https://doi.org/10.15218/ejnm.2019.14 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article Knowledge and Attitude of Pregnant Women towards Antenatal Exercise in Erbil City ABSTRACT INTRODUCTION Exercise is essential for pregnant women’s health and wellbeing.It is a safe and effec- tive way to gain many physical and mental health benefits,pregnancy is a good time to develop healthy lifestyle habits including regular exercise and good nutrition [1,2,3,4,5]. Improving the quantity and quality of information related to physical exercise has the potential to correct Background and objective: Antenatal exercises provide many health benefits not only to pregnant mothers, but also to the fetuses. In the absence of medical or obstetrical compli- cations, pregnant women are encouraged to continue and maintain active lifestyles during their pregnancies. The objective of this study is to assess knowledge and attitude of preg- nant women towards antenatal exercises. Methods: A descriptive cross -sectional study was conducted to assess mother's knowledge and attitudes regarding exercise during pregnancy. The convenience sample of the study included 100 pregnant women. The study was conducted in Najdi Heydari Health Care Center in Erbil City / Kurdistan region / Iraq from December 2016 to Feb, 2017. Data were collected by interview with the pregnant women. A questionnaire was constructed to collect the data by researchers. A statistical package for social science (SPSS, version20) was used for data analysis the data. All statistical procedures were tested on a probability of P-value was ≤ 0.05 significant. Results: The majority of the study sample had poor overall knowledge regarding antenatal exercises (93%), Interest in attending antenatal exercise classes 80%, the barrier to attend antenatal exercise 79% during pregnancy. There was very highly significant relationship between the pregnant women’s educational level and overall knowledge regarding exer- cise during pregnancy. Conclusion: The knowledge of women about exercise during pregnancy was less than av- erage and women do not believe in the positive effect of exercises during pregnancy. The main reason for poor knowledge was inadequate antenatal exercise education. It is recom- mended that the apply antenatal exercise education teaching program is important to in- crease pregnant women’s knowledge regarding to exercise during pregnancy and change their believe regarding antenatal exercises. Key Words: Pregnancy, Antenatal exercises, Knowledge, Attitude, Assessment Warda Hassan Abdullah; Department of Midwifery, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: warda.abdullah@hmu.edu.krd) Badia Mohammed Najib; Department of Midwifery, College of Nursing, Hawler Medical University, Erbil, Iraq. 108 Erbil Journal of Nursing & Midwifery Received: 30/11/2018 Accepted: 27/8/2019 Published: 30/11/2019 mailto:mailtowarda.abdullah@hmu.edu.krd https://doi.org/10.15218/ejnm.2019.14 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article inaccurate perceptions and confer several benefits on maternal and fetal health. Effective intervention strategies should fo- cus not only on the pregnant woman but also extend to her family, friends and exer- cise provider [3,4]. The American College of Obstetricians and Gynecologists [6] and the American College of Sports Medicine (ACSM) [7] recommend low-impact, mod- erate-intensity and regular exercises for pregnant women irrespective of their phys- ical fitness level for approximately 30 minutes on most days of the week its nec- essary to the mother and fetus. Knowledge regarding benefits and contraindications to antenatal exercise significantly influenced the attitude of the women towards exer- cise in pregnancy. There is sample and con- sistent evidence that promoting physical activity in women of reproductive age may be a promising approach for the preven- tion of excessive weight gain, gestational diabetes mellitus and subsequent compli- cations suffered by children born from pregnancies [8]. Therefore, providing the essential training and an emphasis on the benefits of exercise, decreases the worry of pregnant women about probable adverse effects on the fetus and also with emphasis on this fact that specific exercise during pregnancy with the preparation of the pel- vic floor muscles and the abdominal, pre- pares the mother for the easier vaginal de- livery and without damage to the fetus, also improve mothers' performance for having physical activity [8.9]. And there is some evidence showed that physical activi- ty during pregnancy is linked with a short- en length of labor and reduce delivery complications during delivery, including a diminished need for cesarean section deliv- ery [10,11] exercises throughout pregnancy it can shorten the duration of labor and reduce delivery complications [12, 13]. Now, information shows that for many communities, activity levels are inadequate and many people have adopted a seden- tary lifestyle. Likewise, there is a low level of awareness about exercise during preg- nancy. Many previous studies indicated that information about antenatal exercise is inadequate among pregnant women [14,15,16,17]. This preliminary study assessed the preg- nant women’s knowledge and attitude regarding exercise during pregnancy. For a purpose of developing a prenatal exer- cises program to be implemented in a group of pregnant women to find out the effect of such program on pregnancy out- come. Across-sectional, descriptive study was carried out in Erbil City, Kurdistan region, Iraq from December 1, 2016 to February 30, 2017 with a convenient sample of 100 pregnant women who attended Najdi Heydari Health Care Center, Kurdistan Region, Iraq and agreed to participate in the research. Women with major psycho- logical diseases excluded from the study. The study was approved by the Ethical Committee in the College of Nursing, Hawler Medical University, Registration No:8, 16/ 3/2016 and Directorate of Health No 13203, 25/10/2016, Erbil City. The purpose of the study was explained to all subjects in the study,then informed verbal consents were taken during a re- searcher interview with the pregnant women.,. Data were collected through interview with pregnant women. A ques- tionnaire was constructed to collect the data by researchers, based on the recom- mendations of antenatal exercises by American College of Obstetrics and Gyne- cologists,2015 [6] and other literature review, which included the following vari- ables: pregnant women demographic da- ta, pregnant obstetrical history, knowledge of exercise during pregnancy 109 Erbil Journal of Nursing & Midwifery METHODS https://doi.org/10.15218/ejnm.2019.14 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article percentage (48%) of the study sample their age ranged between 20-25 years and X ± SD 28.79±5.818 and the majority (39%) of them had primary school educa- tion. In addition, the highest percentage (77%) of them were housewives and 93% of the study sample was multigravida Figure 1 shows the highest percentage (93%) of the study sample had poor over- all knowledge regarding antenatal exercis- es during pregnancy. and the last part is the pregnant women’s attitude about the possibility of the ante- natal exercise class during pregnancy peri- od. The response of the knowledge items included two answers 0 = incorrect and 1 = correct. There were 38 questions related to knowledge about exercise (7 items for types of exercise,12 items for benefits,11 items for contraindication, and finally 8 items for discontinuing of exercise during pregnancy). To measure the content valid- ity of the tool, the questionnaire was pre- sented through a panel of 16 experts. The split-half reliability was determined, meas- ured through computation of Pearson Cor- relation Coefficient. The Correlation coeffi- cient was (r = 0.779). Data were prepared, organized and entered into the computer file; a statistical package for social science (SPSS, version 20) was used for data analy- sis the data.Data were analyzed through the application of two approaches, which included: Descriptive data analysis ap- proach (Mean, Standard deviation, fre- quencies and percentage), and inferential statistical analysis. Fisher exact test was used when more than 20% of the cells of the table have expected count less than 5. All statistical procedures were tested on a probability of p-value was ≤ 0.001 very highly significant (VHS), ≤ 0.01 highly sig- nificant (HS), ≤ 0.05 significant (S) >0.05 non-significant (NS). The results of the study showed that 72% of mothers attended primary health care center in the second trimester and 28% in the third trimester of pregnancy. None attended antenatal exercise class during the last pregnancy and 100% of them their activity was at level one activity (only daily activities). Table 1 Shows sociodemo- graphic characteristics of 100 pregnant women. Regarding age group, the highest 110 Erbil Journal of Nursing & Midwifery RESULTS Table 1: Demographic data of the study sample n= 100 Variables F (%) Age (years) ≤20 21 – 25 26 – 30 31 – 35 M ± SD (28.79±5.818) Education level Illiterate Primary Secondary Institute College Occupation Formal employment Privet employment Housewife Student Gravida 1 2-4 ≥ 5 12 48 34 6 18 39 26 8 9 11 9 77 3 3 93 4 (12) (48) (34) (6) (18) (39) (26) (8) (9) (11) (9) (77) (3) (3) (93) (4) https://doi.org/10.15218/ejnm.2019.14 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article Figure 1: Distribution of the study partici- pants by the level of knowledge regarding antenatal exercises n=100 Table 2 shows that the highest percentage (94%), (94%), (94%), (93%) the respectively of the study sample had poor knowledge regarding the types, benefits, contraindica- tions, discontinuity of exercise during pregnancy . Table 3 shows that 79%, 80% of the study sample stated that the barrier to attending antenatal exercise is lack of time and family barriers respectively. Table 4 indicates the relationship between the age group of the study sample with their overall knowledge regarding antena- tal exercise classes during pregnancy, the results of this table show the following: There was no statistically significant rela- tionship between the pregnant women’s age with their overall knowledge regarding exercise during pregnancy. (P< 0.557). Ta- ble 5 indicates the relationship between the educational level of the study sample with pregnant women overall knowledge regarding antenatal exercise classes during pregnancy, the results of this table show the following: There was a very highly sta- tistically significant relationship between the pregnant women’s educational level and overall knowledge regarding exercise during pregnancy, (P <0.000). 111 Erbil Journal of Nursing & Midwifery 0 20 40 60 80 100 Overall Knowledge of exercise during pregnancy Poor Fair Good Table 2: Pregnant women’s knowledge regarding antenatal exercise among study sample n=100 Variables Good Fair Poor Total F (%) F (% ) F (% ) F (%) Types of Exercise 3 (3) 3 (3) 94 (94) 100 (100) Benefits of Exercise 0 (0) 6 (6) 94 (94) 100 (100) Contraindication of Exercise 5 (5) 2 (2) 93 (93) 100 (100) Discontinuity of Exercise 3 (3) 3 (3) 94 (94) 100 (100) Table 3: Attitude of pregnant women towards antenatal exercises Variables Yes No Total 100 F (%) F (%) F (%) Lack of time 79 (79) 21 (21) 100 (100) Harmful the mother 14 (14) 86 (86) 100 (100) Harmful the Fetus 14 (14) 86 (86) 100 (100) Lack of money for transport 8 (8) 92 (92) 100 (100) Family barriers: 80 (80) 20 (200) 100 (100) Lack health services 28 (28) 72 (72) 100 (100) Feels uncomfortable 2 (2) 98 (98) 100 (100) https://doi.org/10.15218/ejnm.2019.14 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article Muhammad (2014) reported that 81.2% of the study sample had inadequate knowledge regarding the effect of exercise during pregnancy [17] and Wijesiriwardana & Gunawardena (2015) showed the major- ity of their study sample had poor knowledge concerning antenatal exercise [16]. pregnant women that involved in this study had poor knowledge about types of antenatal exercises such as walking, leg raising, pelvic floor, and yoga, these results are inconsistent with a study carried out by Chidozie et al. (2014), reported that most of the women had knowledge of pelvic floor exercise, muscle strengthening exer- cise, and relaxation and breathing exercise as types of antenatal exercises [19]. Knowledge was inadequate concerning benefits of exercise among the study sam- ple as (6%) of them stated it reduces the risk of back pain, prevents excessive weight gain. This shows that pregnant 112 Erbil Journal of Nursing & Midwifery *Fisher-exact test was applied Antenatal exercises improve maternal and fetal health and enhance normal delivery. Prenatal exercise is neglected in the Kurdi- stan region community. The antenatal ex- ercise program is not conducted in primary health care centers. The results of the pre- sent study showed that the activity level of all study samples is at level one activity which means only daily activity. And that might due to the attitudes of a community about exercise in general and during preg- nancy specifically. The study showed that knowledge of study sample was very poor as the majority of them had poor overall knowledge and information concerning antenatal exercise, as such services are not available for pregnant women in the gov- ernment agencies. These results are con- sistent with the findings of another study Table 4: Relationship between age groups of the study sample with pregnant women’s overall knowledge regarding antenatal exercises classes n=100 Table 5: Relationship between the educational level of the study sample with pregnant women’s knowledge regarding antenatal exercise class n=100 Variables Illiterate F (%) Primary F (%) Secondary F (%) Institute & College F (%) Total F (%) P-Value Good Fair Poor 0 (0) 0 (0) 18(18) 0 (0) 1(1) 31(31) 0 (0) 0 (0) 26 (26) 0 (0) 6 (6) 11(11) 0(0) 7(7) 93(93) .0..0> Total 18 (18) 32(32) 26(26) 17(17) 100(100) DISCUSSION Variables <20 20 – 25 26 - 30 31 – 35 Total P-Value F (%) F (%) F (%) F (%) F (%) Good Fair Poor 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 3 (3) 1 (1) 7 (7) 0. 577 12 (12) 45 (45) 31 (31) 5 (5) 93 (93) Total 12 (12) 45 (45) 3 4 (34) 6 (6) 100 (100) https://doi.org/10.15218/ejnm.2019.14 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article knowledge about antenatal exercises. These results supported by a study done by Chidozie et al (2014) stated most of the women believe that antenatal exercise re- duces the risk of back pain and prevents excessive weight gain [19]. Regarding con- traindication to antenatal exercise, women in this study had poor knowledge as only (5%) of them stated that vaginal bleeding, uterine contractions, difficulty in breathing, and presence of back pain during pregnan- cy are contraindications to exercise during pregnancy. These results are in agreement with the recommendations of the Ameri- can College of Obstetrician and Gynecol- ogists (2015) and Sujindra et al (2015) [6, 20].Another appealing finding in this study is that they had poor knowledge also re- garding discontinuity of exercise the small percentage of them mentioned the follow- ing factors for discontinuity exercise during pregnancy: vaginal bleeding, regular pain- ful contraction, and amniotic fluid leakage, these factors are reported as well by Amer- ican College of Obstetrician and Gynecol- ogists as a guideline to discontinue exercis- es during pregnancy [6]. The majority of study participants mentioned that exercise is possible during pregnancy. This empha- sizes that women are interested to be in- volved in the antenatal exercise, therefore, it needs to incorporate exercise in prenatal care by health care providers. This result agrees with a study conducted by Watson et al. (2015) and Lovenson et al. (2015), that mentioned 78% of women agreed that most women can continue their regular exercise during pregnancy [18, 21].Women were asked about their interest of involve- ments in antenatal exercise classes. In this study, 80% of pregnant women agreed to attend antenatal exercise classes these re- sults are encouraging to include antenatal exercise in the education program of Pregnant women. The majority of study sample stated the following limitations for attending prenatal exercises lack time 79%, family barriers and childcare activities 80%. These results are consistent with a study conducted by Khatri et al. (2014), men- tioned that most of the study sample they can attend an antenatal education pro- gram once weekly for half an hour [22]. Regarding the association between the age of pregnant women and overall knowledge related to exercise during pregnancy was not statistically significant, these results are consistent with findings of other stud- ies, which showed that no statistically sig- nificant association between age of preg- nant women’s and overall knowledge [15,16,17]. There was a significant relation- ship between the level of education and pregnant women’s overall exercises knowledge during pregnancy this results is agree with the findings of Loveness et al (in 2014), which reported that were signifi- cant associations between adequate knowledge of physical exercise during pregnancy and their education level [21] and also is in agreement with study con- ducted by Atiya & Muhammad in 2014 , who showed that level of knowledge about exercise increase with increasing level of education [22]. Chidozie et al. (2015) re- ported that there was a statistically signifi- cant relationship between the level of edu- cation and women overall knowledge exer- cises during pregnancy [1]. Women’s knowledge about exercise during pregnancy was less than average and women’s responses indicate that they do not believe in the positive effect of exercis- es during pregnancy. The main reason for poor knowledge was inadequate antenatal exercise education. It is recommended that the antenatal exercise education- teaching program is important to increase pregnant women’s knowledge regarding to 113 Erbil Journal of Nursing & Midwifery CONCLUSION https://doi.org/10.15218/ejnm.2019.14 Erbil j. nurs. midwifery, Vol. 2, No. (2), Nov, 2019 Original Article exercise during pregnancy and to change their beliefs regarding antenatal exercise. The authors are thankful for the staff at Najdi Heydari Health Care Center. Materni- ty and Rizgary Teaching Hospitals, Erbil City, Iraq. 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