Introduction

Physical inactivity (PA) is recognized globally as the fourth leading risk factor for premature death1. It has a short-and long-term risk among women during pregnancy2. Pregnant women who are physically inactive are at higher risk of gestational diabetes, preeclampsia, weight gain, and complications during labor and childbirth3. In addition, a sedentary lifestyle raises the risk of perinatal depression and anxiety4.

According to the American College Obstetricians and Gynecologists, PA has protective effects against the risks of macrosomia, obesity, and other associated cardiometabolic disorders, reduces weight gain and gestational diabetes by 25% during pregnancy5. Pregnancy physical activity (PPA) is mitigate the risk of large newborn, operative and instrumental deliveries, low back pain, perinatal depression, and cesarean section by 15% and coping a labor pain6. It can reduce the risk of pregnancy-related illnesses such as depression by 25% and the risk of developing gestational diabetes, high blood pressure, and preeclampsia by 40%7. In India evidence shows that sedentary lifestyle is a major risk factor for 50% of cesarean deliveries8. A systematic review conducted on randomized controlled trials reported that physical inactivity increases the risk of preeclampsia by 30–33%9. Despite the well-established benefits of PA during pregnancy, some pregnant women and clinicians express concerns about potential fetal risks associated with certain exercise conditions10. Specifically, vigorous PA performed under dehydration, supine position, or during prolonged motionless standing has been scrutinized10.

In Africa, evidence shows that the practice of PPA is low, mainly due to poor knowledge and awareness of its benefits11,12,13,14. For instance, a study in South Africa reported that 46% of pregnant women were physically inactive11. The other study from southwest Ethiopia reported that 76.4% of pregnant women were physically inactive12. While research confirms the health benefits and safety of engaging in physical activity throughout pregnancy for both mother and baby, there is limited knowledge about the physical activity practices among pregnant women in Ethiopia. There are cultural factors that may influence physical activity in women in Ethiopia. For instance, females are seldom allowed to do physical exercise in Ethiopia. They are supposed to stay home, look after children, and take care of household chores15. Pregnant women in Ethiopia is not allowed to engage in demanding indoor and outdoor activities in the current study due to sociocultural factors, misconceptions and traditional beliefs16. Thus far, to our knowledge, there have been no studies examining the associations between physical activity practice and knowledge, attitude, reproductive variables, perception, awareness, perceived benefits and barriers of physical activity. We therefore addressed these issues which is covered a large geographical area and addressed multicenter health facilities of the study. Therefore, this study aimed to assess physical activity practice and its associated factors among pregnant women attending antenatal care (ANC) in public health facilities of Harari Regional State, Eastern Ethiopia.

Methods and materials

Study setting, design, and period

Harari regional state is one of the nine regional states found in Ethiopia. Harar city is the capital of the Harari region found 510 km away from Addis Ababa in the eastern part of the country. The Harari region is the smallest regional state in Ethiopia, with nine Woredas and 36 Kebeles, and 59,487 total households. According to the 2016 Harari Regional Health Bureau report, the region has a total population of 240,000, of those 123,072 are females and 53,383 are women of reproductive age group17. There are two public hospitals, one private Hospital, one military Hospital, and eight public health centers with 1191 health professionals in the region. Antenatal care services (ANC) is provided using 2002 WHO focus ANC model by male or female midwives/clinical nurses in all public health facilities in the region. An institution-based cross-sectional study design was employed among pregnant women attending ANC services in selected public health facilities of the Harari region, eastern Ethiopia, from December 15, 2023 to January 15, 2024.

Study population, sample size and procedure

Based on the 2022 national population census projection, the region has estimated total populations of 276,000, of which 137,000 females and 139,000 males, 72,525 households, 8740 were pregnant women, 38,382 under five children and 8181 under one children. All pregnant women aged 18 years and above were included in the study. However, pregnant women with medical complications or contraindications such as pre-eclampsia, severe anemia, cardiovascular diseases, and women with injuries like limited mobility, and severe mental health conditions that could impede physical activity were excluded from the study18,19. The sample size was computed using the Epi-Info version 7.2, considering the assumption for a single population proportion: a 57.9% proportion of physical activity from a previous similar study in Ethiopia, 95% confidence interval, 5% margin of error, and 10% response rate. The stratified random sampling was used to select the study participants. Accordingly, health facilities were stratified as urban and rural, then 50% of the facilities were selected from each stratum using a lottery method. The total calculated sample size was 435 pregnant women. Finally, study units were selected using a systematic random sampling technique after proportional allocation of sample size to each selected health facility and using the client registration book as a sampling frame.

Data collection methods

Data were collected using structured and pretested questionnaires adapted from the standardized pregnancy physical activity questionnaire (PPAQ) through face-to-face interviews and client medical record reviews20. The questionnaires contain socio-demographic characteristics, reproductive and medical factors, knowledge, attitude and perception towards PPA, and physical activity practice during pregnancy. PPAQ contain thirty-one items grouped into four themes: household, occupational, sports/exercise and transportation, and sedentary activities20.

Physical activity was assessed using a 31-item questionnaire that captured the frequency, duration, and intensity of various activities across four domains: household/caregiving, occupational, leisure, and sedentary activities. Pregnant women were asked to estimate the amount of time spent on each activity per day or per week during pregnancy, with duration ranging from zero to seven days per week.​.

Total physical activity was calculated by summing the product of duration and intensity (in METs) for each reported activity. Activities were classified based on their intensity levels using Metabolic Equivalent of Task (MET) values: sedentary (< 1.5 METs), light (1.6–2.9 METs), moderate (3.0–5.9 METs), and vigorous (≥ 6.0 METs)20.

Total activity was quantified in MET minutes per week and categorized as ‘Good’ or ‘Poor’ based on the median value. Participants with METs scores equal to or above the median (≥ 60.36) were classified as having a ‘good’ level of physical activity21.

Attitude towards pregnant physical activity was measured using 6 items/questions with “yes” and “no” response options. Each response was assigned a score, with higher scores indicating a more positive attitude toward physical activity. A composite index score was calculated by summing the responses across all items. Pregnant women who scored at or above the median of this composite score were classified as having a good attitude22.

The perceived benefit of pregnant physical activity was assessed through 13 items/questions designed to capture the participants’ beliefs about the positive outcomes of physical activity22. Each item used a 5-point Likert scale, with response options ranging from “Strongly agree” to “Strongly disagree,” allowing participants to express the degree of their agreement23. The participant’s response was summed to form a composite score. Accordingly, participants who scored equal to or above the median were categorized as having a good perceived benefit22.

The perceived barrier to physical activity was measured using 8 items/questions that identified participants’ hindered ability to engage in physical activity during pregnancy. Each item was rated on a 5-point Likert scale, with the response range from “strongly agree” to “strongly disagree”. A composite score was calculated by summing the scores of all items, with higher scores indicating a greater perception of barriers toward physical activity. Participants who scored equal to or above the median were categorized as having a good perceived barrier24.

Socio-demographic variables like the study subjects’ age was recorded based on their response, and categorized into 18–24, 25–34, and ≥ 35 years, marital status categorized as married, divorced, and widowed, residence categorized into urban or rural, educational status categorized as no formal education, primary education, secondary education, and diploma and above, occupational status categorized into housewives, employed; governmental or private, unemployed, and merchant, and average monthly income was categorized as ≥ 2800 Ethiopian birr, and < 2800 Ethiopian Birr. Reproductive variables include type of facility where ANC was attended (health center, hospital), pregnancy intention (planned, unplanned), parity (nulliparous, primiparous, multiparous) and abortion history (yes/no). In addition, variables like knowledge, attitude and perception, awareness, perceived benefits and barriers of physical activity were included in the study25,26,27.

Data quality control

The data collection instrument was developed in English, then translated into Afan Oromo and Amharic, and back translated to English to check its consistency. Six midwives with bachelor’s degrees data collectors, and a supervisor (Master of Public Health degree holder), who fluently speak Amharic and Afan Oromo languages were recruited based on their previous experience in data collection.

Training on the data collection process and ethical considerations was given to data collectors, and a pretest was conducted on 5% of the sample size in a separate non-selected facility two weeks before the actual data collection. During this process, inconsistencies in the questionnaire were identified and corrected to minimize potential issues during data collection. The revised questionnaire was then finalized for use in the main study.

The questionnaire was checked for completeness daily during data collection, and errors were corrected on the spot. Routine supervision was carried out daily.

Data processing and analyses

The data was checked for completeness and entered Epi-Data 3.1, and exported to SPSS version 26.0 for analysis. Univariate analysis was employed to describe the outcome and explanatory variables. Multicollinearity was checked using the variance inflation factor (VIF) for independent variables. Bivariate and multivariable binary logistic regression analyses were done to identify factors associated with the practice of physical activity. Independent variables with a P-value < 0.25 in the bivariable analysis were considered for the multivariable analysis model. Adjusted odds ratio (OR) with 95% CI was used to report association, and the significance level was declared at P-value < 0.05.

Ethics approval and consent to participate

The ethical approval was obtained from Haramaya University Institutional Health Research Ethics Review Committee (IHRERC) with reference number (IHRERC/237/2023). All methods were performed in accordance with the relevant guidelines and regulations of the Declaration of Helsinki. Data collectors handled confidentiality and privacy issues using a consent form attached to the questionnaire. Participants’ personal information identifiers, such as names, were not written on the tools during data collection/interview. The study’s purposes, procedures, duration, risks, and benefits were clearly explained to participants before obtaining written informed consent. Informed voluntary written informed consent was obtained from each participant, while those who were not willing to engage in the study at any time were allowed to withdraw.

Consent for publication

Not applicable. This study does not involve the publication of any identifiable patient/participant data or images.

Results

Socio-demographic characteristics

A total of 435 pregnant women participated in the study with the mean (± SD) age of the participants was 26.1 (± 4.6) years and 54.5% of the participants were in the age group of 25–34 years. One in eight participants (12.2%) have never attended formal education and 55.5% of the participants were housewife. More than half of study participants, 52.6% of pregnant women were urban residents, and 90.1% of the participants were married. The median average monthly income of the participants was 2800 (IQR: 1500 4700) Ethiopian birr (Table 1).

Table 1 Socio-demographic characteristics of pregnant women attending ANC at public health facilities in Harari regional state, Eastern ethiopia, 2024 (N = 435).
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Obstetric characteristics and KAP of mothers towards PPA

Around two-thirds of the participants (67.6%) were multiparous and 17.0% have history of abortion. Almost three-fifth (58.4%) of the current pregnancy was unplanned type and 79.3% of participants attended antenatal care at health center. More than half (51.7%) of the study participants heard information about PPA. Nearly three-fifth, (58.6%) of the participants had poor attitudes toward PPA and 50.3% had good perceived benefits towards PPA. More than half, (53.1%) of participants had lower perceived barriers toward PPA (Table 2).

Table 2 Obstetric characteristics and KAP of mothers towards PPA among pregnant women attending ANC at public health facilities in Harari regional state, Eastern ethiopia, 2024 (N = 435).
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Physical activity practice among pregnant women

In the current study, the median of PPA score was 60.36 METs per week (IQR: 38.1, 95.2) with 50.1% (95% CI: 45.5, 54.9) participants scored more than the median (good pregnancy physical activity). Regarding the specific domain of physical activity: 50.1% of the participants scored household activities, 49.0% scored occupational activities and 51.5% scored leisure-time physical activities, and 70.6% of the participants experience light sedentary activities (Fig. 1).

Fig. 1
figure 1

The practice of pregnancy physical activity among pregnant women attending ANC at public health facilities in Harari Region, Eastern Ethiopia, 2024 (N = 435).

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Factors associated with pregnancy physical activity

In the multivariable binary logistic regression analysis, type of facilities attended for ANC, maternal age, current residence and having good perceived benefits were significantly associated with PPA. Accordingly, the odds of PPA were nearly three times (AOR = 2.81, 95% CI: 1.53, 5.16) higher among pregnant women who attended ANC services at the health center compared to those who attended at the hospital. The odds of PPA were two times (AOR = 1.94, 95% CI: 1.24, 3.02) higher among pregnant women in the age group of 25–34 years age groups compared to those aged 18–24 years. The odds of PPA were 85% higher (AOR = 1.85, 95% CI: 1.12, 3.06) among pregnant women residing in the urban area compared to rural dwellers. Currently unmarried women were 2.4 (AOR = 2.35, 95% CI: 1.13, 4.90) times higher the odds of PPA compared to married counterparts. Furthermore, the odds of PPA were nearly five (AOR = 4.78, 95% CI: 3.08, 7.42) times higher among pregnant women who had good perceived benefits toward PPA compared to their counterparts (Table 3).

Table 3 Factors associated with pregnancy physical activity among women attending public health facilities in Harari region, ethiopia, 2024 (N = 435).
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Discussion

The study aimed to assess PPA and its associated factors among pregnant women attending ANC at public health facilities in Harari region of Eastern Ethiopia. The findings revealed that PPA was 50.1% (95% CI: 45.5, 54.9) and maternal age, marital status, health center attending for ANC, place of residence, and beliefs towards PPA were important factors associated with PPA.

The PPA practice in the current study is higher than the pooled meta-analysis and subnational report in Ethiopia which reported the magnitude ranging 20.7–34%16,28,29. The higher level of PA observed in this study may be attributed to the predominance of urban dwelling among the participants, who were likely to have better awareness and knowledge of PPA30. However, the PPA practice in the current study was lower than studies report in Nigeria (84.7%), United Arab Emirates (75%), and India (92.8%)31,32,33.The discrepancy may be due to the difference in sociocultural characteristics, measurement, accessibility to health information, and the dominant housewife participants in the current study12,16,34. Moreover, pregnant women in Ethiopia is not allowed to engage in demanding indoor and outdoor activities in the current study due to sociocultural factors, misconceptions and traditional beliefs23,29,35. For instant, studies in East Africa highlight that cultural beliefs often shape maternal health behaviors, with certain communities perceiving exercise as harmful during pregnancy, potentially impacting the overall level of awareness around antenatal exercise36,37.

In this study, 70.6% of pregnant women engaged in sedentary activities consistent with previous research that highlights low PA levels among pregnant women with 79.3% classified as sedentary12, but higher than a study conducted in Nigeria (49.0%) were sedentary38, pooled meta-analysis shows that half of the studies participants were sedentary behavior39. This findings also align with the previous research that pregnant women often spend more than 50% of their time in sedentary behaviors12. A systematic review highlighted that increased sedentary time during pregnancy is significantly associated with higher levels of C-reactive protein and LDL cholesterol, as well as larger newborn abdominal circumference40. Furthermore, higher sedentary behavior has been linked to shorter gestation periods and inhibited fetal growth41. These findings highlight the importance of physical activity interventions among pregnant women.

The current study also shows that women attending a health center had 2.81 times higher the odds of practicing physical activity compared to those who attending hospital. This finding comparable with the study conducted Uganda that showed women attending antenatal services in primary care settings had higher PA levels due to routine health promotion activities42. Similarly, study conducted in China showed that women visiting primary health facilities were more likely to receive counseling on PA, which increases participation in physical exercise29. While another found that pregnant women attending ANC at health centers had more favorable perceptions of PA compared to those at tertiary hospitals in Nigeria43. This findings highlight that health care workers who work at the hospital should allocate adequate time to counsel pregnant women on maternal health promotion practices. This finding highlight that health center health care workers might be because they have more time to counsel maternal health care of pregnancies and births, therefore they are more experienced in maternal health care services-related matters.

Pregnant women aged 25–34 years had 1.94 times higher odds of physical activity compared to those aged 15–24 years. The finding is consistent with previous studies in Ethiopia, Nigeria, and USA show that 25–34 years were more likely practiced adequate physical activity compared to youths (15–24 years)12,29,44. This might be due to better knowledge, attitude toward physical activities among elders29. A possible reason for age 25–34 years in Eastern Ethiopia, were more engaged in different household and occupational activities during pregnancy compared to youths which are mostly unexperienced and primigravida. The responsibility and social role during this age might also contribute to better physical activity among elder mothers compared to youths12. In Ethiopia, religious belief and culture have an impact on social values. Specifically, it is common to find within a married household that older household members would be expected to manage any household or occupational activities.

Likewise, urban dwellers were 1.85 times higher the odds of practicing PPA compared to rural residents. This is in line with previous study in Ethiopia12. This could be due to better infrastructure, social support, and better environments that offer better conditions and access to PA in urban areas. In addition, urban dwellers have better access to information and health promotion services compared to the rural residents30.

This study found that unmarried pregnant women had 2.35 times higher the odds of engaging in PA compared to married pregnant women. This may be unmarried women having fewer household responsibilities and caregiving duties, allowing more time for physical activity45. Similar studies have been reported in Tanzania and Poland, where unmarried or single women exhibited higher levels of physical activity during pregnancy potentially due to greater autonomy and fewer domestic obligations46. Conversely, studies conducted in Mekelle, Ethiopia, and South Africa have shown that being married is positively associated with physical activity during pregnancy. These discrepancies may be due to differences in educational levels, urban versus rural residency, sociocultural factors, sample sizes, and the assessment tools used across studies12,47.

In the current study, we also found that pregnant women with a good perception of the benefits of physical activity were 4.78 times higher the odds of practicing PPA. Women with better awareness of physical activity can be more motivated to engage in physical activities48. In addition, studies in Australia and Canada revealed, educational interventions that shifts perception can effectively improve physical activity among pregnant women49. This result also aligns with previous findings, indicating that pregnant women generally view physical activity as beneficial, important, and safe in comparison to those who hold negative perceptions14.

Strengths and limitations of the study

This study address physical activity practice among pregnant women, however it is subject to certain limitations it delimits the relevance of its results to only pregnant women who attending antenatal care at public health facilities which cannot be generalized to the all pregnant population of Ethiopia. In addition, the current study did not include important information like dietary habits, preexisting health conditions, and missed in-depth data on cultural norms, family support, and community beliefs, which could influence the PPA. Despite that, data was collected the last seven day of PA using face -to- face interview which prone to recall biases. Finally, the limitation of this study was not observational data.

Conclusions

This study revealed that pregnant women reported low physical activity comparing with WHO recommending at least 150 min of moderate-intensity aerobic physical activity per week during pregnancy. ANC attending at health center, place of residence, marital status, maternal age, and personal beliefs regarding exercise during pregnancy were significantly associated with physical activity. Thus, integrated physical activity counseling should be instituted into Antenatal Care (ANC) Services specifically at the hospital level. Intervention that improve awareness on the benefits of physical activity during pregnancy along with personalized counseling should be considered targeting rural dwellers, married and young age women.