Research Article

Physical activity and exercise during pregnancy in Greece: A cross-sectional study

HJOG 2021, 20 (2), 75-92 | doi: 10.33574/hjog.0075

Ermioni Tsarna, Ioanna Mavrommati, Grigorios Bogdanis, Olga Triantafillidou,  George Paltoglou, Panagiotis Christopoulos

2ndDepartment of Obstetrics and Gynecology, Aretaieion University Hospital, Athens Medical School, Greece

Correspondence: Ermioni Tsarna, 2nd Department of Obstetrics and Gynecology, Aretaieion University Hospital, Athens Medical School, Greece, Tel.: +306946349866, e-mail: ermina1990@windowslive.com


Abstract

Introduction: Physical activity and exercise during pregnancy is regarded safe and beneficial in absence of pregnancy complications. The aim of this cross-sectional study is to describe physical activity of pregnant women in Greece and explore if it changes during pregnancy compared to the period before pregnancy.

Material and Methods: The study was conducted in a private maternity hospital. Women were asked to fill in an adapted questionnaire based on Pregnant Physical Activity Questionnaire; birth outcomes and anthropometric measurements of the neonate were collected by the research midwife.

Results: In our study population of 193 pregnant women, approximately half reported no or minimal physical activity during pregnancy and were less active than current guidelines’ recommendations. Gynaecologist’s opinion regarding exercise during pregnancy was conceived as positive only by a minority of women. Overall, women were less active during pregnancy than before, although they spent more time slowly walking for fun or exercise. Lastly, significant decrease was observed in all occupational activities involving slow or quick walking and lifting weights.

Conclusions: These results indicate that systematic counselling of pregnant women regarding physical activity and exercise during pregnancy will be needed to achieve optimal physical activity levels for the majority of women in Greece.

Keywords: Physical activity, exercise, pregnancy

Introduction

Physical activity is well recognised as an important contributor to health and well-being; its beneficiary effect during pregnancy is nowadays widely accepted. Increased physical activity during pregnancy has been associated with favourable birth outcomes, namely reduced risk for preterm birth, reduced duration of labour, and less frequent delivery complications1–3. In addition, more physically active pregnant women on average gain less weight during pregnancy and suffer less frequently from gestational diabetes mellitus, preeclampsia, varicose veins, and deep vein thrombosis compared to pregnant women that are less physically active1–3. Last but not least, physical activity has been shown to improve pregnant women’s psychology, as it alleviates fatigue, stress, anxiety, and depression1,2.

Several public health and clinical guidelines regarding physical activity and exercise during pregnancy have been published around the World. These guidelines are mostly addressed to developed countries, such as Australia, Canada, Japan, the United States, and European countries4. In general, most guidelines advise against vigorous exercise and/or athletic competition during pregnancy, although high-intensity physical activity before pregnancy might continue as long as the pregnant woman feels comfortable4. With regard to physical activity duration, two hours per week is regarded as the minimum; aerobic exercise is usually indicated, although strengthening exercises are also advised in some guidelines4. In case of dizziness, shortness of breath, vaginal bleeding, amniotic fluid leakage, and abdominal or back pain, exercise discontinuance is advised4. Despite the existence of the aforementioned guidelines, women’s adherence has been shown poor and their physical activity during pregnancy is reported low across the world5–13.

The aim of this study is to describe physical activity and exercise habits of pregnant women in Greece, to compare the aforementioned with current guidelines regarding physical activity during pregnancy, and to explore the change in their physical activity before and during pregnancy.

Material and Methods

This was a cross-sectional study conducted in a private maternity hospital located in the capital city of Greece, Athens. Pregnant women giving birth were approached to participate, with the exception of pregnant women with an elective caesarean section for any indication. Women were asked to fill in a questionnaire and provide informed consent, so that the birth outcomes and anthropometric measurements of the neonate could be collected by the research midwife. The study protocol was approved by the Research Ethics Committee of the Maternity Hospital.

The assessment of the intensity and frequency of physical activity before and during pregnancy was based on the Pregnant Physical Activity Questionnaire (PPAQ)14. This is a semi-quantitative questionnaire that examines the daily or weekly time spent during pregnancy for activities that involve physical activity14. The examined activities are grouped into occupational activities, activities related to the household, to sports or exercise, and to transportation14. In addition, three questions that reflect inactivity are also included in the questionnaire14. PPAQ was translated by two independent translators from English to Greek; all of the translated questions were identical with the exception of the two questions related to lowing lawn. These were combined into one question regarding gardening, which was deemed necessary for cultural reasons. Furthermore, two questions regarding preparing meals and light cleaning in house were merged into one for cultural reasons as well. In addition, all questions were asked both for the period during pregnancy and for the period before pregnancy, so that any change in pregnant women’s physical activity due to the pregnancy could be examined. In order to ensure that the translated and adapted questionnaire remained internally consistent, Cronbach’s alpha was calculated. Apart from the aforementioned, women were asked to report the number of previous pregnancies, vaginal labours, and caesarean sections, as well as their demographic and anthropometric characteristics. Birth outcomes, such as mode of birth, birth weight, and gestational age at birth, were recorded by the research midwife.

Pregnant women’s baseline characteristics were described using means and standard deviation for continuous variables, and frequencies and proportions for categorical variables. In addition, the level of physical activity, sports, and exercise before and during pregnancy was described with frequencies and proportions. In order to compare physical activity before and during pregnancy, McNemar’s test for paired nominal data was applied. In case that calculation of p-value for McNemar’s test was not possible due to zero expected frequencies, consecutive levels were merged so that expected frequencies were positive values. Furthermore, a graphical representation was obtained for all physical activity variables with a significant difference before and during pregnancy, to estimate whether activity increased or decreased during pregnancy. Level of significance was 0.05 for all the aforementioned statistical analyses.

In a sensitivity analysis, we examined whether our results regarding changes in physical activity during pregnancy were driven by women that were advised to bed rest by their gynaecologist due to medical indications. To this end, we repeated the aforementioned analyses after excluding from our sample all women that were advised by their gynaecologist to bed rest.

All statistical analyses were performed using R statistical software (version 3.4.0; R Foundation for Statistical Computing, Vienna, Austria)15 and the following software packages: “tableone”16, “psych”17, “ggplot2”18, “Hmisc”19, “dplyr”20, and “reshape2”21.

Results

Two hundred twenty four (224) women were invited to participate in this study. Of these, 193 agreed to participate and filled in the study questionnaire. Thus, study sample size is 193 women. The internal consistency of the study questionnaire was regarded satisfactory, since Cronbach’s alpha was 0.77 (0.73-0.82).

In our study population, on average maternal age at labour was 31.5 years old (standard deviation (SD), 4.4), weight before pregnancy was 62.4 kg (SD, 11.4), and BMI was 22.81 (SD, 3.75), while mean maternal weight at labour was 75.8 kg (SD, 12.6) and gestational weight gain 13.5 kg (SD, 6.9). Notably, one hundred sixty eight (168, 87%) women were checking their body weight every month or more frequently during pregnancy. For the majority of our study population (124, 64.2%) this was their first pregnancy, while only 50 (25.9%) women had one or two living children and no woman had more than two living children. Only 19 (9.8%) women had a prior caesarean section, of which two gave birth vaginally. All but 9 (4.7%) women had conceived naturally, and six (3.1%) women had a multiple pregnancy. With regard to smoking, 85 (44%) were smoking before pregnancy, whereas only 23 (11.9%) continued smoking during pregnancy. Nonetheless, 88 (45.6%) women reported exposure to passive smoking at home during pregnancy. In addition, during this pregnancy 96 (49.7%) women reported vomiting episodes, while 35 (18.1%) women were advised to bedrest due to medical indications. With regard to birth outcomes, mean gestational age at birth was 38.53 (SD, 1.38) completed weeks, mean birth weight was 3075.1g (SD, 499.7), and 80 (47.6%) of the neonates were boys. The labour was induced in 117 (61.7%) women; in 6 (3.2%) women labour started with cervical mucus discharge, in 37 (19.6%) with uterine contractions, and in 29 (15.3%) with rupture of membranes. Ninety two (92, 47.9%) women gave birth vaginally, while 100 (52.1%) had a caesarean section. Descriptive statistics for our study population baseline characteristics are presented in more detail in Supplementary Table 1.

With regard to physical activity, 88 (45.6%) women reported low physical activity before pregnancy, 76 (39.4%) moderate, 26 (13.5%) vigorous, and 3 (1.6%) were professionally involved in sports. During pregnancy, 62 (32.1%) women conceived their gynaecologist’s opinion for physical activity during pregnancy as positive or probably positive, 25 (13%) as negative or probably negative, and 106 (54.9%) as neutral. With regard to exercise during pregnancy, excluding occupational activities, the following activities were examined: slow walking, quick walking, quick walking up hills, jogging, swimming, dancing, prenatal exercise class, and other physical activities for fun or exercise (Supplementary Table 2).Overall, twenty three (11.9%) women did not exercise at all, of which only seven were advised by their gynaecologist to bed rest. Seventy two (37.3%) women had minimal physical activity during pregnancy, meaning less than 30 minutes spent per activity per week. Of these, only 14 were advised by their gynaecologist to bed rest. Thirty five (18.1%) women exercised regularly during pregnancy, meaning at least two hours spent per week in one of the aforementioned activities.

Pregnant women reported significant changes in their physical activity during pregnancy related to several activities. This was observed in all domains, including household related activities (Supplementary Table 3) and transportation related activities (Supplementary Table 4), but was more pronounced in activities for fun or exercise (Supplementary Table 2) and work related activities (Supplementary Table 5). In general, pregnant women significantly decreased their physical activity, with the only exception of slow walking for fun or exercise that was more frequent during pregnancy (p<0.01)(Figure 1). Namely, women spent less time in preparing meals and light cleaning(p<0.01), heavy cleaning(p<0.01), playing with children(p<0.01 for playing while sitting or standing, and p=0.01 for playing while walking or running), quickly walking(p<0.01 for fun or exercise, p<0.01to go to places), walking quickly up hills(p<0.01), jogging(p=0.01), swimming(p=0.04), dancing(p<0.01), standing or walking slowly at work(p<0.01while carrying things, p<0.01 without carrying things), walking quickly at work (p<0.01while carrying things, p<0.01 without carrying things), and other physical activity for fun or exercise (p=0.04)(Figures 2-5). Furthermore, women reported less time spent sitting at work or class(p<0.01)but more time spent watching television during pregnancy (p<0.01)(Figure 6).  The aforementioned results were reasonably stable in a sensitivity analysis of 158 women that were never advised by their gynaecologist to bed rest due to medical indications. In particular, only the reduction of time spent in swimming and other physical activity for fun or exercise lost statistical significance. In addition, a significant reduction of time spent in dressing, bathing, and feeding children while standing was observed in this sensitivity analysis.

Figure 1. Weekly time spent walking slowly for fun or exercise before and during pregnancy.


Figure 2. Daily time spent preparing meals and walking quickly to go to places, and weekly time spent in heavy cleaning and walking quickly for fun or exercise before and during pregnancy.

Figure 3. Daily time spent playing with children, and weekly time spent in other activities for fun or exercise before and during pregnancy.

Figure 4. Weekly time spent jogging, swimming, dancing, and walking up hills for fun or exercise before and during pregnancy.

Figure 5. Daily time spent standing and walking slowly or quickly, with or without carrying things at work before and during pregnancy.

Figure 6. Daily time spent sitting at work or class, and watching television or video before and during pregnancy.

Discussion

In our study population of 193 pregnant women, approximately half reported no or minimal physical activity during pregnancy and, thus, were less active than current guidelines’ recommendations. Notably, gynaecologist’s opinion regarding exercise during pregnancy was conceived as positive only by a minority of women. Overall, women were less active during pregnancy than before, although they spent more time slowly walking for fun or exercise. Finally, significant decrease was observed in all occupational activities involving slow or quick walking and lifting weights.

To our knowledge, this is the first study to describe physical activity during pregnancy in Greece and examine the change in physical activity before and during pregnancy. We, thus, cannot compare our results with previous studies from Greece. Nonetheless, in consistence with our results, research in other developed and developing countries has shown that few women meet the current guidelines regarding physical activity during pregnancy5–13. In addition, previous research in developed western countries has shown that on average women reduce their physical activity during pregnancy, as was the case in our study22–24. However, it is not possible to compare the degree of this reductionbetween studies, since different questionnaires were used to assess physical activity22–24. The underlying factors that influence the level of prenatal physical activity are less well studied. Notably, in our study gynaecologist’s opinion for exercise in pregnancy was rarely conceived as positive, which might contribute to the observed low levels of physical activity. To improve how women perceive their gynaecologist’s opinion for exercise in pregnancy and ultimately achieve an increase in women’s physical activity, gynaecologists and midwifes in Greece need to consult pregnant women systematically, rather than on demand basis. To this end, publication of local guidelines and patients’ information leaflets might, also, help.

Physical activity during pregnancy has been associated with favourable birth outcomes, less frequent pregnancy and delivery complications, and improved maternal mental health. Nonetheless, concerns have been raised regarding potential risks both in uncomplicated and complicated pregnancies. During pregnancy an increase in joint laxity is observed, which in combination with the displacement of the centre of gravity may predispose pregnant women to musculoskeletal injuries during exercise and/or falls and traumatic injuries 25. Furthermore, exercise on the supine position may trigger hypotension due to compression of the inferior vena cava by the gravid uterus, and is not advised during pregnancy 26. Finally, exercise’s safety is debated in a wide range of medical conditions during pregnancy; such are anaemia, hypertension, preeclampsia, cervical insufficiency, vaginal bleeding, placenta previa, premature uterine contractions, and premature rupture of membranes4. In presence of the aforementioned medical conditions, most guidelines advise against physical activity during pregnancy 4; in line with these guidelines, 18.1% of women participating in our study were advised to bed rest by their gynaecologist for various reasons.

In contrast to the low adherence to guidelines regarding prenatal physical activity, in our study occupational activities were to an extent modified during pregnancy in accordance with current scientific evidence. In particular, lifting weights and standing, which are regarded as potential risk factors for many pregnancy complications and adverse birth outcomes, were considerably reduced during pregnancy in our study population3. However, since our study was not designed to examine occupational hazards during pregnancy, we have no further data to explore if other undesirable occupational exposures, such as shift work and exposure to chemicals, were also limited during pregnancy.

Notwithstanding our findings, this study had several limitations. The sample size was relatively small and women were recruited in a single-centre. Furthermore, since the study was conducted in a private maternity hospital located in the capital city of Greece, our sample might differ from the general population in Greece with regards to socioeconomic position. Giving birth in a private facility has a cost that is not affordable by a proportion of Greek population; therefore, we expect that physical activity and exercise habits of such women may not be well described by our study results. In addition, occupational differences from the general population might also exist. Agricultural and livestock occupations are expected to be underrepresented in our sample, since such occupations are more frequent in Greek countryside rather than the capital city. Similarly, manual occupations might be underrepresented, as they are more frequent among women of lower socioeconomic position. Last but not least, to our knowledge PPAQ has never been used and validated in Greece before. In spite of our efforts to ensure the internal consistency of the translated and adapted study questionnaire, external validation was not feasible.

Conclusions

In our study, the majority of pregnant women were less physically active than advised by current guidelines and conceived their gynaecologist’s opinion for physical activity in pregnancy as neutral or negative. In addition, they significantly decreased physical activity during pregnancy compared to the period before pregnancy. Nonetheless, occupational hazards related to physical activity were reduced during pregnancy. These results, collectively, indicate that systematic counselling of pregnant women regarding physical activity and exercise during pregnancy will be needed to achieve optimal physical activity levels for the majority of women in Greece.

Conflict of Interest Statement

None to declare.

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