Factors associated with antenatal exercise in Arba Minch town, Southern Ethiopia: A community-based cross-sectional study.

BACKGROUND: Many health risks in pregnant women and their foetuses can be reduced by practicing antenatal exercise. However, the adequate practice of antenatal exercise among pregnant women is low in Ethiopia. Therefore, this study aimed to assess the practice of antenatal exercise and its associated factors among pregnant women in Arba Minch town.
METHODS: A community-based cross-sectional study design was conducted. Data were collected by using a structured questionnaire from 422 pregnant women selected by a simple random sampling technique. Descriptive statistics were computed and a binary logistic regression model was fitted. In multivariable logistic-regression adjusted odds ratio (AOR) with 95% confidence intervals were used to determine the strength of associations. The significance level was declared at a p-value < 0.05.
RESULTS: Among 410 participants, 32.9% (95% CI 28%-37%) adequately practiced antenatal exercise. Factors negatively associated with an adequate antenatal exercise were husband's primary school level [Adjusted odds ratio (AOR) = 0.3, (95% CI: 0.1, 0.7)], history of miscarriage [AOR = 0.3, (95% CI: 0.1, 0.7)], inadequate knowledge [AOR = 0.2, (95% CI: 0.1, 0.3)], and unfavorable attitude [AOR = 0.3, (95% CI 0.2, 0.5)]. Whereas, factors positively associated with an adequate antenatal exercise were employment status of women [AOR = 4.8, (95% CI: 1.8, 13.1)], and a practice of regular exercise before current pregnancy [AOR = 1.9, (95% CI: 1.1, 3.2)].
CONCLUSIONS: The findings of this study indicated that adequate practice of antenatal exercise was found to be low. Appropriate measures should be taken to improve the husband's educational level, mother's occupation, knowledge, and attitudes towards antenatal exercise. Special consideration should be given to those with a history of miscarriage and women should be encouraged to practice regular exercise before pregnancy.

Introduction

Physical activity is a bodily movement produced by the contraction of skeletal muscles in all stages of life while exercise is a structured, planned, and repetitive movement produced by skeletal muscles [1]. Pregnant women are encouraged to continue and maintain moderate-intensity physical exercise using both aerobic and muscle conditioning activities during pregnancy in the absence of medical or obstetrical complications under the guidance of health care providers [2-4].

Regular participation in exercise has become an important component of a healthy lifestyle, so antenatal exercise has become a fundamental aspect of women’s lives and an important constituent of antenatal care [5,6]. American College of Obstetrics and Gynecology (ACOG) recommended that low to a moderate regular impact exercise regime for pregnant mothers performed for at least 20 to 30 minutes on most days of the week and gradually progressed over a period of time can be followed to improve overall fitness [4]. These exercises include aerobic exercises such as aerobics, swimming, cycling, walking, dancing, core stability, pelvic floor exercises, breathing exercises, postural education, back care foot & leg exercises, and pelvic tilting [4].

Scientific pieces of the literature showed that, in most cases, appropriate antenatal exercise is a safe and effective way to gain many physical and mental health benefits such as avoiding sedentary- and obesity-associated risks for both the mother and foetus [7]. Numerous health benefits of antenatal exercise during pregnancy were documented such as the reduced risk of excessive gestational weight gain, gestational diabetes, preeclampsia, preterm birth, varicose veins, deep vein thrombosis, reduced length of labour, fatigue, stress, anxiety, and depression, as well as decrease delivery complications and improved well-being [8].

Furthermore, antenatal exercise improves the functioning of the foetal and neonatal cardiac autonomic nervous system, normalizes birth weights, and reduces adiposity at birth and in early childhood. Additionally, babies born seem to be calmer, are leaner, more intelligent with improved neurological and mental development and their children had significantly higher scores on oral language and general intelligence tests [9].

Physical inactivity in the general population and lack of antenatal exercise was taken as the leading risk factors for death estimating 3.2 million deaths worldwide and the fourth leading risk factor for early mortality worldwide [10]. It was reported that lack of antenatal exercise increased the prevalence of chronic diseases such as cardiovascular disease, type 2 diabetes, osteoporosis, cancer, and their risk factors such as raised blood pressure, postpartum haemorrhage, raised blood sugar, and overweight [11].

Nonetheless, scholars around the world documented that antenatal exercise is not adequately practiced and does not meet sufficient exercise recommendations [12-16]. In Indian, 35.2% [12], in Campinas Brazil, 29% [13], in Colombo Sri Lanka, 13.6% [14], in Pakistan, 20% [15], 27.2% in Serbia [17], and in Gondar town, Northern Ethiopia, 37.9% [16] of the study participants practiced antenatal exercise. The participation of pregnant women in physical activity during pregnancy in Africa is also low [18]. To guide contextual interventions, examining the physical activity during pregnancy is recommended [18]. However, the status of antenatal exercise practice in Southern Ethiopia has not been assessed yet. Hence, this study was aimed to assess the adequate practice of antenatal exercise and associated factors among pregnant women in Arba Minch town, Southern Ethiopia.

Methods and materials

Study design, period, setting, and population

The community-based cross-sectional study design was conducted from December 1st to 30th, 2019 GC in Arba Minch town, Southern Ethiopia. Arba Minch town is located 454 Km to South of Addis Ababa (capital city of Ethiopia) and about 280 Km from the regional town of Hawassa. According to the 2007 census, the total population of the town was 74,879, of whom 39,208 were men and 35,671 were women [19]. A total of 23.5% were found to be reproductive age group, among these, 4,084 women were pregnant. The numbers of health institutions in Arba Minch town were 1 governmental general hospital, 3 health centers, 11 health posts, 33 private clinics, and 13 drug stores.

The source population was all pregnant women in Arba Minch town. All pregnant women who lived in Arba Minch town at least for six months were included while pregnant women who had medical or obstetric complications and serious psychological conditions were excluded.

Sample size determination and sampling technique

The sample size was determined by using single population proportion formula through Open Epi, Version 3, open-source considering the following assumptions: the adequate practice of antenatal exercise to be 50%, 95% confidence level of certainty (alpha = 0.05), 5% marginal error, and adding 10% non-response rate. The final sample size was determined as 422. There were four sub-cities in the town which were divided into 11 Kebeles (small administrative unit of Ethiopia). The sample size was allocated to all Kebeles proportionally to their number of pregnant women size. Each pregnant woman was selected by a simple random sampling technique using a family folder as a sampling frame (Fig 1).

Fig 1

Schematic representation of sampling procedure of pregnant women in Arba Minch town, Southern Ethiopia 2020.

The institutional review board (IRB) of Arba Minch University, College of Medicine and Health sciences ethically approved the study with a letter reference number (IRB/129/12 on the date of 14/11/2019). Permissions were obtained from each Kebele. Before enrolment, the pregnant women were informed about the objectives of the study, and its importance and informed verbal consent was taken from all study participants before data collection because some of the study participants cannot read and write and their consent was recorded in the questionnaire. For minors, the consent was taken from parents.

Study variables

The dependent variable of this study was the practice of antenatal exercise. Independent variables were: socio-demographic characteristics like age, occupation, religion, monthly income, educational level, employment and marital status, obstetric characteristics like gravidity, gestational ages, parity, and the number of children and history of miscarriage, the practice of exercise before pregnancy and knowledge and attitude towards practices of antenatal exercise.

Data collection tools and procedures

Data were collected using a pre-tested structured questionnaire by face-to-face interview. The questionnaire was designed in English from kinds of literature on related topics [12,14,20] and based on ACOG recommendations of antenatal exercises [4] and was translated to Amharic version for better understanding by data collectors and interviewees. A total of eight data collectors (4 diploma nurses and 4 diploma midwives) were involved in data collection and two master holders in public health were assigned for supervision. The questionnaire contained socio-demographic characteristics, obstetric characteristics, the practice of antenatal exercise, and knowledge and attitude towards practices of antenatal exercise.

Those participants who exercised at least three times a week for a minimum of 20 minutes according to ACOG recommendations [4] were categorized to have an adequate practice of antenatal exercise. Knowledge of antenatal exercise was measured by asking sixteen questions about the benefit and contraindication of antenatal exercise with categorical responses of “yes” and “no” with an item score of “1”, and “0” respectively. Then, the sum was computed and those who responded correctly to the mean and above value were considered as they had adequate knowledge and those who scored less than the mean value were labelled as they had inadequate knowledge about antenatal exercise. The attitude of the woman concerning performing antenatal exercise during pregnancy was measured by asking 8 questions and classified as favourable or unfavourable. Those who answered to 8 attitude questions and scored greater than and equal to mean values were categorized to have favourable attitudes whereas, those who scored less than mean values were categorized to have unfavourable attitudes.

Data quality control

Before actual data collection time, a pre-test was done on 5% [21] women in Mirab Abaya town using the Amharic questions and modifications were done. The training was given to data collectors and supervisors before the beginning of actual data collection. Supervisors closely followed the data collection process. The completed questioners were checked for completeness and consistency on daily basis.

Data analysis

The collected data were coded and entered into Epi Data version 4.6 then exported to SPSS version 25 for analysis. Descriptive statistics like frequencies, percentages, means, and standard deviations were computed. The binary logistic regression model was used. Variables with a p-value ≤ 0.25 in the bi-variable analysis were entered into the multivariable analysis. In addition, the context and findings of previous studies were considered in the identification of candidate variables for multi-variable logistic-regressions to adjust for possible confounding variables. AOR with 95% CI was used to measure the strength of associations and a p-value of < 0.05 was used to determine the presence of association with the outcome variable. Hosmer and Lemeshow model fitness test was used to assess model fitness and it was a good fit.

Results

Socio-demographic characteristics of study participants

Of the 422 women interviewed, 410 (97.2%) provided complete information and were used in these analyses. The mean ± SD (standard deviation) age of the participants was 25.8 ± 5.2 years and the minimum and maximum ages were 16, and 42 years, respectively. The majority of women were within the age category of ≥ 25 years (56.8%). More than half of the study participants 231 (56.3%,) were protestant Christians. A majority of the participants 390 (95.1%) were married. Most women 176 (42.9%) attended primary school while around 30% of their husbands attended their education in college and above. Concerning occupation, 335 (81.7%) of the women were none employed. The monthly mean income of the study participants was 1,347 Ethiopian birr. More than half (64.1%) of the respondents belong to the income level of ≥ 1,347 Ethiopian birrs (Table 1).

Table 1

Socio-demographic characteristics of pregnant women in Arba Minch town, Southern Ethiopia, 2020 (n = 410).

Variables	Categories	Frequency (n)	Percentage (%)
Age (in years)	< 25	177	43.2
	≥ 25	233	56.8
Religion	Orthodox	137	33.4
	Protestant	231	56.3
	Catholic	10	2.4
	Muslim	32	7.8
Marital status	Married	390	95.1
	Divorced	13	3.2
	Widowed	7	1.7
Woman educational status	Unable to read and write	36	8.8
	Able to read and write	24	5.9
	Primary school	176	42.9
	Secondary school	88	21.5
	College and above	86	20.9
Husband educational status	Unable to read and write	13	3.2
	Able to read and write	52	12.7
	Primary school	107	26.1
	Secondary school	115	28.0
	College and above	123	30.0
Occupation	Employed	75	18.3
	Non employed	335	81.7
Income (ETB)	< 1,347	147	35.9
	> = 1,347	263	64.1

ETB-Ethiopian Birr (1ETB = 0.0241243 USD).

Obstetric characteristics of the respondents

The majority of the participants were multigravida 272 (66.3%). Nearly half (46.6%) of them had 1–2 number of living children while more than 90% of the women had no history of miscarriage. Forty-six percent of the women were within four to six months of pregnancy followed by seven to nine months of pregnancy. Half of the pregnant women commenced their antenatal care and visited the health institution 1–2 times (Table 2).

Table 2

Obstetrical characteristics of the study participants in Arba Minch town, Southern Ethiopia, 2020 (n = 410).

Characteristics	Categories	Frequency (n)	Percent (%)
Gravidity	Prim gravida	138	33.7
	Multigravida	272	66.3
Parity	Nulliparous	136	33.2
	Prim-parous	135	32.9
	Multiparous	140	34.1
Number of alive child they have	No child	135	32.9
	1–2 child	191	46.6
	>2 children	83	20.2
History of miscarriage	Yes	39	9.5
	No	371	90.5
Gestational age	<4 months	34	8.3
	4–6 months	189	46.1
	7–9 months	187	45.6
ANC follow up	Not started	102	24.9
	1–2 times	208	50.7
	Three and above	100	24.4

ANC-Antenatal care.

Sources of information for antenatal exercise

A total of 29.3% of respondents revealed that family/friends were the commonest sources of information (Table 3).

Table 3

Sources of information about antenatal exercise among pregnant women in Arba Minch town Southern, Ethiopia, 2020.

Source	Frequency	Percent (%)
Health care provider	97	23.7%
Health extension workers	99	24.1%
Family/friends	120	29.3%
Mass media (Tv, radio)	43	10.5%
Internet	38	9.3%

Pregnant women’s knowledge about antenatal exercise

From total respondents, 233(56.8%) of the pregnant women reported that antenatal exercise reduces the risk of back pain. The majority, 219(53.4%) of pregnant women responded that excessive weight can be prevented by antenatal exercise. About 235(57.3%) of pregnant women reported that antenatal exercise increases energy and stamina. A total of 217(52.9%) women indicated that antenatal exercise helps to cope with labour and delivery pain. Regarding the contraindication of antenatal exercise, a total of 199 (48.53%) pregnant women reported that vaginal bleeding as a contraindication for antenatal exercise. The mean score value of pregnant women’s knowledge about antenatal exercise was 7.99 out of 16. Among all participants, only 190 (46.34%) scored above the mean value and had adequate knowledge about antenatal exercise (Table 4).

Table 4

Knowledge of antenatal exercise of study participants in Arba Minch town, southern, Ethiopia, 2020 (n = 410).

Benefits and contraindication of antenatal exercise	Response	Frequency	Percent
Reduces risk of back pain	Yes	233	56.8
	No	197	43.7
Prevents excessive weight gain	Yes	219	53.4
	No	191	46.6
Increases energy and stamina	Yes	235	57.3
	No	175	42.7
Help cope with labour and delivery pain	Yes	217	52.9
	No	193	47.1
Can reduces risk of diabetes mellitus	Yes	143	34.9
	No	267	65.1
Can decrease high blood pressure during pregnancy	Yes	196	47.8
	No	214	52.2
Helps more rapid postnatal recovery	Yes	190	46.3
	No	220	53.7
Can prevents antenatal and postnatal depression	Yes	213	52.0
	No	197	48
Benefits general health and development of the baby	Yes	241	58.8
	No	169	42
Contraindications
Vaginal bleeding	Yes	199	48.5
	No	211	51.5
Uterine contractions	Yes	185	45.1
	No	225	55.9
Chest pain	Yes	196	47.8
	No	214	52.2
Difficulty of breathing	Yes	205	50
	No	205	50
Premature labour	Yes	201	49.0
	No	209	51
Poorly controlled type 1 diabetics	Yes	179	43.7
	No	231	56.3
Dizziness	Yes	227	55.4
	No	183	44.6
Over all knowledge	Adequate	190	46.3
	Inadequate	220	53.7

Attitude towards antenatal exercise among pregnant women

Among total respondents, 17(17.8%) of pregnant women strongly agree that antenatal exercise during pregnancy is necessary. From total respondents, only 31(7.6%) strongly disagree that antenatal exercise during pregnancy is risky to the foetus. The median score value of pregnant women’s attitude about antenatal exercise was 27. Among all participants only 46% 95%CI (42%-51%) pregnant women scored above mean value and had a favourable attitude towards antenatal exercise (Table 5).

Table 5

Attitude towards the antenatal exercise of respondents among pregnant women in Arba Minch town, southern, Ethiopia, 2020 (n = 410).

Attitudes regarding antenatal exercise	Strongly agree		Agree		Uncertain		Disagree		Strongly disagree
	No.	%	No.	%	No.	%	No.	%	No.	%
Do you feel exercise during pregnancy is necessary?	73	17.8	214	52.2	39	9.5	79	19.3	5	1.2
Do you feel exercise during pregnancy is risky to the fetus?	4	1	94	22.9	104	25.4	177	43.6	31	7.6
Do you feel antenatal exercise suit with our culture?	21	5.1	176	42.9	73	17.8	118	28.8	22	5.4
Do you feel pregnant women should perform exercise under the guidance of health care professionals?	91	22.2	172	42.0	81	19.8	60	14.6	6	1.5
Do you feel ANEx can reduce pregnancy related complication?	57	13.9	188	45.9	87	21.2	75	18.3	3	0.7
Do you feel ANEx helps in post-delivery recovery?	24	5.9	167	40.7	109	26.6	100	24.4	10	2.4
Do you feel the exercising helps you get back to your shape?	27	6.6	165	40.2	101	24.6	107	26.1	10	2.4
Do you feel exercise regimen should vary from one to others?	17	4.1	177	43.2	102	24.9	99	24.1	15	3.7
Over all attitude	Unfavourable				Number		Percent (%)
					220		54%
	Favourable				190		46%

ANEx-antenatal exercise, No.-number.

The practice of antenatal exercise among pregnant women

Nearly half 206(50.2%) of the respondents participated in physical exercise before becoming pregnant. Among total respondents, 135 (32.9%) respondents adequately practiced antenatal exercises while the majorities 275(67.1%) of the women practiced inadequately. Walking was the commonest type of exercise reported by 231 (89.9%) of the respondents. Most common reasons why pregnant women not practiced antenatal exercise in the current pregnancy were lack of information (32.9%) (Table 6, Fig 2).

Table 6

Practice of antenatal exercise among study participants in Arba Minch town, Southern, Ethiopia, 2020 (n = 410).

Variable		Response		Number	Percent (%)
Have you ever done regular exercise before becoming pregnant?		Yes		206	50.2
		No		204	49.8
Do you practice any antenatal exercise in this current pregnancy?		Yes		257	62.7%
		No		153	37.3%
If yes what type of exercise you exercising now?			Walking	231	89.8%
			Aerobics	2	0.7%
			Relaxation &breathing	102	39.7%
			Pelvic floor exercise	12	4.6%
			Back exercise	76	29.6%
			Ankle and toe raising	100	38.9%
			Stationary cycling	1	0.4%
How many times per week did you exercise?	Less than two times/week			122	47.8%
	Three and above/week			135	52.2%
Minutes exercised per session	< 20 minutes			122	47.8%
	≥20minutes			135	52.2%
Overall antenatal exercise practice	Inadequate practice			275	67.1%
	Adequate practice			135	32.9%

Fig 2

Reasons for not practicing antenatal exercise in the current pregnancy among participants in Arba Minch town, Southern Ethiopia, 2020.

Factors associated with practices of antenatal exercise

Bivariable and multivariable binary logistic regression analyses were done to assess the association between the selected variables and the practice of antenatal exercise. During adjusted multivariable binary logistic regression analysis, six explanatory variables were significantly associated. From these, husband’s primary school level, history of miscarriage, inadequate knowledge, and unfavourable attitude was positively associated with adequate antenatal exercise whereas, employment status of women and practice of regular exercises before current pregnancy were negatively associated (Table 7).

Table 7

Bi-variable and multi-variable analysis of factors associated with the practices of antenatal exercise in Arba Minch town, Southern Ethiopia, 2020 (N = 410).

Variables	Categories	Adequate antenatal exercise		COR (95%CI)	AOR (95%CI)	P values
		Yes	No
Husband’s educational status	Unable to read and write	6	7	2.0 (0.6, 6.3)	1.5 (0.1, 1.9)
	Able to read and write	15	37	0.9 (0.5, 1.9)	0.7 (0.3, 1.9)
	Primary school	32	75	0.9 (0.6, 1 0.8)	0.3 (0.1, 0.7)	0.014
	High school	45	70	1.5 (0.9, 2.6)	1.5 (0.4, 1.7)
	College & above	37	86	1	1
History of miscarriage	Yes	6	33	0.3 (0.1, 0.8)	0.3 (0.1, 0.7)	0.010
	No	129	242	1	1
Regular exercise done before becoming pregnant.	Yes	83	123	1.9 (1.3, 3.0)	1.9 (1.1, 3.2)	0.023
	No	52	152	1
Knowledge	Inadequate	43	177	0.3 (0.2, 0.4)	0.2 (0.1, 0.3)	0.001
	Adequate	92	98	1	1
Attitude	Unfavorable	30	189	0.13 (0.08, 0.21)	0.3 (0.2, 0.5)	0.003
	Favorable	105	86	1	1
Age (years)	< 25	53	124	0.8 (0.5, 1.2)	1.2 (0.7, 2.3)
	> 25	82	151	1	1
Occupation	Employed	64	11	3.4(1.7, 6.7)	4.8 (1.8, 13.1)	0.002
	Non-employed	211	124	1	1
Gravidity	One time	34	104	1.4 (0.7, 3.2)	1.8 (0.1, 8.3)
	2–3 time	91	127	3.2 (1.5, 6.6)	1.0 (0.2,1.3)
	More than 3	10	44	1	1

1 = reference group, COR = Crude odds ratio, AOR = Adjusted odds ratios.

Those pregnant women who had husbands with primary schooling levels were 70% times less likely to practice adequate antenatal exercise than those whose husbands with college and above level educational status [AOR = 0.3, (95% CI: 0.1, 0.7)]. History of miscarriage is also negatively associated with practices of antenatal exercise. Those women who had a history of miscarriage were 70% less likely to practices antenatal exercise than those women without a history of miscarriage [A = 0.3, (95% CI: (0.1, 0.7)]. Having practices of regular exercise done before becoming pregnant was a risk to have antenatal exercise. Pregnant women with a practice of previous regular exercise were 1.9 times more likely to practice adequate antenatal exercise than those without a history of previous regular exercise [AOR = 1.9, (95% CI:1.1, 3.2)]. Occupation of pregnant women had also an association with practices of antenatal exercise. Those employed pregnant women were 4.8 times more likely to practice adequate antenatal exercise than those who were unemployed [AOR = 4.8, (95% CI: 1.8, 13.0)]. Having inadequate knowledge and an unfavourable attitude to antenatal exercise also affects negatively the practices of antenatal exercise. Those pregnant women who had inadequate knowledge of antenatal exercise were 80% less likely to practice antenatal exercise than those who knew [AOR = 0.2, (95% CI: 0.1, 0.3)]. And also women with unfavourable attitudes were 70% less likely to practice antenatal exercise than those who had favourable attitudes towards antenatal exercise [AOR = 0.3 (95% CI 0.2, 0.5)] (Table 7).

Discussion

This study focused on assessing the adequate practice of antenatal exercise and its associated factors among pregnant women. The overall adequate practice of antenatal exercise during the current pregnancy in this study setting was 32.9% (95% CI: 28%-37%). This finding is in line with the study done, in Gondar town Northern Ethiopia, Pakistan, and Ireland [15,16,21]. But, lower than the result of the studies conducted in Nigeria and Zambia [11,15,22]. This difference might be due to lack of experience of physical exercise before pregnancy, low level of knowledge of antenatal exercise, lack of motivation, lack of awareness, and health care provider counselling in this study setting.

The majority of the women practiced walking, relaxation/breathing, and ankle and toe exercise as predominant antenatal exercise types in pregnancy. Walking was the most common type of exercise mentioned by respondents. This finding is in agreement with a study outcome from Seri Lanka and Pakistan [14,15]. This may be attributed to the fact that the walking activity is easy to carry out and there are no costs or equipment involved when performing the activity. On another hand, the study conducted in Zambia found that aerobics is the predominantly prescribed antenatal exercise [23].

Stationary cycling was the least practiced type of antenatal exercise in this study. This finding coincides with previous studies done in Nigeria [20]. Stationary Cycling exercises are not common in Arba Minch might be due to the lack of fitness programs in the town, and maybe unaffordable.

Regarding the frequency and duration of antenatal exercise among those who practiced, the majority of the women in the present study exercised for less than three days weekly and less than 30 minutes duration of exercise per session. This is in agreement with the study conducted in Nigeria and Zambia [20,23]. However, some of the women exercised in line with standard recommendations of ≥ 30 minutes daily. This is below the standard recommended exercise level of ≥ 30 minutes on most days of the week [4].

The majority of the women (34.9%) were guided by themselves (self-prescriber) to practice the exercise and other people while the role of health professional was very low. Majority of the exercisers unfulfilled the standards of ACOG. To get the benefits of antenatal exercise it might be important to have the antenatal exercise guideline which will help health professionals and health extension workers to guide women to strengthen ongoing maternal health promotion and education interventions. The most principal reasons given by the women for not engaging in an antenatal exercise in current pregnancy were lack of information and recommendation from health care providers and fear of foetal and women risks.

The result of the multivariable binary logistic regression model revealed that having the habit of regular exercise before becoming pregnant, and women having occupation status of employed showed significant positive associations. Whereas, women having husbands with primary education level, women having a history of miscarriage, having inadequate knowledge and unfavourable attitude towards antenatal exercise showed significant negative associations.

This study showed that the practice of antenatal exercise had a significant association with exercise performance before pregnancy. The practice of antenatal exercise was higher among those women who did physical exercise before becoming pregnant when compared with those women who did not. This finding is in line with a study that reported from, Brazil, Gondar town Northern Ethiopia [13,16]. This may be due to women who had practiced antenatal exercise cannot get challenges in adherence to the advice of health professionals about antenatal exercise. It was found that the practice of antenatal exercise had a significant association with the occupation status of being employed. The antenatal exercise was highly practiced among those women who were employed when compared to the unemployed. This study finding is consistent with the research findings conducted in Zambia [23]. This might be those employed women can easily afford different information sources like TV, radio, smartphone which can help them to have the knowledge and a favourable attitude towards antenatal exercise and its health effects.

The education status of husbands had a statistically significant association with the practice of antenatal exercise. Those women who had husbands with a primary school level were 70% times less likely to practice an antenatal exercise as compared to those women whose husbands had education level of college and above. This might be because highly educated husbands can have a good awareness of the importance of antenatal exercise for women and their foetuses than less educated and uneducated husbands. Therefore, these educated husbands can help their wives to engage in antenatal exercise. In this society, there are unique cultural norms and values such as the respect of husband’s advice by their wives which affects the decisions of women.

Those women who had ever history of miscarriage were less likely to practice antenatal exercise compared to those women who did not have. This might be due to safety concerns since they once had a miscarriage before; more precautions may be taken due to fear of risk (harm) to their foetus. Those women who had inadequate knowledge of antenatal exercise were less likely to practice antenatal exercise when compared to those women with adequate knowledge. This finding was in line with the report of a study done in Gondar town, Northern Ethiopia [16]. This might be due to, the finding of this study revealed that, from total respondents, 53.7% had inadequate knowledge about antenatal exercise. These individuals may not know the benefits of ANEx for themselves and their foetuses. Likewise, women with unfavourable attitudes were less likely to practices antenatal exercise when compared to women having favourable attitudes to practices of antenatal exercise. This finding was in agreement with the report of a study done in Gondar town, Northern Ethiopia [16]. This may be due to the feeling of women towards the benefits and contraindications of ANEx. The finding of this study showed that about 54% of participants had unfavourable attitudes which means they had negative attitudes towards the benefits of ANEx so that they cannot adhere to practices of adequate antenatal exercise.

Strengths and limitations of the study

This study was community-based which can make the findings more generalizable to the pregnant women in the town. It is difficult to establish a temporal relationship as the study design was cross-sectional. Practice evaluation tools need to be observation checklists, but interview questions used to this may reduce the quality and adequacy of participants’ antenatal exercise judgment.

Despite these limitations, the findings from this study will contribute to the understanding of the factors associated with adequate practices of antenatal exercise in the study area.

Conclusion and recommendations

In this study, the adequate practice of antenatal exercises was found to be low. Husband’s primary school level, history of miscarriage, inadequate knowledge, and unfavourable attitude was negatively associated with adequate antenatal exercise whereas, the employment status of women and practice of regular exercise before current pregnancy was positively associated with adequate antenatal exercise. Appropriate measures should be taken to improve the husband’s educational level, mother’s occupation, knowledge, and attitudes towards antenatal exercise. Special consideration should be given to those with a history of miscarriage and women should be encouraged to have practices of regular exercise before pregnancy. And also further study should be conducted by triangulating with a qualitative study.

Questionnaire for the study of factors associated with antenatal exercise in Arba Minch town, Southern Ethiopia.

(DOCX)

Click here for additional data file.

SPSS data set for the study of factors associated with antenatal exercise in Arba Minch town, Southern Ethiopia.

(SAV)

Click here for additional data file.

14 Aug 2021

PONE-D-21-11918

Practice of antenatal exercise and its associated factors among pregnant women in Arba Minch town, Southern Ethiopia: A community based cross-sectional study

PLOS ONE

Dear Dr. Beyene,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Reviewer 2 has indicated a number of points regarding your methods and the presentation of your manuscript that should be addressed. Please attend carefully to each of their points when preparing your revisions.

Please submit your revised manuscript by Sep 23 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see:  http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at  https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Jamie Males

Staff Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information.

3. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For more information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

4. Please include a caption for figure 1.

5. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files

6. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have addressed all the comments. As indicated in my earlier comments, given the paucity of information on prenatal physical activity in Africa, this study would contribute to the body of knowledge on prenatal physical activity and exercise in Africa.

Reviewer #2: Thank you for the opportunity to review this manuscript. The approach is not new, however, it brings data from a population that has been little studied in relation to the practice of PE and with that the material becomes more interesting.

Title – very long - Practice of antenatal exercise and its among pregnant women in Arba Minch town, Southern Ethiopia: A community based cross-sectional study

Suggestion - Factors associated with antenatal exercise in Arba Minch town, Southern Ethiopia: A community based cross-sectional study

Abstract -

I suggest that the results with positive or negative association according to the PE practice be presented separately, both in the results and in the conclusion

Ethics – “informed consent was taken” - Written or verbal? If verbal, how was this obtained and recorded?

Introduction

– please update your data

Reference 3 - according to article - Review of Recent Physical Activity Guidelines During Pregnancy to Facilitate Advice by Health Care Providers. Evenson KR, Mottola MF, Artal R.Obstet Gynecol Surv. 2019 Aug;74(8):481-489. doi: 10.1097/OGX.0000000000000693.

Reference 7 - according to article - Physical Activity Patterns and Factors Related to Exercise during Pregnancy: A Cross Sectional Study. Nascimento SL, Surita FG, Godoy AC, Kasawara KT, Morais SS.PLoS One. 2015 Jun 17;10(6):e0128953. doi: 10.1371/journal.pone.0128953. eCollection 2015.

Method:

Sample size – “adequate practice of 95 antenatal exercise to be 50%” - Very high 50%, what is the reference used?

I also suggest that you include a figure that explains the representativeness of the sample in different districts, sub-districts, this was not made explicit and can be very well explained with a figure or even a map.

Results

– Will the tables not be shown in the results? They are all in the supporting information. I believe it is fundamental to see the numbers of the data presented and the tables must appear in the text, especially 5, 6 and 7 with the analyses.

And it needs to be very clear which associations are positive and which are negative (this in the results, discussion and conclusion)

Discussion

It also needs to contextualize more in the discussion the importance of marriage, education of the woman and the husband in the society where the study was carried out.

And in the limitations, further reinforce the question of the representativeness of the sample, that is, how much it represents the city, region or country where the study was carried out.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

28 Sep 2021

Thank you for your valuable comments to improve this article

Submitted filename: The rebuttal letter to PLOSE ONE.docx

Click here for additional data file.

18 Nov 2021

Factors associated with antenatal exercise in Arba Minch town, Southern Ethiopia: a community-based cross-sectional study

PONE-D-21-11918R1

Dear Dr. Beyene,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Please also note one of the reviewer identified an important text change in the conclusion section (see comments appended below) that you will need to address during our final technical checks

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Dario Ummarino, Ph.D.

Senior Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the quick response. The authors have attended to the comments to my satisfaction. The manuscript can be accepted.

Reviewer #2: The presentation of results at the conclusion of the article is reversed - this needs to be corrected - see-

"Husband’s primary school level, history of miscarriage, inadequate knowledge, and unfavourable attitude was positively associated with adequate antenatal exercise whereas, the employment status of women and practice of regular exercise before current pregnancy was negatively associated with adequate antenatal exercise."

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Prof Daniel Ter Goon

Reviewer #2: No

13 Dec 2021

PONE-D-21-11918R1

Factors associated with antenatal exercise in Arba Minch town, Southern Ethiopia: a community-based cross-sectional study

Dear Dr. Beyene:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Dario Ummarino

Staff Editor

PLOS ONE