (43) . The prevalence of smoking among women in our study was low by 2.86%. But in a study in Lebanon almost one quarter (23%) of participants reported smoking during pregnancy (45) . The prevalence of smoking in Lebanon is higher than in Saudi Arabia was due to a kind of fanaticism in the customs, traditions and religious restraint that prevents smoking in general and prevents the women in particular in Saudi Arabia. Regular aerobic exercise during pregnancy has been shown to improve or maintain physical fitness (46,37) . Although the evidence is limited, some benefit to pregnancy outcomes has been shown, and there is no evidence of harm when not contraindicated. Observational studies of women who exercise during pregnancy have shown benefits such as low-back pain, is an excellent alternative (51) . Studies have shown that exercise during pregnancy can lower glucose levels in women with GDM (52, 53) , or help prevent preeclampsia (54) Exercise has shown only a modest decrease in overall weight gain (1–2 kg) in normal weight, overweight, and obese women (55, 56) . 40.95% of participants at this study practice exercise during Pregnancy. In Brazil, 12.9% of women reported to engage in some type of physical activity during pregnancy (57) . in the United States, one study reported that only 15.8% of pregnant women are engaged in exercise during pregnancy at the recommended level (58) . our result higher that than the results of other studies in Brazil and United States because most of the women in the United States and Brazil are the workers and therefore do not have enough time to exercise, unlike women in Arabia. Walking was the most prevalence exercise that practiced among our participants during Pregnancy. It is safe sport, could be done without the need for equipment, and does not cause tired so much. According to our results there was no effect of doing exercise at Normal delivery, but doing exercise affect at Cesarean delivery. This means doing exercise reduce the need to Cesarean delivery. This is consistent with Zeanah et al., whose reported significantly fewer cesarean sections in women who performed 40 min of moderate intensity exercise regularly during pregnancy (59) , and Melzer et al., whose reported that inactive women were 3.7 times more likely to require operative delivery than active women who did at least 30 min of moderate physical activity per day (60) . But this contrary to Barakat et al., whose reported that Light-intensity resistance training that is performed over the second and third trimester of pregnancy does not affect the type of delivery (61) . It is certain that the reduction of C-sections limits the costs and complications compared with Normal delivery. Having chronic problem affected by doing exercise in our study. These results are considered logical because, Physical inactivity is a primary cause of most chronic diseases. Physical inactivity is a modifiable risk cardiovascular disease

. A systematic review associated physically demanding work with increased risk of premature birth (17) , whereas a recent large cohort study showed increased risk of early spontaneous abortion with > 7 h/wk of high impact exercise (18) . Potential risk factors of exercise have been listed as fetal hyperthermia with potential teratogenic effects, reduction of oxygenated blood flow (leading to fetal hypoxia) and reduction in essential substrates leading to fetal growth restriction (19) . After the 13th week of pregnancy, about 1.2 extra MJ (300 kcal) per day are required to meet the metabolic needs of pregnancy (20,21) . This energy requirement is increased further when daily energy expenditure is increased through exercise. In weight bearing exercise, such as walking, the energy requirement progressively increases with the increase in weight during the course of the pregnancy (22) .

Nutritional supplements during pregnancy:-
The role of maternal health and nutrition has been emphasized by the recognition of the problem of low birth weight which affects some 20 million newborns annually, mainly in developing countries. This is essentially an end result of interference with fetal growth following inadequate nutrition and infections in pregnant women in these countries (23) . periods of the life span include pregnancy and lactation, during which time nutrient requirements increase to support fetal and then infant growth and development (24) . Its recommended intakes for 14 of the 21 essential micronutrients increase during pregnancy. These nutrients comprise 7 vitamins, 5 minerals, and Choline (25) . During pregnancy the best to get vitamins and minerals from the food you eat, but same time you will need to take a supplement. Folic acid is one of important supplement for pregnancy, as it can help to prevent birth defects. Also, vitamin D for regulates the amount of calcium and phosphate in the body, which are needed to keep bones, teeth and muscles healthy. Iron, Vitamin C, Vitamin B12 and Calcium helps to keep healthy (26) .

Herbs during pregnancy:-
In pregnancy, women often use herbal medicines due to the perception that these substances are more natural and therefore safer to use as compared to pharmaceutical medicines (27,28) .a review of studies from the Western world, reported that the prevalence of herbal medicine use in pregnancy ranged from 1 to 60% (27) .Concerns range, with some herbal medicines, from teratogenicity to an increased risk of maternal bleeding or impact on neonatal hormones due to the hormonal nature of the herbal medicine (29) .In a previous study,39% of the women reporting having used herbal medicines during pregnancy had used herbal medicines that were considered possibly harmful or herbs where information about safety in pregnancy was missing (30) . physical activity and mode of delivery: -Only three study evaluated the effect of physical activity on mode of delivery, of which tow failed to show significant differences between caesarian rates in women with and without exercise during pregnancy (20,31) . Only one study showed an association between physical activity and mode of delivery, suggesting a considerably decrees risk of caesarian among active pregnant women (26 ).
Gestational diabetes mellitus (GDM) and exercise:-Gestational diabetes mellitus (GDM) is one of the most common complications of pregnancy and is associated with a substantially elevated risk of adverse health outcomes for both mothers and offspring (28) and there is strong relation 1182 sheep between exercise and GD. data from prospective cohorts show that physical activity before pregnancy , in early pregnancy or during pregnancy are associated with lower risk of developing GDM. ) 28 , 32 , 33 , 34 ,35) In another cohort study the result was Women who engage in intense physical activity before pregnancy have a 44% and 24%risk reduction for GDM and abnormal glucose tolerance, respectively (39) . The Canadian Diabetes Association (CDA) recommends that -Physical activity should be encouraged, with the frequency, type, duration, and intensity tailored to individual obstetric risk‖ (36) . The American Diabetes Association also suggests -Women without medical or obstetrical contraindications are encouraged to start or continue a program of moderate exercise as part of treatment for GDM‖ (37) . however, in A Randomized Controlled Trial There was no evidence that offering women a 12-week standard exercise program during the second half of pregnancy prevents gestational diabetes or improves insulin resistance in healthy pregnant women with normal body mass indexes (38) .
Objectives:-1. To assess the prevalence of women doing exercise during pregnancy. 2. To assess the prevalence of women consuming dietary supplement and herbs during pregnancy. 3. To identify the type and duration of exercise. 4. To identify the type of supplement and herbs. 5. To assess the effect of exercise, supplement and herbs on mode of delivery (normal vaginal delivery or cesarean)

Methodology:-
Retrospective study in AlmadinahAlmonawarah/ KSA. The study will be conducted on 231 Subjects selected randomly covering different age, social levels and education. (high school students, university students, housewives, public people, teachers, faculty members, etc). Data obtained by Using designed mannual questionnaire that was covering the following topics socio-demographic characteristics (as age, education and Social status) , assess some potential risk factors (as history of Chronic diseases, Caesarean births, Gestational Diabetes, Eclampsia). And another several questions to assess the interviewee's knowledge of exercise and using supplement and herbs during pregnancy. Data collecting period was during August 2016.

Results:-
The research was conducted on 202 pregnant females subjects in KSA,0.9 %( n=2) of the subjects aged less than 19 years old, 39

Discussion:-
Pregnancy begins at conception with the union of a man's sperm and a woman's egg to form a single-cell embryo (40) . Full-term pregnancy typically lasts 38 weeks from conception or 40 weeks from the first day of a woman's last normal menstrual period.1It is known that woman's health is essential to the good health of her baby. Women who eat well and exercise regularly along with regular prenatal care are less likely to have complications during pregnancy. They are also more likely to successfully give birth to a healthy baby. So, women who begin their pregnancy with a healthy lifestyle such as; exercise, good nutrition, and nonsmoking should be encouraged to maintain those healthy habits. While those who do not have healthy lifestyles should be encouraged to view the preconception period and pregnancy as opportunities to embrace healthier routines (1) . This study conducted to assess the effect of exercise, supplement and herbs during pregnancy in Al-Madinah Al-Monwarah 2016. There was a low prevalence of chronic diseases among participants at this study by 28.1%. our finding closes to the results of an American study which reported that 27% of pregnant women suffered from a chronic disease (41) . This similarity in the results due to the convergence of life conditions and medical care between KSA and USA. The most common chronic diseases at our study was Iron deficiency with 11.90%. In recent study Prevalence of anemia (Hb<11gm/dl) on pregnant women in Pakistan was found to be 96% (42) . This difference prevalence of anemia between the two countries naturally because of the different economic levels and types of food between the two countries. Also, pressure was one of the common chronic diseases among our participants with ‫.%33.3‬ This percentage is much lower than the rates in other countries, (17 %) in Nigeria (43) , (17.2%)in Finland (44) . This difference is due to the difference in the nature of life, the level of economic, quality of food, and the pressure faced by women between Saudi Arabia and those countries. Nulliparous and grand multiparous women had been reported in previous studies to be at increased risk of hypertensive disorders of pregnancy, especially Pregnancy induced hypertension (PIH) and Pre-eclamptic toxemia (PET) (43) . The prevalence of smoking among women in our study was low by 2.86%. But in a study in Lebanon almost one quarter (23%) of participants reported smoking during pregnancy (45) . The prevalence of smoking in Lebanon is higher than in Saudi Arabia was due to a kind of fanaticism in the customs, traditions and religious restraint that prevents smoking in general and prevents the women in particular in Saudi Arabia. Regular aerobic exercise during pregnancy has been shown to improve or maintain physical fitness (46,37) . Although the evidence is limited, some benefit to pregnancy outcomes has been shown, and there is no evidence of harm when not contraindicated. Observational studies of women who exercise during pregnancy have shown benefits such as decreased gestational diabetes mellitus GDM (47,48) , cesarean and operative vaginal delivery (37,49,50) , and postpartum recovery time (37) , although evidence from randomized controlled trials is limited. In those instances 1184 where women experience low-back pain, water exercise is an excellent alternative (51) . Studies have shown that exercise during pregnancy can lower glucose levels in women with GDM (52,53) , or help prevent preeclampsia (54) . Exercise has shown only a modest decrease in overall weight gain (1-2 kg) in normal weight, overweight, and obese women (55,56) . 40.95% of participants at this study practice exercise during Pregnancy. In Brazil, 12.9% of women reported to engage in some type of physical activity during pregnancy (57) . in the United States, one study reported that only 15.8% of pregnant women are engaged in exercise during pregnancy at the recommended level (58) . our result higher that than the results of other studies in Brazil and United States because most of the women in the United States and Brazil are the workers and therefore do not have enough time to exercise, unlike women in Saudi Arabia. Walking was the most prevalence exercise that practiced among our participants during Pregnancy. It is considered a safe sport, could be done without the need for equipment, and does not cause tired so much. According to our results there was no effect of doing exercise at Normal delivery, but doing exercise affect at Cesarean delivery. This means doing exercise reduce the need to Cesarean delivery. This is consistent with Zeanah et al., whose reported significantly fewer cesarean sections in women who performed 40 min of moderate intensity exercise regularly during pregnancy (59) , and Melzer et al., whose reported that inactive women were 3.7 times more likely to require operative delivery than active women who did at least 30 min of moderate physical activity per day (60) . But this contrary to Barakat et al., whose reported that Light-intensity resistance training that is performed over the second and third trimester of pregnancy does not affect the type of delivery (61) . It is certain that the reduction of C-sections limits the costs and complications compared with Normal delivery. Having chronic problem affected by doing exercise in our study. These results are considered logical because, Physical inactivity is a primary cause of most chronic diseases. ‫‬ Physical inactivity is a modifiable risk factor for cardiovascular disease and a widening variety of other chronic diseases, including diabetes mellitus, cancer (colon and breast)، obesity, hypertension, bone and joint diseases (osteoporosis and osteoarthritis)، and depression (62) . There is incontrovertible evidence that regular physical activity contributes to the primary and secondary prevention of several chronic diseases and is associated with a reduced risk of premature death (62) . Unfortunately, no mandatory system exists for reporting the harmful effects of dietary supplements. Dietary ingredients used in dietary supplements are not subject to the premarket safety evaluations required of new food ingredients, new uses of old food ingredients, or medications (63) . The most of our participants take supplements during pregnancy. Like our results a study in US reported that the majority of pregnant women in the US are using a dietary supplement at some time during their pregnancy (64) . Also in Finland (65) . Literature showed association between demographic and lifestyle factors and dietary supplement use during pregnancy (66,69) . Based on our results use of dietary supplements did not affect on the type of delivery, (Normal vaginal delivery or cesarean delivery). While other studies found that effects of vitamin D deficiency include increased risk of cesarean delivery (CD) (70,71) . Folic acid and Iron supplements were the most common dietary supplement used during pregnancy by participants at this study with 81.90% and 75.71% respectively. Because of the convincing evidence that periconceptional folic acid supplementation can decrease neural tube defects in some women, many health organizations recommend routine folic acid supplementation during pregnancy. For example, the US Centers for Disease Control and Prevention (CDC) recommends that all women of childbearing age who are capable of becoming pregnant should consume 0.4 mg/d folic acid. This recommendation has been adopted by several clinical practice associations, such as the American Academy of Pediatrics and the National Healthy Mothers, Healthy Babies Coalition (72,73) . Although multivitamin and folic acid supplementation is recommended during early pregnancy, these findings could reflect the difficulties some women encounter with tolerance of supplementation, particularly iron supplements, due to nausea and vomiting in early pregnancy (74,75) . Iron deficiency anemia is believed to be a common health problem in the Arabian Gulf (76) . Because of the recognized benefits of additional iron during pregnancy, the World Health Organization recommends daily iron supplementation (60 mg/d) for all pregnant women for 6 months or, if 6 months of treatment cannot be achieved during the pregnancy, either continuation of supplementation during the postpartum period or an increased dosage of 120 mg/d iron during pregnancy (77,78) .
About 20.95% of participants at our study take herbs during pregnancy. The prevalence of herbal medicines uses among pregnant women from the Middle East varied from 22.3% to 82.3% (79) . Although the fact that knowledge of the potential side effects of many of these products is limited, particularly with respect to their use in pregnancy (80,82) . studies reported higher usage of herbs among women from rural areas that were less educated (79,83,86) . In the current study the most common used herb was anise (20.95%). A study in Alexandria reported that aniseed was the most common herb used (40.2%) (87) . In Qatar revealed that only (1%) of pregnant women used aniseed (84) . In this there was no effect of using herbs during pregnancy on type of delivery (Normal vaginal delivery or cesarean). This is contrary to Mabina et al., whose found that Herbal medication use may lead to fetal distress, as indicated by the 1185 high frequency of meconium-stained liquor and high caesarean section rates in this group of women presenting in labour (88) . Limitation:-Our results are subject to certain limitations. For example, inclusion of a large number of participants was not feasible and the time for collecting the data was from one month to two so it was limited. Also, inability to obtain a detailed obstetric history to measure the effect more specifically and we did not ask about socioeconomic state of the participants .The study type maybe a cause for difficulty in recall if we did it in more than two months it will be clinical trial and that is more accurate than retrospective study .Furthermore, the rarity of study's topic in Saudi Arabia especially in ALMadinahALmonawarh made us face many barriers especially in literature review.

Conclusions:-
From this study we concluded thatthere was high prevalence of practice exercise among women during Pregnancy in KSA. Walking was the most common exercise that practiced among Saudi women during pregnancy. According to our results there was no effect of doing exercise at normal delivery, but doing exercise affect at cesarean delivery. This means exercise reduces the need for caesarean delivery. Also, doing exercise reduces having chronic diseases. There was high prevalence of taking dietary supplement during pregnancy among Saudi women, Folic acid and Iron supplements were the most common dietary supplement used during pregnancy by Saudi women. Using of dietary supplements did not affect on the type of delivery, (Normal vaginal delivery or cesarean delivery).There was low prevalence of taking herbs during pregnancy among Saudi women, the most common used herb was anise. There was no effect of using herbs during pregnancy on type of delivery (Normal vaginal delivery or cesarean).

Recommandations:-
1. Further studies about effect of exercise, supplement and herbs during pregnancy. 2. Raise awareness among women, using various ways, about the importance of exercise during pregnancy. 3. For pregnant women exercise regularly and continuity but stay away from the arduous and dangerous sports. 4. The use of dietary supplements should be with extreme caution under the supervision of a doctor, especially in pregnancy. 5. General health education for pregnant women about the benefits and harms of herbal use during pregnancy in ante-natal care especially for herbs commonly used.