Addis et al.

BMC Psychology (2022) 10:146

https://doi.org/10.1186/s40359-022-00847-z

RESEARCH Open Access

Physical exercise and its associated

factors among Ethiopian pregnant women:
a cross‑sectional study based on the theory
of planned behavior
Abebaw Addis1, Wallelign Alemnew2*, Ayenew Kassie2 and Simegnew Handebo3

Abstract
Introduction: Women in Ethiopia prefer sedentary behavior and are physically inactive during pregnancy; this
increases the risks of pregnancy-related complications. Therefore, this study aimed to assess physical exercise and its
associated factors among pregnant women attending Antenatal Care at Debermarkose Referral Hospital, Northwest
Ethiopia: using the theory of planned behavior.
Methods: An institution-based cross-sectional study was conducted from 23rd February to 10th June, 2020. A sys-
tematic random sampling technique was used to select 333 study participants. Data were collected with face-to-face
interviews using a pretested structured questionnaire. Epi-info and STATA version 14.0 were used for data entry and
analysis respectively. Multivariable linear regression analysis was done to identify the association between depend-
ent and independent factors, and p < 0.05 was used as a cutoff to determine statistical significance at multivariable
logistics regressions.
Result: A total of 333 pregnant women were participated in this study with response rate of 98%. The proportion
of variance (R2) in intention accounted for the factors was 0.79. The magnitude of intention to do physical exercise
during the current pregnancy was 3.8 ± 2. primary level of education (β = 0.43; 95% CI 0.25, 0.61), 2nd trimester ges-
tational age (β = 0.19; 95% CI 0.04, 0.33), 3rd trimester gestational age (β = 0.17; 95% CI 0.02, 0.32), Attitude (β = 0.34;
95% CI 0.19, 0.49), subjective norm (β = 0.12; 95% CI 0.01, 0.23) and perceived behavioral control (β = 0.45; 95% CI 0.33,
0.57) were significantly associated with pregnant womens’ intention to do physical exercise during pregnancy period.
Conclusion and recommendations: This study provided that the theory of planned behavior could be successfully
applied to identify the factors related to the intention to do physical exercise during pregnancy The program design-
ers who work on pregnancy better consider providing Information education and communication to change the
attitude, work on influencing significant individuals and barriers and enabling factors.
Keywords: Intention, Physical exercise, Theory of planned behavior, Pregnant women

Introduction
Physical exercise during pregnancy is associated with
short and long-term benefits for the mother and fetus [1,
*Correspondence: [email protected] 2]. Healthy pregnant women should follow the Ameri-
2
Department of Health Education and Behavioural Sciences, College can College of obstetrician and gynecologists (ACOG)
of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia and society of obstetrician and gynecologist of Canada
Full list of author information is available at the end of the article

© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​
mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Addis et al. BMC Psychology (2022) 10:146 Page 2 of 9

(SOGC) recommendations that states healthy pregnant Furthermore, the factors that increase or decrease inten-
women should be physically active throughout preg- tions to do physical exercise are not well identified in the
nancy by achieving at least 150 min of moderate inten- study area. Therefore, this study aims to assess the mag-
sity aerobic physical exercise per week to reduce the risk nitude of intention to do physical exercise and its associ-
and acquire benefit from the recommended exercise [3, ated factor among pregnant women who were attending
4]. The risks are pregnancy-induced hypertension, ges- antenatal care at Debermarkose referral hospital based
tational diabetes mellitus, prolonged duration of labor, on the theory of planned behavior.
low back pain, delivering macrosomia baby, influences
on the mode of delivery, and excessive weight gain [5]. Methods
Studies indicated that aerobic exercise reduces the risk of Study design and setting
gestational diabetes millets by 55% throughout the preg- An institution-based cross-sectional study was con-
nancy and 25% during early pregnancy exercise [6–9]. ducted from 23rd February to 10th June 2020 among
Furthermore, aerobic physical exercises during preg- Debermarkose referral hospital of antenatal care atten-
nancy shorten the duration of first stage labor and reduce dant pregnant women. It is situated in the Amhara
Cesarean by 15% [10–12]. National Regional state at 376 km away from Addis
Ethiopia is one of the Sub-Saharan Africa countries that Ababa city in North West direction of the country.
has high maternal mortality ratio (MMR) reported at 412
[13]. Even though the country has in good progress in the Sampling and sample size determination
reduction of maternal mortality rate still it has a wide gap As far as the knowledge of the investigators there was no
as compared to developed countries which are 12 [14]. study conducted in Ethiopia on intention to do physical
In the reduction of maternal complication during preg- activity among pregnant women. Therefore, a pilot study
nancy physical exercise has great importance as the study was conducted to get the standard deviation and mean
confirmed [15]. A study done in Eastern Ethiopia showed intention. The sample size was determined using the sin-
that 16.3% of maternal death during pregnancy is due to gle population mean and double population mean for-
hypertensive disorder of pregnancy [16]. Another study mula as below;
done in Ethiopian urban areas on level and intensity of
physical activity showed that pregnant mothers acquired n = (Zα/2 )2 δ 2
1.46 MET (Metabolic Equivalent) which is considered as d2 = 1.962 × 52 = 323
physically inactive and low as compared to women from
low income countries [17]. Recent studies also show that (0.04 × 13.64)2
novelty-seeking and personality traits are associated with where n = sample size, Zα/2 = 95%confidence level,
higher level of physical activity [18, 19]. δ = standard deviation (5), d = degree of accuracy desired
According to the theory of planned behavior three to set (0.04) and, mean intention (13.64). By adding a
kinds of considerations: beliefs about the likely con- 5% non-response rate the final sample size was 339 par-
sequences of the behavior (behavioral beliefs), beliefs ticipants. Those participants with placenta Previa, pre-
about the normative expectations of others (normative mature rupture of membrane, and pregnancy-induced
beliefs), and beliefs about the presence of factors that hypertension were excluded.
may facilitate or impede performance of the behavior To select a sample of 339 antenatal care attendants
(control beliefs) guide human behavior [20]. In combi- from the total 819 attendants (total number of ANC
nation with those indirect constructs, direct attitude attendants in the Hospital), we assigned a consecutive
toward the behavior, direct subjective norm, and direct number from 1 to N in the ANC registration book. Then
perception of behavioral control lead to the formation of sampling started by selecting an element from the list
a behavioral intention [21]. It has been applied to stud- at random and then every kth element in the frame was
ies of the relations among beliefs, attitudes, behavioral selected, where k was the sampling interval.
intentions and behaviors in various fields [20, 21]. Stud-
ies have also applied the constructs of theory of planned Measurement
behavior model to predict intention to do physical exer- Intention Intention to do physical exercise is the out-
cise during pregnancy, hence attitude, perceived behav- come variable, it is the mother’s readiness to do physical
ioral control and subjective norm had direct relation exercise during the current pregnancy. It was measured
with intention to do physical exercise [22–24]. However, with four items having a five-point Likert scale (Cron-
to date, no research has applied the theory of planned bach’s α = 0.96). The questions were asked like “I intend
behavior model to study the magnitude of pregnant to do physical exercise during the pregnancy period.”
mothers’ intention to do physical exercise in Ethiopia. The responses were 1 “strongly disagree”, 2 “disagree”, 3
Addis et al. BMC Psychology (2022) 10:146 Page 3 of 9

“neutral”, 4 “agree”, and 5 “strongly agree”. The composite of normative belief and motivation to comply [21]. The
score ranged from four to twenty and the high score indi- internal consistency of items was (Cronbach’s α = 0.92).
cate high intention [25]. Indirect Perceived behavioral control It is composed of
Regular physical exercise is an aerobic physical exercise control belief i.e. one’s perception to do physical exercise
that lasts 30 min continuously at least 3 days a week like and perceived power. The questions of control belief were
brisk walking, stationary cycling, and swimming [26]. asked like “how the access of the facilities may affect your
Direct attitude Individual feelings and beliefs about physical exercise during pregnancy. The responses were
physical exercise. It was measured with seven items hav- (1) “not at all”, (2) “not”, (3) “neutral”, (4) “somewhat” and
ing a five- Likert scale (Cronbach’s α = 0.89). The ques- (5) “very much”. And questions of perceived power were
tions were asked, “For me exercising regularly for 30 min asked like “if I feel that I don’t have access of the facilities,
per day at least 3 days a week during my pregnancy will it would be more difficult to do physical exercise. The
be…” The response was 1 “bad” …0.5 “good”. The compos- questions were asked like “I intend to do physical exer-
ite score ranges from seven to thirty five the high score cise during the pregnancy period.” The responses were (1)
indicates a high attitude towards physical exercise [27]. “strongly disagree”, (2) “disagree”, (3) “neutral”, (4) “agree”,
Direct subjective norm Perception of individuals of the (5) “strongly agree”. It was assessed by a total of ten items
social pressure to do physical exercise. It was measured for perceived control and five for perceived power meas-
with five items having five-point Likert scale (Cronbach’s uring items. The final value of the variable was produced
α = 0.95). Subjective norm questions were asked, “Most by computing the sum product of perceived control and
people who are important to me think that I should perceived power [21]. The internal consistency of items
exercise regularly during my pregnancy period”. The was (Cronbach’s α = 0.84).
response was 1 “strongly disagree”, 2 “disagree”, 3 “neu- Knowledge knowledge about physical exercise during
tral”, 4 “agree” and 5 “strongly agree”. The composite score pregnancy was asked with eleven items. The items were
ranges from five to twenty five the higher score indicates developed from works of various literatures [28–31] and
high social influence towards physical exercise [25]. have Cronbach’s α = 0.76 for the internal consistency of
Perceived behavioral control The perceived ability of the items. Each response was valued with “1” for correct
an individual to control factors that influenced physical responses and “0” for incorrect responses. The knowl-
exercise. It was measured with five items having a five- edge score of each individual was obtained by summing
point likert scale (Cronbach’s α = 0.91). The questions up all the ten items and the expected score ranged from
were asked, “For me doing regular physical exercise dur- 0 to 11.
ing my pregnancy is…” The responses were 1 “very dif-
ficult” …0.5 “easy”. The composite score ranges from five Data collection procedure and data quality control
to twenty five and the higher score indicates higher per- The data were collected using a structured, pretested and
ceived ability of individuals to control factors [21, 25]. interview administered questionnaire prepared by the
Previous experience Individuals who have done exercise investigators after reviewing different literatures [14, 21,
during the antenatal period at least once in life time. And 25, 32, 33]. Elicitation study was conducted using semi-
the questions were asked like “have you ever done physi- structured interview to explore relevant salient behavio-
cal exercise during pregnancy period?”. ral belief among the study population towards physical
Indirect Subjective norm It is composed of normative exercise, normative belief that influence them to do or
belief i.e. one’s belief about perceived social pressure to not to do physical exercise and about control beliefs. Six-
do physical exercise and motivation to comply. The nor- teen pregnant women participated in the elicitation
mative questions were asked as “my husband thinks that study. Salient beliefs were identified and the commonly
I should do physical exercise during pregnancy.” The held beliefs were used in the development of the ques-
responses were (1) “strongly disagree”, (2) “disagree”, (3) tionnaire for the main study. The questionnaire was ini-
“neutral”, (4) “agree”, (5) “strongly agree”. And the moti- tially prepared in English and then translated to Amharic
vations to comply questions were asked like “how much (local language) then back to English. Four data collec-
do you care about what your husband think you should tors and one supervisor were recruited from health pro-
do physical exercise during pregnancy?” The responses fessionals holding BSc degree. Content validity test was
were (1) “not at all”, (2) “not”, (3) “neutral”, (4) “somewhat” conducted by participating 6 experts from midwifery,
and (5) “very much”. It was assessed by a total twelve health behavior and Obstetrics and gynecologists. It was
items for normative belief measuring and six motivations determined by Item-level Content Validity Index (I-CVI)
to comply with measuring items. The final value of the of 0.78 or higher, Scale level Content Validity Index by
variable was produced by computing the sum product Universal Agreement (S-CVI/UA) 0f 0.8 or higher and
Addis et al. BMC Psychology (2022) 10:146 Page 4 of 9

Scale level Content Validity Index by Average (S-CVI/ Knowledge towards about antenatal exercise
Ave) 0.9 or higher. The mean knowledge score of the respondents was 5.28
(SD ± 2.38). The majority (81%) of the participants knew
Data processing and analysis that aerobic exercise like brisk walking during pregnancy
Prior to the use of the instrument the reliability analysis prevent excessive weight gain and 90% reduce risk of high
or internal consistency test for the TPB constructs car- blood pressure, and more than half (54%) knew that it
ried out and the result was above 0.7 which is accept- is not recommended for a woman with vaginal bleeding
able (Cronbach’s alpha); it shows how closely related a (Table 2).
set of items are as a group. All collected data was coded,
cleaned and entered in to epi-data version 4.6 and was Obstetric characteristics of women
transferred to SPSS version 20 statistical software for its The majority of the participants 144 (43.2%) were mul-
analysis. Descriptive analysis was used to see frequency tigravida, 101 (30.3%) were multiparous and 88 (26.4%)
distribution, mean and standard deviation. Correla- were primigravida. Most of the respondents were belongs
tion analysis was done between indirect and direct TPB with in third trimester pregnancy 114 (34.2%).
variables in order to see the relation between them. Lin-
ear regression analysis was fitted to test the association Theory of planned variables
between dependent variable and independent variables. The median score of direct attitude, subjective norm and
The assumptions of normality of dependent variable perceived behavioral control was 3.57, 4 and 3.6 respec-
which is intention statistically using skewness and kurto- tively. Indirect measures of theory of planned behavior
sis test i.e., Z value of skewness and it was found to be were assessed and the median score of indirect attitude
between − 1.96 and + 1.96 so that it was normally dis- was 104 ± 83. The median intention was 3.8 ± 2.
tributed. Linearity assumption was checked using scatter
plot of the standardized residuals versus the predicted Correlation of theory of planned behavior variables
values from the regression analysis. Multicollinear- with intention
ity assumptions were tested by variance inflation factor All of the theory of planned behaviour variables had sig-
(VIF) and the value of all variables were below ten. The nificantly correlated with intention at p value of < 0.05.
assumption of outlier was tested using box plot and there Indirect attitude had highest correlation followed by
was no outlier. R ­ 2 was used for the ability of explanatory direct perceived behavioural control. Indirect perceived
variables to explain dependent variables. First all inde- behavioural control had negative correlation with inten-
pendent variables were entered in simple linear regres- tion (Table 3).
sion and those variables whose p value less than 0.2 were
included in multiple linear regressions. Unstandardized β Multiple linear regressions
coefficient was used to interpret the effect of factors asso- The level of education, occupation, experience of regu-
ciated to intention to do physical exercise. Variables with lar exercise, gestational age, knowledge about physical
p value less than 0.05 at 95%confidence interval were exercise and all the direct theory of planned behaviour
considered as statistically significant. variables were with a p value of < 0.2 in simple linear
regression.
Results In multiple linear regression, variables which increased
A total of 333 participants were engaged with a response intention to do physical exercise were identified and
rate of 98.2%. Regarding to the religion, most (73.3%) these were level of education, gestational age, attitude,
were orthodox Christian followers. About one-fourth subjective norm, and perceived behavioural control were
(24%) of the participants had no formal education, and significantly associated variables with intention to do
the majority (90.7%) were resided in urban while 60.7% regular physical exercise with at 95% confidence interval.
were house wife in occupation. Almost all (99.1%) of the The variance explained by intention to do regular
women were married (Table 1). physical exercise from factors was 79%. The standardized
regression coefficient suggested that direct perceived
Physical activity characteristics of pregnant women behavioral control (β = 0.52) was the strongest fac-
About 6.1% had physical activity with the majority tor of intention to do regular physical exercise followed
(95.2%) of participants did brisk walking and the remain- by direct attitude (β = 0.27) and direct subjective norm
ing engaged in jogging. Nearly half (47.6%) reported they (β = 0.11).
engage for 15 min and while most (81%) them engaged in The participant level of education was significantly
physical activity irregularly per week while about 14.3% and positively associated with intention to do regular
did twice a week. physical exercise. Participants who attained primary level
Addis et al. BMC Psychology (2022) 10:146 Page 5 of 9

Table 1 Sociodemographic characteristic of pregnant women in Debermarkose referral hospital, North West, Ethiopia 2020 (n = 333)
Variable Category Frequency (n) Percentage (%)

Age < 25 63 18.92

25–35 222 66.67
35 and above 48 14.41
Marital status Married 330 99.1
Divorced 1 0.3
Widowed 2 0.6
Level of education No formal education 25 7.5
Primary level 84 25.2
Secondary level 128 38.4
College and above 41 12.3
Husbands level of education No formal education 80 24.02
Primary level 42 12.7
Secondary level 99 29.9
College and above 112 33.8
Residence Urban 302 90.7
Rural 31 9.3
Orthodox Christian 244 73.3
Religion Muslim 47 14.1
Protestant 42 12.6
Occupation of women House wife 202 60.7
Daily laborer 40 12
Merchant 57 17.1
Government employee 34 10.2
Husband’s occupation Daily laborer 95 28.5
Merchant 84 25.2
Farmer 45 13.5
Government employee 107 32.1
Monthly family income ≤ 2000 131 39.3
2001–5000 130 39.0
≥ 5001 72 21.6

Table 2 Knowledge of pregnant mothers towards aerobic exercise (brisk walking for 30 min per day at least 3 days in a week during
pregnancy) in Debermarkose referral hospital, North West, Ethiopia 2020
Answer (yes) Frequency Percent (%)

Reduces back pain Yes 94 28.2

Prevents excessive weight gain Yes 270 81
Reduces risk of high blood pressure Yes 304 91.2
Reduces risk of gestational diabetes Yes 205 61.5
Reduces the likely hood of cesarean section delivery Yes 59 17.7
Helps more rapid recovery after delivery Yes 59 17.7
Aerobic exercise (brisk walking) is not recommended for woman
with-------?
Vaginal bleeding during pregnancy Yes 180 54
Severe anemia during pregnancy Yes 264 79.2
Uncontrolled type 1 DM during pregnancy Yes 37 11.1
Uncontrolled hypertension during pregnancy Yes 29 8.7
Severe head ache Yes 260 78
Addis et al. BMC Psychology (2022) 10:146 Page 6 of 9

Table 3 Correlation of theory of planned behavior variables with intention

I DATT​ DSN DPBC IDATT​ ISN IPBC

I
DATT​ 0.75* 1
DSN 0.76* 0.81* 1
DPBC 0.78* 0.83* 0.85* 1
IDATT​ 0.79* 0.78* 0.78* 0.82* 1
ISN 0.67* 0.75* 0.83* 0.79* 0.71* 1
IPBC − 0.16* − 0.27* − 0.21* − 0.28* − 0.23* − 0.19* 1
I intention, IDATT​ indirect attitude, DATT​direct attitude, ISN indirect subjective norm, DSN direct subjective norm, IPBC indirect perceived behavioral control, DPBC
direct perceived behavioral control
* Significant at a p-value less than 0.05

education (1–8) were 0.43 (B = 0.43:95% CI 0.25–0.61) and what types of exercises are recommended. Therefore,
times more likely to increase intention than those with they might plan to do exercise to gain the above benefits
no formal education provided that other variables are and avoid the risks [36, 37].
constant. Moreover, the intention of mothers in second Our study found that gestational age is a significant
and third trimester increased by 0.19 (B = 0.19; 95% CI associated factor of intention to do physical exercise. Par-
0.04–0.33) and 0.17 (B = 0.17; 95% CI 0.02–0.32) than ticipants in second and third trimesters had increased
those mothers in first trimester. intention than those in first trimester. It is supported by
For a score increase of direct attitude, intention to do a study conducted in Brazil [38]. Most pregnancy related
regular physical exercise increased by 0.34 (B = 0.34; complications such as gestational hypertension, Gesta-
95% CI 0.19–0.49). A positive score increase in direct tional DM and fear of labor complications occurred in
perceived behavioral control could result in increase of the second and third trimesters so that pregnant women
intention to do physical activity by 0.45 (B = 0.45; 95% may engage in physical exercise to prevent those com-
CI 0.33–0.57). For a positive unit increase in a subjec- plications [37, 39]. Furthermore, pregnant mothers gain
tive norm could result increase of intention to do regular weight in these trimesters and health professionals could
physical exercise by 0.12 (B = 0.12; 95% CI 0.01–0.023) recommend them to do physical activity during antena-
(Table 4). tal visits [40]. Therefore, program planners who work on
pregnancy, better to focus on second and third trimesters
to increase physical exercise.
Discussion This study revealed that perceived behavioral control
This study assessed intention to do physical exercise and is an associated factor of intention to do regular physi-
associated factors among pregnant women attending cal exercise. This is supported with a study done in Tai-
ANC at Debermarkose referral hospital using the theory wan [41]. This is because of pregnant mothers who are
of planned behavior. The participants’ level of education, confident, wanted doing regular physical exercises are
gestational age and theory of planned behavior variables more intended. This suggests that encouraging pregnant
such as perceived behavioral control, attitude and sub- mothers to aim for doing regular physical exercise should
jective norm were associated variables of intention to do involve consideration of doing regular exercise is under
physical exercise among pregnant women. The current their control that means when a pregnant mother able
study revealed that the mean value of intention to do reg- to overcoming barriers to do physical exercise like time
ular physical exercise was 3.8. It suggested that the aver- constraint, fear of injury, fear of miscarriage may lead to
age intention to do physical exercise was almost agreeing. increased intention to do regular exercise. This finding is
This finding is supported by other study [34]. supported by Ajzen’s theoretical assumption; the more
This study showed that participants’ level of education pregnant mothers have a high degree of control over fac-
is an important associated factor of intention to do exer- tors that facilitate or imped them made easy to perform
cise regularly. This finding is consistent with studies con- what they want [25].
ducted in the Tigray region of Ethiopia and India [35]. It Attitude was a positively associated with intention
might be due to that those individuals with higher level of to do regular physical exercise. The finding is consist-
education have better health literacy regarding the ben- ent with previous studies conducted on intention to do
efits of exercise during pregnancy, and knew how to do physical activity [27, 42]. This is because of individuals
Addis et al. BMC Psychology (2022) 10:146 Page 7 of 9

Table 4 Multiple linear regression of intention to do regular Taiwan [41]. This implies that the decision to do physical
physical exercise and associated factor among pregnant mothers exercise is made not only by the individuals themselves
in Debermarkose referral hospital, 2020 but also influenced by them significant others such as
Variable β Β p value 95% CI for B families, friends, health professionals, spouse and neigh-
bors. As a result interventions to improve doing regular
Education level exercise among pregnant women should target those
No formal education (ref ) important others as a whole rather than focusing only on
Primary level 0.19 0.43 < 0.01* 0.25 0.61 pregnant mothers [25].
Secondary level 0.09 0.21 0.05 − 0.01 0.41
College and above 0.06 0.18 0.35 − 0.20 0.58
Residence Limitations of the study
Urban (ref ) Since the data was from self-report there could be the
Rural 0.03 0.16 0.17 − 0.06 0 .38 probability of the occurrence of recall and social desira-
Participants occupation bility bias. Furthermore, due to the cross-sectional nature
House wife (ref ) of the study, it doesn’t show cause and effect relationship.
Daily laborer − 0.05 − 0.05 0.08 − 1.46 0.08
Recent studies showed that personality trait has an effect
Merchant − 0.05 − 0.05 0.16 − 1.19 0.19
on intention to do physical exercise so future researchers
Government employee 0.01 0.01 0.92 − 1.42 1.59
better to incorporate personality trait as an explanatory
Experience of exercise
variable.
No (ref )
Yes − 0.06 − 0.05 0.718 − 0.34 0.23 Conclusion
Gestational age Theory of planned behavior could be successfully applied
First trimester (ref ) to determine the associated factors of intention to do
Second trimester 0.08 0.19 0.01* 0.04 0.33 physical exercise during pregnancy. Factors of intention
Third trimester 0.17 0.17 0.02* 0.02 0.32 to do regular physical exercise were direct perceived
Gravidae behavioral control, direct attitude, direct subjective
One (ref ) norm, participants level of education, and gestational
Two to four 0.12 0.26 0.32 − 0.26 0.78 age. Therefore, information education and communica-
Above four 0.17 0.38 0.17 − 0.17 0.94 tion is required to bring favorable attitude, to reduce per-
Parity ceived berries and interventions should also consider the
None (ref ) mother, friend, spouse and health professionals who had
One − 0.12 − 0.39 0.15 − 0.94 0.15 influence to her decision.
Two and above − 0.16 − 0.34 0.21 − 0.87 0.19
Knowledge 0.02 0.1 0.35 − 0.02 0.04
Abbreviations
TPB variables ACOG: American college of obstetrician and gynaecologists; AOR: Adjusted
Attitude 0.27 0.34 < 0.01* 0.19 0.49 odds ratio; ATT​: Attitude; CI: Confidence interval; DM: Diabetic mellitus; I: Inten-
tion; MET: Metabolic equivalent; MMR: Maternal mortality ratio; PBC: Perceived
subjective norm 0.11 0.12 0.03* 0.01 0.23
behavioral control; SN: Subjective norms; SOGC: Society of Obstetrician and
perceived behavioral 0.52 0.45 < 0.01* 0.33 0.57 Gynecologist of Canada; TPB: Theory of planned behaviour; WHO: World
control Health Organization.
* Significant at a p-value less than 0.05
Acknowledgements
We would like to forward our heartfelt gratitude to the University of Gondar
College of Medicine and Health Sciences Institute of Public Health for provid-
who believe that regular physical exercises reduce gesta- ing us ethical clearance and help us to conduct research. In addition, we
tional DM, pregnancy induced hypertension and prevent would like to thank Debermarkose referral Hospital administrative staffs for
their kind cooperation. Finally, we would like to acknowledge study partici-
miscarriage are more probable to have favorite feeling pants, data collectors and supervisors for their time and contribution to this
towards physical activity and plan to do it [23, 43]. In work.
addition, the finding is supported by the elicitation study
Author contributions
done to formulate the indirect attitude. Thus, formation All authors made substantial contributions to conception and design, acquisi-
positive attitude of pregnant mothers could increase the tion of data, or analysis and interpretation of data; took part in drafting the
physical exercise behavior. article or revising it critically for important intellectual content; agreed to sub-
mit to the current journal; gave final approval of the version to be published;
The current study found that subjective norm was a and agree to be accountable for all aspects of the work. All authors read and
positively associated with intention to do regular physical approved the final manuscript.
exercise. This is consistent with a research conducted in
Addis et al. BMC Psychology (2022) 10:146 Page 8 of 9

Funding meta-analysis Submit your next paper to pregnancy associated transient

The authors have received funds from Amhara National Regional Health osteoporosis of the hip (PR-TOH): a non—obstetric indi. Eur J Obstet
Bureau for this research work. However, the funder has no any impact on Gynecol Reprod Biol. 2021;262:1–3.
conception and design, acquisition, or analysis and interpretation of data. 11. Domenjoz I, Kayser B, Boulvain M. Effect of physical activity during preg-
nancy on mode of delivery. Am J Obstet Gynecol. 2014;211(4):401e.1-
Availability of data and materials 401e.11. https://​doi.​org/​10.​1016/j.​ajog.​2014.​03.​030.
The datasets used and/or analyzed during the current study are available from 12. Perales M, Calabria I, Lopez C, Franco E, Coteron J, Barakat R. Regular
the corresponding author on reasonable request. exercise throughout pregnancy is associated with a shorter first stage of
labor. Am J Heal Promot. 2016;30(3):149–54.
13. Broussard NH, Page J, Tekleselassie TG, Ferede T, Reda HT. Ethiopia. Youth
Declarations and employment in sub-Saharan Africa: working but poor. 2014, p.
163–231.
Ethics approval and consent to participate 14. Alkema L, Chou D, Hogan D, Zhang S, Moller A-B, Gemmill A, et al.
Ethical clearance was obtained from Ethical Review Committee of Institute of National, regional and global levels and trend in MMR between 1990 and
Public Health, Collage of Medicine and Health Sciences, University of Gondar 2015. Lancet. 2016;387(10017):462–74.
with Ref No/IPH/838/06/2012. Written cooperation letter also obtained from 15. Sanabria-Martínez G, Poyatos-León R, Notario-Pacheco B, Álvarez-Bueno
Debermarkose referral hospital to conduct interview from the participants C, Cavero-Redondo I, Martinez-Vizcaino V. Effects of physical exercise
and to facilitate the research processes. All the study participants were fully during pregnancy on mothers’ and neonates’ health: a protocol for an
informed about the purpose of the study, their right to refuse, assurance of umbrella review of systematic reviews and meta-analysis of randomised
confidentiality and privacy during interview. Informed, voluntary and written controlled trials. BMJ Open. 2019;9(9):1–7.
consent was obtained from each participant before data collection. Strict 16. Smith R, Assefa N, Loxton D, Chojenta C, Tesfaye G. Magnitude, trends and
confidentiality was maintained through anonymous recording and coding of causes of maternal mortality among reproductive aged women in Kersa
questionnaire. And all necessary methods were carried out in accordance with health and demographic surveillance system, eastern Ethiopia. BMC
the guidelines of institutional and Declaration of Helsinki. Womens Health. 2018;18(1):1–10.
17. Hjorth MF, Kloster S, Girma T, Faurholt-Jepsen D, Andersen G, Kæstel P,
Consent for publication et al. Level and intensity of objectively assessed physical activity among
Not applicable. pregnant women from urban Ethiopia. BMC Pregnancy Childbirth.
2012;12(154):1–8.
Competing interests 18. Khosravi M. Burnout among Iranian medical students: prevalence and its
The authors declare that they have no competing interests. relationship to personality dimensions and physical activity. Eur J Transl
Myol. 2021;31(1):318–24.
Author details 19. Khosravi M, Mirbahaadin M, Kasaeiyan R. Understanding the influence of
1
Amhara Regional State Health Bureau, Bahir Dar, Ethiopia. 2 Department high novelty-seeking on academic burnout: moderating effect of physi-
of Health Education and Behavioural Sciences, College of Medicine and Health cal activity. Eur J Transl Myol. 2020;30(2):318–24.
Sciences, University of Gondar, Gondar, Ethiopia. 3 School of Public Health, 20. Viswanath kgbkrk. Health and health. 2008, p. 1–590.
Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia. 21. Ajzen I. Constructing a theory of planned behavior questionnaire.
Biofeedback and selfregulation [Internet]. 2010;17(March):1–7. Available
Received: 16 December 2021 Accepted: 6 May 2022 from: http://​www.​people.​umass.​edu/​aizen/​tpb.​html.
22. Mummery WK, Spence JC, Hudec JC. Understanding physical activity
intention in Canadian school children and youth: an application of the
theory of planned behavior. Res Q Exerc Sport. 2000;71(2):116–24.
23. Poobalan AS, Aucott LS, Clarke A, Smith WCS. Physical activity attitudes,
References intentions and behaviour among 18–25year olds: a mixed method study.
1. Barsky E, Smith T, Patricios J, Collins R, Branfield A, Ramagole M. South BMC Public Health. 2012;12(1):1.
African sports medicine association position statement on exercise in 24. Wing Kwan MY, Bray SR, Martin Ginis KA. Predicting physical activity of
pregnancy. SAJSM. 2012;24(2):69–71. first-year university students: an application of the theory of planned
2. Abbasi M, Van Den Akker O. Journal of reproductive and infant A behavior. J Am Coll Heal. 2009;58(1):45–55.
systematic review of changes in women’s physical activity before and 25. Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process.
during pregnancy and the postnatal period. J Reprod Infant Psychol. 1991;50(2):179–211.
2015;2015(33):325–58. 26. Gerrard J. Exercise during pregnancy. Br J Midwifery. 2020;28(7):450.
3. AGOC. Physical activity and exercise during pregnancy and the postpar- 27. Hamilton K, Fleig L, Henderson J, Hagger MS. Being active in pregnancy:
tum period. Am J Obs Gynecol. 2020;135(804):178–88. theory-based factors associated with physical activity among pregnant
4. Mottola MF, Davenport MH, Ruchat S, Davies GA, Poitras VJ, Gray CE, et al. women. Women Heal. 2019;59(2):213–28. https://​doi.​org/​10.​1080/​03630​
2019 Canadian guideline for physical activity throughout pregnancy. Br J 242.​2018.​14528​35.
Sport Med. 2019;52:1339–46. 28. Ribeiro CP, Milanez H. Knowledge, attitude and practice of women in
5. Hinman SK, Smith KB, Quillen DM, Smith MS. Exercise in pregnancy: a Campinas, São Paulo, Brazil with respect to physical exercise in preg-
clinical review. Sports Health. 2015;7(6):527–31. nancy : a descriptive study. Reprod Health. 2011;8(31):1–7.
6. Mishra S, Kishore S. Effect of physical activity during pregnancy on gesta- 29. Alvis ML, Morris CE, Garrard TL, Hughes AG, Hunt L, Koester MM, et al.
tional diabetes mellitus. Indian J Endocrinol Metab. 2018;22(5):661–71. Educational brochures influence beliefs and knowledge regarding exer-
7. Poston L. Do physical activity interventions prevent gestational diabetes? cise during pregnancy: a pilot study. Int J Exrcise Sci. 2019;12(15):581.
BJOG Int J Obstet Gynaecol. 2015;122(9):1175. 30. Sujindra E, Bupathy A, Suganya A, Praveena R. Knowledge, attitude, and
8. Tobias DK, Zhang C, Van Dam RM, Bowers K, Hu FB. Physical activity practice of exercise during pregnancy among antenatal mothers. Int J
before and during pregnancy and risk of gestational diabetes mellitus: a Educ Psychol Res. 2015;1(3):234–7.
meta-analysis. Diabetes Care. 2011;34(1):223–9. 31. Watson ED, Oddie B, Constantinou D. Exercise during pregnancy: knowl-
9. do Nascimento GR, Borges MC, Figueiroa JN, Alves LV, Alves JG. Physical edge and beliefs of medical practitioners in South Africa: a survey study.
activity pattern in early pregnancy and gestational diabetes mellitus risk BMC Pregnancy Childbirth. 2015;15(245):1–7.
among low-income women: A prospective cross-sectional study. SAGE 32. Lee CF, Chiang IC, Hwang FM, Chi LK, Lin HM. Using the theory of Planned
Open Med. 2019. https://​doi.​org/​10.​1177/​20503​12119​875922. behavior to predict pregnant women’s intention to engage in regular
10. Di Girolamo R, Galliani C, Buca D, Liberati M, Antonio FD, Quaresima exercise. Midwifery. 2016;42:80–6. https://​doi.​org/​10.​1016/j.​midw.​2016.​
P, et al. Log in Outcomes of second stage cesarean section follow- 09.​014.
ing the use of a fetal head elevation device: a systematic review and
Addis et al. BMC Psychology (2022) 10:146 Page 9 of 9

33. Adeniyi AF, Ogwumike OO. Physical activity and energy expenditure:
findings from the Ibadan pregnant women’s survey. Afr J Reprod Health.
2014;18(2):117–26.
34. Hausenblas H, Downs DS, Giacobbi P, Tuccitto D, Cook B. A multilevel
examination of exercise intention and behavior during pregnancy. Soc
Sci Med. 2008;66(12):2555–61.
35. Gebregziabher D, Berhe H, Kassa M, Berhanie E. Level of physical activity
and associated factors during pregnancy among women who gave birth
in Public Zonal Hospitals of Tigray. BMC Res Notes. 2019;12(1):1–6. https://​
doi.​org/​10.​1186/​s13104-​019-​4496-5.
36. Muñoz-Galiano IM, Connor JD, Gómez-Ruano MA, Torres-Luque G. Influ-
ence of the parental educational level on physical activity in schoolchil-
dren. Sustain. 2020;12(9):1–11.
37. Ghodsi Z, Asltoghiri M. Does exercise training during pregnancy affect
gestational age and gestational weight gain? Procedia Soc Behav Sci.
2011;2012(31):418–22.
38. Nascimento SL, Surita FG, Godoy AC, Kasawara KT, Morais SS. Physical
activity patterns and factors related to exercise during pregnancy: a cross
sectional study. PLoS ONE. 2015;10(6):1–14.
39. Wojtyła C, Ciebiera M, Wojtyła-Buciora P, Janaszczyk A, Brzęcka P, Wojtyła
A. Physical activity patterns in third trimester of pregnancy—use of preg-
nancy physical activity questionnaire in Poland. Ann Agric Environ Med.
2020;27(3):388–93.
40. Poote A, McKenzie-McHarg K. Antenatal care. Cambridge handbook of
psychology, health and medicine. 3rd ed. Cambridge: Cambridge Univer-
sity Press; 2019.
41. Newham JJ, Allan C, Leahy-Warren P, Carrick-Sen D, Alderdice F. Intentions
toward physical activity and resting behavior in pregnant women: using
the theory of planned behavior framework in a cross-sectional study.
Birth. 2016;43(1):49–57.
42. Rauff EL, Downs DS. A prospective examination of physical activity pre-
dictors in pregnant women with normal weight and overweight/obesity.
Women’s Heal Issues. 2018;28(6):502–8. https://​doi.​org/​10.​1016/j.​whi.​
2018.​09.​003.
43. Magro-Malosso ER, Saccone G, Di Tommaso M, Roman A, Berghella V.
Exercise during pregnancy and risk of gestational hypertensive disorders:
a systematic review and meta-analysis. Acta Obstet Gynecol Scand.
2017;96(8):921–31.

Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in pub-
lished maps and institutional affiliations.

Ready to submit your research ? Choose BMC and benefit from:

• fast, convenient online submission

• thorough peer review by experienced researchers in your field
• rapid publication on acceptance
• support for research data, including large and complex data types
• gold Open Access which fosters wider collaboration and increased citations
• maximum visibility for your research: over 100M website views per year

At BMC, research is always in progress.

Learn more biomedcentral.com/submissions