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KNOWLEDGE OF ANTENATAL EXERCISE AMONG PREGNANT WOMEN IN
NSUKKA LOCAL GOVERNMENT AREA OF ENUGU STATE, NIGERIA
By
DR C. C. IGBOKWE
08061680773
chima.igbokwe@unn.edu.ng
DEPARTMENT OF HUMAN KINETICS AND HEALTH EDUCATION
UNIVERSITY OF NIGERIA, NSUKKA
AND
L. I. ABUGU
07067657007
ijeoma.abugu@unn.edu.ng
DEPARTMENT OF HUMAN KINETICS AND HEALTH EDUCATION
UNIVERSITY OF NIGERIA, NSUKKA
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Abstract
This study determined the level of knowledge of antenatal exercise among pregnant women in
Nsukka LGA, Enugu state. Four specific objectives with four corresponding research questions
and one null hypothesis guided the study. A cross sectional survey research design was adopted
for the study. The study population comprised 2,008 pregnant women registered at the 16 health
facilities that offer antenatal care services in Nsukka LGA at the time of the study. Multistage
sampling procedure was employed to draw 204 pregnant women for the study. Researchers’
designed questionnaire termed Knowledge of Antenatal Exercise Questionnaire (KAEQ) was
used to collect data. Frequency and percentage were used to answer research questions while chi-
square statistic was used to test the null hypothesis at .05 level of significance. The results of the
study indicated that pregnant women possessed low knowledge of types of antenatal exercise
(38.9%), very high knowledge of benefits of antenatal exercise (80.6%) and average knowledge
of contra-indications to antenatal exercise. All pregnant women irrespective of parity had
average knowledge of antenatal exercise. There was no significant difference in the knowledge
of antenatal exercise based on parity (ᵡ2=4.985, p= .283 > .05). The researchers recommended
that health and physical educators and other health care workers should educate women in
general and pregnant women in particular on the need for antenatal exercise.
Key words: Knowledge, Antenatal exercise, Pregnant women.
Introduction
Pregnancy and childbirth are normal physiological processes in the lives of females that
each woman aims to achieve without much stress. Antenatal exercise is an integral part of
antenatal care services (ANCs) aimed at promoting the health of both the pregnant woman and
her baby. Motolla and McLaughlin (2011) noted that lack of exercise may pose a great risk to
pregnant women. Khatri, Sirohi, Dexit, Rai and Pandey (2014) reported higher percentage of
caesarean birth (62%) in non-exercising pregnant women than exercising pregnant women
(26%). Several studies in Nigeria and other parts of the globe equally suggested that women who
exercised during pregnancy had better pregnancy outcomes than those who did not exercise
(Wadsworth, 2007; Barakat, Palez, Montejo, Lauces & Zakyunthinaki, 2011; Jayasudya, 2013).
Antenatal exercise is therefore necessary for healthier pregnancy outcomes.
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Antenatal exercise is any physical activity during pregnancy for the promotion of health
and well being of the pregnant woman. Several exercises have been recommended during
pregnancy. According to Nkhata, Nkandu, Schula and Mweshi (2016), some of the exercise
recommendation in pregnancy include – Kegels’ (pelvic floor) exercise, swimming, brisk
walking, indoor stationary bicycling and low impact aerobics. Other studies suggested different
forms of exercises such as muscle strengthening, back care, stretching and abdominal exercises
provided the mother consults with her health care provider before commencement of the exercise
(Breed, 2011; Leifermen, Gutilla, Paulson & Pivarnik, 2012; Sujindra, Bupathy, Suganya &
Praveena, 2015). Equally, the American Congress of Obstetricians and Gynecologists (ACOG)
and Committee on Obstetrics Practice, (2002) recommended that pregnant women can exercise
moderately for 30 minutes on most days of the week. Exercise for sedentary women and those
with medical or obstetric complications are also promoted in the ACOG’s recommendation but
only after medical evaluation. These exercises help to relieve the common ailments during
pregnancy.
Pelvic floor exercise helps to strengthen the pelvic floor muscles that become weakened
due to strain of pregnancy on the muscle. Bennett and Brown (1996) described pelvic floor
exercise thus; sit, stand or lie with legs slightly apart, close and draw up around the back passage
as if though preventing a bowel action then repeat around the front two passages as though
preventing a flow of urine, hold for as long as is comfortable breathing normally, then relax and
repeat four times. The authors further stated that all women should practice this exercise very
regularly antenatally, particularly after emptying the bladder. This exercise prevents incontinence
of urine, hemorrhoids and better outcome of labor. An added advantage of this exercise is
increased sexual satisfaction in the women. LaHaye and LaHaye (1998) reported that in addition
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to strengthening the pelvic floor muscles to control voiding of urine and better outcome of child
birth, many women reported experiencing orgasm for the first time in their lives after practicing
pelvic floor exercise for some weeks.
Abdominal exercise strengthens abdominal muscles and prevents back pain while aerobics
such as brisk walking, cycling and swimming has been shown to improve cardiovascular fitness
and endurance (Ribeiro & Milanez, 2011). Breathing exercise improves venous return and aid
the oxygen supply to both the pregnant woman and her baby and also relaxation exercise relieves
tension in the body thus improving emotional health of the woman (Benett & Brown, 1996).
More importantly, exercise has been shown to reduce some of the major complications of
pregnancy and delivery. Dignon and Reddington (2013) asserted that conditions like pre-
eclampsia, gestational diabetes, birth weight and type of delivery have been shown to improve
when exercise is undertaken. Khatri et al. reported lower rate of caesarean delivery, back pain
and urinary incontinence in exercising women when compared to non-exercising women.
Common ailments during pregnancy can include low back pain, sciatica, sacroiliac joint
pain, pelvic floor weakness and incontinence (Khatri et al., 2014). These problems may be due to
the anatomical and physiological changes that occur in pregnancy. Khatri et al. stated that these
problems may be due to hormone of pregnancy, increased weight gain and change in posture as a
result of forward shift in the centre of gravity of the body. Engaging in regular physical activity
in pregnancy has been associated with increased fitness, prevention of excessive weight gain,
low back pain, lower anxiety and depressive symptomatology (Leiferman et al., 2012).
However, there are contra-indications to some of the exercises in pregnancy. Breed
(2011) gave such contraindications as cardiac disease, lung disease, incompetent cervix,
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persistent vaginal bleeding, severe anemia, history of premature labor and rupture of membrane.
Therefore Sujindra et al., (2015) recommended that pregnant mothers with health challenges
should consult their health care practitioner before engaging in any form of antenatal exercises.
This notwithstanding, exercise is recommended in most women without any obstetric
complication. Pregnant women might not be aware of the types of exercise during pregnancy as
well as the inherent benefits. This may be attributed to lack of knowledge of different types of
exercise during pregnancy.
Knowledge of antenatal exercise by pregnant women is very necessary. World Health
Organization-WHO (2006) stated that knowledge is a pre-requisite to any practice. The report
further indicated that many of the prevailing ailments in the society are to a large extent caused
by anti-health practice because people are uninformed. Knowledge in this study refers to level of
awareness of antenatal exercises possessed by pregnant women attending health facilities in
Nsukka LGA, Enugu State. Knowledge of antenatal exercise by pregnant women will influence
their practice thereby promoting their overall health and fitness and that of their babies. Also
more favourable pregnancy outcome is anticipated in exercising pregnant woman. Poor
knowledge of antenatal exercise will invariably lead to poor or non practice of this health
promoting behavior thereby predisposing women to many preventable pregnancy related
problems. However, several factors might influence knowledge of antenatal exercises among
pregnant women.
Factors that can influence knowledge of antenatal exercise include: level of knowledge, level
of education, safety concerns, ethnicity, previous involvement in regular exercises and phobia
among pregnant mothers ( Mbada, Adebayo, Adeyemi, Arije, Dada & Akinwade, 2014). Others
could be parity, occupation, culture and religion.
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Despite the myriads of benefits associated with engagement in physical exercise during
pregnancy, pregnant women unfortunately are afraid to exercise during pregnancy for fear of
complications that may arise from such (Mbada et al., 2014; Nkhata et al., 2015). Even those
that were exercising prior to pregnancy tend to stop the exercise due to lack of information on
the safety of such exercises (Dignon & Reddington, 2013). Several studies (Ribeiro & Milanez
2011; Mbada et al., 2014; Sujindra et al., 2015; Nkhata et al., 2015) in Nigeria and other parts of
the world indicated that there is inadequate knowledge of antenatal exercise by pregnant women.
None of such studies to the best knowledge of the researchers have been conducted in Nsukka
LGA, Enugu State. In view of the above, the need arose to determine if pregnant women in
Nsukka LGA have adequate knowledge of exercise during pregnancy which will aid them to
engage in these exercises in order to ameliorate the common ailments during pregnancy and
anticipate favourable pregnancy outcome. Findings of the study will be useful to health
educators, health care practitioners, curriculum planners, pregnant women and all those involved
in the care of pregnant women.
Purpose of the Study
The purpose of the study was to determine the level of knowledge of antenatal exercise
among pregnant women in Nsukka LGA, Enugu State. Specifically, the study sought to
determine the level of knowledge of;
1. types of antenatal exercises among pregnant women in Nsukka LGA;
2. benefits of antenatal exercises among pregnant women in Nsukka LGA;
3. contraindications to antenatal exercise among pregnant women in Nsukka LGA; and
4. antenatal exercise among pregnant women in Nsukka LGA based on parity.
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Research Questions
1 What is the level of knowledge of different types of antenatal exercise among pregnant
women in Nsukka LGA?
2 What is the level of knowledge of benefits of antenatal exercise among pregnant women
in Nsukka LGA?
3 What is the level of knowledge of contraindications to antenatal exercise among pregnant
women in Nsukka LGA?
4 What is the level of knowledge of antenatal exercise among pregnant women in Nsukka
LGA based on parity?
Hypotheses
1. There is no significant difference in level of knowledge of antenatal exercise possessed
by pregnant women in Nsukka LGA based on parity.
Methods
The study adopted cross sectional survey research design. Population for the study consisted of
all 2,008 pregnant mothers registered and attending antenatal clinic in the 16 health facilities that
that offer antenatal care services in Nsukka LGA from January to August 2016 (office of the
monitoring and evaluation unit, Health Department Nsukka LGA). There are 50 health care
facilities in the three development centers in Nsukka LGA out of which 16 offer antenatal care
services. A sample size of 204 respondents was chosen, representing approximately 10 per cent
of the population. Multistage sampling procedure was used to arrive at the sample. First stage
involved drawing six health facilities (two from each development centre) from the existing 16
health facilities that offer antenatal care services using simple random sampling of balloting
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without replacement while second stage involved the use of purposive sampling technique on
antenatal clinic days to select 34 pregnant women each from the sampled six health facilities.
This procedure produced 204 pregnant mothers for the study.
A researchers’ designed questionnaire on knowledge of antenatal exercise among
pregnant women referred to as Knowledge of Antenatal Exercise Questionnaire (KAEQ) was
used for data collection. The instrument comprised two sections. Section A solicited information
on personal data of the respondents while section B sought information on knowledge of
antenatal exercise. Dimensions of knowledge investigated in relation to exercise during
pregnancy were types of exercise, benefits and contraindications of antenatal exercise. Face
validity of the instrument was established by three experts in Health Education, University of
Nigeria Nsukka. The KAEQ was administered to 20 women that attended antenatal care clinic in
District Hospital Enugu Ezike after which split half was used to determine reliability of the
instrument. Spearman Brown correlation coefficient was utilized to determine reliability
coefficient which yielded .71. Data was collected by the researchers and research assistants
during antenatal clinic days at the sampled health facilities. Informed consent was obtained
verbally from the respondents prior to administration of the instrument. Completed copies of the
instruments were collected on the spot after completion to ensure maximum return rate. Out of
204 copies distributed and retrieved, 194 were used for data analysis. The data were coded and
analyzed using IBM Statistical Package for the Social Sciences (SPSS) version 21. Frequency
and percentage were used to answer research questions. In determining the level of knowledge of
antenatal exercise, Ashur’s (1977) modified version by Okafor (1997) criteria for determining
knowledge was used. By this criteria, scores below 20 per cent was considered very low level of
knowledge (VLK), 20-39 per cent was considered low level of knowledge (LK), 40-59 per cent
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was considered average level of knowledge (AK), 60-80 per cent was considered high level of
knowledge (HK) while a score above 80 per cent was considered very high level of knowledge
(VHK). Chi-square statistic was used to test the null hypotheses at .05 level of significance and
appropriate degree of freedom.
Results
Table 1
Level of knowledge of Different Types of Antenatal Exercise by Pregnant Women (n=194)
Types of Antenatal Exercise Correct Response Incorrect Response
f % f % Decision
Pelvic floor exercise 49 25.3 145 74.7 LK
Muscle strengthening exercise 83 42.8 111 57.2 AK
Relaxation and breathing exercise 126 64.9 68 35.1 HK
Back care exercise 38 19.6 156 80.4 VLK
Swimming 33 17.0 161 83.0 VLK
Cycling 40 20.6 154 79.4 LK
Walking 139 71.6 55 28.4 HK
Stretching 96 49.5 98 50.5 AK
Overall percentage 38.9 61.1 LK
Key: HK- high knowledge, AK- average knowledge, LK- low knowledge, VLK- very low knowledge
Data in Table 1 show that the overall level of knowledge of different types of antenatal
exercise was low (38.9%).
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Table 2
Level of Knowledge of Benefits of Antenatal Exercise by Pregnant Women (n=194)
Benefits of Antenatal Exercise Correct Response Incorrect Response
f % f % Decision
Reduces back pain during pregnancy 164 84.5 30 15.5 VHK
Increases muscular and cardiovascular fitness 142 73.2 52 26.8 HK
Strengthens pelvic floor muscles during pregnancy 152 78.4 42 21.6 HK
Relieves some discomforts during pregnancy 150 77.3 44 22.7 HK
Prevents excessive weight gain during pregnancy 170 87.5 24 12.5 VHK
Better ability to cope with labour and delivery 162 83.5 32 16.5 VHK
Increases energy and stamina during pregnancy 154 79.4 40 20.6 HK
Leads to more rapid postnatal recovery 158 81.4 36 18.6 VHK
Overall percentage 80.6 19.4 VHK
Key: VHK- very high knowledge, HK- high knowledge.
Data in Table 2 above show that there is very high level of knowledge of benefits of
antenatal exercise (80.6%) among pregnant women attending health facilities in Nsukka LGA.
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Table 3
Level of Knowledge of Contraindications to Antenatal Exercise by Pregnant Women (n=194)
Contraindications to Antenatal Exercise Correct Response Incorrect Response
f % f % Decision
Vaginal bleeding during pregnancy 74 38.1 120 61.1 LK
Uterine contraction during pregnancy 78 40.2 116 59.8 AK
Abdominal pain during pregnancy 86 44.3 108 55.7 AK
Difficulty in breathing during pregnancy 86 44.3 108 55.7 AK
Dizziness during pregnancy 74 38.1 120 61.9 LK
Chest pain during pregnancy 66 34 128 66 LK
High blood pressure during pregnancy 96 49.5 94 40.5 AK
Muscle weakness during pregnancy 118 60.8 76 39.2 HK
Average percentage 43.7 56.3 AK
Key: HK- high knowledge, AK- average knowledge, LK- low knowledge.
Data in Table 3 show that there is average level of knowledge of contraindication to
antenatal exercise (43.7%).
Table 4
Level of Knowledge of Antenatal Exercise by Pregnant Women Based on Parity (n=194)
Item parity
One child(n=50) 2-4 children(n=114) 5 children &above(n=30)
f % Decision f % Decision f % Decision
Knowledge of types 20 40 AK 41 36 LK 14 46.7 AK
Knowledge of benefits 39 78 HK 91 79.8 HK 27 90 VHK
Knowledge of contraindications 24 48 AK 45 39.5 LK 11 36.7 LK
Overall % 55.3 AK 51.8 AK 57.8 AK
______________________________________________________________________________
Key: LK-low knowledge, AK- average knowledge, HK- high knowledge, VHK- very high knowledge.
Data in Table 4 indicate that women with five and above children have slightly higher
knowledge (57.8%) than those with one child (55.3%) while those with two to four childre have
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the least knowledge of antenatal exercise (51.8%). The table further indicates that all pregnant
women irrespective of parity have average level of knowledge of antenatal exercise.
Table 5
Summary of Chi-square Analysis of no Significant Difference in the Level of Knowledge of
Antenatal Exercise possessed by Pregnant Women Based on Parity (n=194).
______________________________________________________________________________
Item parity
One child(n=50) 2-4 children(n=114)
≥
5 children(n=30) ᵡ2- cal df p-value decision
Correct Incorrect Correct Incorrect Correct Incorrect
O(E) O(E) O(E) O(E) O(E) O(E)
______________________________________________________________________________
Types 20 (19.5) 30(30.5) 41(44.4) 73(69.6) 14(18.3) 16(11.7) 5.431 2 .246 accept
Benefits 39(40.4) 11(9.6) 91(91.9) 23(22.1) 27(24.7) 3(5.3) 6.200 2 .160 accept
Contraindications 24(20.4) 26(29.6) 45(46.6) 69(67.4) 11(12.3) 19(17.7) 3.323 2 .443 accept
Overall ᵡ2 4.985 2 .283 accept
______________________________________________________________________________
Table 5 shows the calculated ᵡ2 value with their corresponding p-values for types (ᵡ2=5.431,
p= .246 > .05); benefits (ᵡ2=6.200, p= .160 > .05); contraindications (ᵡ2= 3.323, p= .443 > .05).
Since the overall p- value is greater than .05 (ᵡ2=4.985, p= .283 > .05), the null hypotheses of no
significant difference was accepted. This implies that knowledge of antenatal exercise possessed
by pregnant women did not differ with parity.
Discussion
The finding of the study in Table 1 showed that the overall level of knowledge of different
types of antenatal exercise possessed by pregnant women was low (38.9%). This finding is not
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plausible. It is expected that pregnant women that attend antenatal care clinics should receive
adequate information on health promoting practices in pregnancy including antenatal exercise.
This finding supports the findings of Sujindra et al. (2015) and Nkhata et al. (2016), who
reported less than average level of knowledge of antenatal exercise among pregnant mothers in
India and Zambia respectively. Similarly, Mbada et al. (2014) reported inadequate knowledge of
antenatal exercise among pregnant women in south west, Nigeria. The reason for low knowledge
could be attributed to lack of valid information on physical activities to pregnant mothers by
health care providers at the health facilities. In this regard, Lieferman, Gutila, Paulson and
Pivarnik (2012) reported low level of antenatal physical activity counseling among health care
providers. This has implication for the education and practice of health care providers.
In this study, pregnant women had high knowledge of walking exercise (71.6%). The level
of knowledge of muscle strengthening exercise was average (42.8%) while the knowledge of
other types of exercise was low. This situation is worrisome bearing in mind the benefits of
antenatal exercise to pregnant women. Pregnant women in this study were aware of only
breathing and walking exercise. Women in our study lacked knowledge of pelvic floor exercise
which is of immense benefit even during the post natal period and afterwards. The low level of
knowledge of swimming could be attributed to prevalent hydrophobia and cultural myths that
makes swimming among pregnant women a taboo (Mbada et al., 2014). Also few people have
skills in swimming. However, those that have swimming skills should be encouraged to continue
swimming while pregnant. This is because the American Pregnancy Association (2008) ranked
exercise in pregnancy in order as Kegel (pelvic floor), swimming, walking, bicycling, aerobics
and dance. There is therefore an urgent need to update the knowledge and skills of health care
providers on the importance and current guidelines regarding antenatal exercise so that they can
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appropriately inform and educate pregnant women on exercise during pregnancy as they visit the
health facilities for antenatal care services.
Findings in Table 2 show that there is very high knowledge of benefits of exercise
among pregnant women. This finding is tenable bearing in mind the benefits of exercise to health
and well being of everybody including pregnant women. This finding is consistent with previous
findings (Downs & Hausenblas, 2004; Pennick & Young, 2007; Mbada et al., 2014; Sujindra et
al., 2015). Most women in this study had high knowledge of all the benefits of exercise outlined.
This consistency with previous findings could be attributed to universality of the knowledge of
effects of exercise in health promotion.
Findings of the study in table 3 show that there is average level of knowledge of
contraindications to antenatal exercise (43.7%). It is expected that women should gain high
knowledge of contraindication to antenatal exercise as they visit health facilities. The finding is
consistent with the findings of Mbada et, al., (2014) who reported that pregnant women in their
study mostly implicated swelling of lower extremities, extreme weight gain or loss, and presence
of back pain during pregnancy as contraindications to exercise during pregnancy. The authors
described that these conditions are at best relative contraindications which should not rule out
engagement in exercise during pregnancy except there are underlying medical or obstetric
complications. This finding could lead to unfounded fear about exercise in pregnancy. Dignon
and Reddington, (2013) reported that pregnant women who were exercising prior to pregnancy
tend to stop during pregnancy for fear of complications. This equally has implications for health
education. Health care workers and health educators should properly educate women in general
and pregnant women in particular about contraindications to antenatal exercise. Despite these
contraindications, women should be encouraged to exercise but under medical supervision or
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after consultation with their health care providers. Exercise like pelvic floor exercise has no
contraindication and should be encouraged despite any condition.
Findings in Table 4 revealed that pregnant women across all parity had average
knowledge of antenatal exercise. However, pregnant women with five or more children had
slightly higher knowledge (57.8%) than women with one child (55.3%) while women with two
to four children had the least level of knowledge (51.8%). The null hypothesis of no significant
difference in the knowledge of antenatal exercise based on parity was accepted (ᵡ2=4.985,
p= .283>.05). This implied that knowledge did not differ significantly with parity. It is expected
that pregnant women with higher parity should possess higher knowledge of antenatal exercise
as they have been visiting health facilities in previous pregnancies and are supposed to have
gained knowledge. This could be explained by the fact that health care workers might not be
giving adequate information on antenatal exercise to pregnant women predisposing them to not
having enough knowledge even with high parity. Therefore there is need to educate pregnant
mothers in this study area on the need for antenatal exercise.
Conclusion
Based on the findings and discussion, the following conclusion were reached; Pregnant
women in Nsukka LGA had low level of knowledge of different types of antenatal exercises,
very high level of knowledge of benefits of antenatal exercises and average level of knowledge
of contraindication to antenatal exercise. In general pregnant women across the parity had
average level of knowledge of antenatal exercise. However, there was no significant difference
in knowledge of antenatal exercise based on parity. This implies that women do not gain much
knowledge of antenatal exercise as they visit health facilities for antenatal care services.
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Therefore there is need to inform, educate and communicate types and contraindications of
antenatal exercise to pregnant women by healthcare workers and caregivers.
Recommendations
Based on the findings and conclusion of the study, the following recommendations are proffered;
1. Health and physical educators and other health care workers should educate women in
general and pregnant women in particular on the types and contraindications of antenatal
exercise during pregnancy.
2. Seminars and workshops should be organized for health care workers in antenatal care
facilities on different types of exercise as well as their benefits and contraindications to
improve their knowledge and inculcate same to their clients
3. Physiotherapists should get actively involved in antenatal care services where they can
inform and educate pregnant women on the importance of carrying out recommended
exercises during pregnancy.
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