Introduction:
Maternal health as an important public health problem globally speaking and the reduction of maternal mortality ratios by three quarters by 2015 has been set as a target for the Millennium Development Goal 5.[1] A recent WHO report on ‘Trends in Maternal Mortality 1990-2014’ revealed that in India the Maternal Mortality Rate (MMR) was reported as 196 maternal deaths per 100, 000 live births during the period 2010-14.[2] Health care interventions by adequate referrals to other health teams are the key to reduce MMR. Antenatal services are amongst the major interventions aimed at reducing maternal and newborn deaths worldwide. Quality antenatal interventions should address common pregnancy-related complaints and also the importance of guided antenatal exercises during pregnancy should be stressed as these provide safe motherhood and improve neonatal outcomes.[3]
Physiotherapy as a profession is concerned with identifying and maximizing the quality of life and movement potential within the spheres of promotion, prevention, treatment/intervention, and rehabilitation (World Confederation of Physical Therapy, WCPT, 1999).[4] Physiotherapy plays an essential role in obstetrics both in the antenatal and postnatal periods. These antenatal exercises focus on maintaining physical fitness and cardiovascular endurance in those who undertake to perform them. The exercises include as aerobics, core stability, pelvic floor exercises, breathing exercises, postural education and back care. Studies have shown that regular, low-impact, moderate intensity exercises help to prevent excessive weight gain, preterm labor and gestational diabetes, and promote stress tolerance and neuro-behavioural relaxation in the growing foetus and postnatal recovery of the mother.[5-8]
Although physical exercise programs for pregnant women are recommended and are steadily increasing in popularity, myriad factors predispose pregnant women to eschew exercise engagement or generate phobia among them. Some of these factors include knowledge and perception with respect to exercise in pregnancy, level of education, race/ethnicity.[9,10] There have been studies in various countries, both developed and developing, which assess the knowledge of the benefits of these exercise in pregnant women.[11-15] Despite these beneficial effects pregnant women do not take up exercise as prescribed, especially in developing countries. In fact, their low level of education, adverse socio-economic conditions, lack of access to good health facilities and fears about exercise during pregnancy often lead to sedentary lifestyle during pregnancy.[15]
A preventive maternal health care service such as physiotherapy as a part of antenatal care can provide optimal benefits for both mother and fetus during pregnancy. Hence this current study aim at exploring the knowledge and perception among pregnant women from India about physiotherapy interventions in antenatal care.
Methodology
Ethical approval for the study was obtained from the Institutional Ethics Committee of Kasturba Medical College, Mangalore, Manipal University, India.[IEC KMC MLR 12-14/294] In this cross -sectional study, a convenience sample of one hundred and six pregnant women were enrolled from the rosters of KMC hospitals, Mangalore from December 2014 to Febuary 2015. The participants who were presenting themselves for regular antenatal check-ups in the Department of Obstetrics and Gynecology were selected on the basis of normal pregnancy. They were aged between 18 – 40 years in any trimester and were able to understand and read either English or Kannada.
The sample size was calculated with the anticipated level of knowledge of pregnant women at 50%, 20% relative precision, 90% confidence interval and 10% non-response error. The sample size was estimated to be 106 women.
Study Instrument: The modified self-administered study instrument was a questionnaire adapted from a previous study by M Sarfaraz et al.[15] The questionnaire was based on close-ended questions and information which included basic demographic data, knowledge of physiotherapy and questions regarding prescription, types, safety measures and the effects of antenatal exercise following pregnancy. The designed questionnaire was content validated by expert’s reviews in a pilot study. The questionnaire was also translated into Kannada and reviewed by language experts. To check reliability of both English and Kannada questionnaires, these were assessed by a test retest method by distribution among 10 pregnant women and the results yielded an agreement of 89.3 to 99.2%, the intraclass coefficient was 0.945 between the raters for all the items in the questionnaire. Pregnant women who were not literate in either English or Kannada were excluded from the study.
Informed consent of all the respondents was obtained from the interested participants. The validated study questionnaire was given to participants on the basis of the language preferred. To fulfil the sample size a total of 165 respondents were collected as 59 samples had a response rate less than 70%. Finally 106 samples satisfying the inclusion criteria with more than 90% response rate were taken for data analysis.
Data analysis
A statistical package for Social Science Software Version 13.0 for Windows was used for analysis. Descriptive statistics of mean and standard deviation, frequencies and percentage were analyzed for demographic and other variables related to attitude, knowledge, and perception about exercises. Inferential statistics of the Chi square was used to determine any association between level of knowledge of antenatal exercises and the respondent’s characteristics. Alpha level was set at .05.
Results
One hundred and six respondents participated in this study. 83% of the respondents were above 25 years of age; 45% had completed graduation/ post-graduation. Their socio-economic status was assessed on the Kuppuswamy scale [16] and it was found that 34% of our respondents belonged to the upper and 66% were middle class. The responses of the participants on parity revealed that the majority of them (58%) were multiparous. The sociodemographic characteristics of respondents are presented in Table 1.
Table 1: Socio-Demographic Characteristics of Participants (n=106) |
| Variable |
Frequency |
Percentage |
Age |
<25 years |
18 |
17 |
25 and above |
88 |
83 |
Educational level |
High School Certificate |
24 |
23 |
Intermediate / Post High School diploma |
33 |
31 |
Graduate / Post- graduate |
49 |
46 |
Occupation |
Unemployed |
30 |
28 |
Semi professional |
38 |
36 |
Professional |
38 |
36 |
Socio economic status |
Upper |
36 |
34 |
Middle |
70 |
66 |
Parity |
Primiparous |
45 |
42 |
Multiparous |
61 |
58 |
The set of questions was designed to check the respondent’s knowledge and perception of and attitude towards the role of physiotherapy in antenatal care. 73% of our study participants were aware of physiotherapy and 70% of the respondents knew that physiotherapy is mainly concerned with exercises. When the respondents were asked about antenatal exercises only 46% of them knew about antenatal exercises. Family and friends (40%) were the main source for their information about antenatal exercises. It was also found that 46% of them were of the opinion that physiotherapists were best fit to prescribe exercises. The respondents had a knowledge of aerobics (28%), back care exercises (20%), abdominal exercises (21%), pelvic floor exercises (13%), relaxation and breathing exercise (21%), respectively, as types of antenatal exercise. However majority of available respondents (80%) were not aware of or not sure about the efficacy of different types of antenatal exercises available.(Table 2)
Table 2: Awareness of Participants towards Physiotherapy, Antenatal classes and Exercises |
| Variables |
Responses |
Frequency |
Percentage |
Are you aware of Physiotherapy? |
Yes |
77 |
73 |
No |
29 |
27 |
| What is your perception of physiotherapy? |
Exercises |
55 |
70 |
Massage |
08 |
11 |
Electrical Stimulation |
06 |
08 |
All |
08 |
11 |
Are you aware of antenatal exercises? |
Yes |
49 |
46 |
No |
57 |
54 |
|
|
|
|
If YES, where did you learn about it? |
Family/Friend |
20 |
41 |
Media |
15 |
31 |
Health Care Centers |
05 |
10 |
At Antenatal class |
04 |
08 |
Other |
05 |
10 |
Who can serve as the best guide to Exercises during pregnancy? |
Physiotherapist |
49 |
46 |
Gynecologist |
43 |
41 |
Self |
08 |
08 |
Other |
06 |
06 |
Awareness of different types of Antenatal Exercises |
Yes
n (%) |
No
n (%) |
Not Sure
n (%) |
Aerobics |
30 (28) |
54 (51) |
22 (21) |
Back Care Exercises |
21 (20) |
61 (58) |
24 (23) |
Abdominal Exercises |
22 (21) |
61 (58) |
23 (22) |
Pelvic Floor Exercises |
14 (13) |
69 (65) |
23 (22) |
Relaxation /Breathing Exercises |
22 (21) |
65 (61) |
19 (18) |
In our study only 15% participants reported that they were referred for physiotherapy by their health care professionals and the majority of references were for back care. Regarding their present exercise routine, 22% of the respondents stated that they continued to perform exercises during pregnancy, walking being the main type of exercise. Respondents also admitted that a lack of time was the main reason for the cessation of their current practice of performing exercises. (Table 3)
Table 3: Practice Patterns for Antenatal References and Physical Activity among Participants |
| Variable |
Responses |
n (%) |
Has physiotherapy for antenatal exercises been prescribed during the present pregnancy? |
Yes |
15 (14) |
No |
91 (86) |
If yes, what exercises were prescribed |
Abdominal exercise |
02 (13) |
Back care exercise |
07 (47) |
Pelvic exercise |
03 (20) |
Relaxation exercises |
03 (20) |
Do you perform exercises now? |
Yes |
23 (22) |
No |
83 (78) |
If yes, what type of exercise do you practice |
Walking |
11 (48) |
Yoga |
04 (17) |
Easy exercises |
08 (35) |
If you had practiced exercises before pregnancy, are there any reasons why you discontinued them? |
Lack of time |
05 (22) |
Tiredness |
04(17) |
When respondents were asked questions in order to check their knowledge of the benefits of antenatal exercises, most of them agreed that it could help to reduce back pain (60%), prevent excessive weight gain (54%), prevent fatigue (63%), and help with labour and delivery (50%). However, the respondents were not aware of the role of antenatal exercises in Preeclampsia, gestational diabetes and urinary incontinence and aiding the development of foetus. 60% of participants perceived that physiotherapy had a positive role in antenatal care. 75% of them also agreed that it helped the new mother to get back into shape.54% knew that physiotherapy reduced pregnancy related complications while 58% believed that it aided postnatal recovery. The findings are given below in Table 4.
Table 4: Knowledge and Attitude of Participants with regard to the Role of Physiotherapy in Antenatal Care |
| Variables |
Disagree
n (%) |
Not sure
n (%) |
Agree
n (%) |
Knowledge |
Exercise during Pregnancy reduce risk of back pain. |
02 (02) |
40 (38) |
64 (60) |
Exercise during Pregnancy prevents excessive weight gain. |
07 (07) |
42 (39) |
57 (54) |
Exercise can help cope with labor and delivery |
03 (02) |
50 (48) |
53 (50) |
Exercise during Pregnancy reduce risk of gestational diabetes. |
10(09) |
52 (50) |
44 (41) |
Exercise during Pregnancy increases energy and stamina. |
04 (04) |
35 (33) |
67 (63) |
Exercise during Pregnancy would reduce risk of urinary incontinence. |
04 (04) |
68(64) |
34 (32) |
Exercise during Pregnancy causes high blood pressure. |
02 (01) |
46 (44) |
58 (55) |
Exercise benefits general health and development of the baby. |
10 (09) |
61 (58) |
35 (33) |
Attitude |
Does physiotherapy have a positive role in antenatal care? |
10 (09) |
29 (27) |
67 (64) |
Is it important to perform exercise under the guidance of health care professionals? |
11 (10) |
31 (29) |
64 (61) |
Do you feel exercise can reduce pregnancy-related complications? |
06 (06) |
43 (41) |
57 (54) |
Do you feel exercise helps in post-delivery recovery? |
10 (09) |
35 (33) |
61 (58) |
Do you feel the exercising helps you get back to your shape |
03 (03) |
24 (23) |
79 (75) |
Do you feel exercise regimen should vary from one pregnant woman to another? |
10 (09) |
56 (53) |
40 (38) |
Do you recommend physiotherapy during pregnancy? |
10 (09) |
65 (61) |
31 (30) |
All the knowledge components (Table 3) were graded on a scale with the most appropriate answer being given corresponding points. The score of the respondents was calculated and if the respondent scored 75 % or above, then she was considered to have good knowledge. Hence the final result of our study shows that 70% of participants had poor knowledge of the role of physiotherapy in antenatal care. Though the results show that respondents aged above 25 years, women with multiple pregnancies, and women who are in middle class in socio-economic status have a better knowledge of antenatal exercises, these findings are not statistically significant between among good and poor knowledge about antenatal exercises. (Table 5)
Table 5: Association between Socio Demographics and Level of Knowledge about Antenatal Exercises. |
Variables |
Good [n, (%)] |
Poor [n, (%)] |
p value |
Level of Knowledge about Antenatal Exercises |
31(30) |
75(70) |
|
Age Group |
< 25 yrs |
06(20) |
12(16) |
0.676* |
25 & above |
25(80) |
63(84) |
Parity |
Primiparous |
10(33) |
35(47) |
0.172* |
Multiparous |
21(67) |
40(53) |
Class |
Upper |
11(35) |
25(33) |
0.832* |
Middle |
20(65) |
50(67) |
| *Not Siginificant |
Discussion
This study assessed the knowledge, perception and attitude of pregnant women in India with respect to the role of physiotherapy in antenatal care. A total of 106 participants in any trimester having a mean age of 27 years were recruited. To assess the socioeconomic status of respondents, the Kuppuswamy scale was used which showed that 33.9% of subjects fall into the upper class category and 66.6% of subjects fall into the middle class.
The women in our study sample were found to have a positive attitude towards physiotherapy during antenatal care and also perceived that antenatal exercises reduce pregnancy-related complications and ensure a safe delivery. However, the majority of them were not aware of different types of antenatal exercises, with poor knowledge of physical therapy exercises in antenatal care. From our study we concluded that 73% of the respondents were aware of physiotherapy and 70% were believed that physiotherapy is mainly concerned with exercise as intervention and the majority of them felt that physiotherapists are the most suited fit to trainers for antenatal exercises. Interestingly, these findings suggest that there is a paradigm shift towards awareness of physiotherapy among pregnant women in India.
Our study had shown that 46% participants were aware of antenatal exercises. However, the majority (80%) of the participants were not aware of the different types of antenatal exercises. The present study also revealed that there was limited physiotherapy referral as only 13% of the participants were referred for physiotherapy as part of the antenatal care regimen. This highlights the fact that health care professionals in our country are unsure of the role of physiotherapy in antenatal care which may further contribute to the ignorance of pregnant women regarding antenatal exercises.
With regard to knowledge of the role of physiotherapy in antenatal care, more than 50% participants in this study agreed that antenatal exercises reduce the risk of back pain, prevent excessive weight gain, promote better ability to manage fatigue, and aid post-delivery recovery. These findings are consistent with previous reports.[11-14] However, this study also revealed that 55% of participants believed that exercises during pregnancy cause an increase in blood pressure, and more than 50% were not sure about the benefits of exercises in preventing gestational diabetes and urinary incontinence and aiding fetal development.
Our study revealed that 60% of the women in this study had a positive attitude towards physiotherapy and antenatal exercises in pregnancy. However, though a majority were positive in attitude and were favorable towards exercise they still believed that it was more important to rest and relax during pregnancy. In fact, few women (22%) reported that they were exercising their present pregnancy. These findings are consistent with previous carried out studies from various countries.[17,18] The reported reasons for the participants discontinuing exercise were a lack of time and tiredness. These finding suggest that despite being aware of benefits of physical exercise, many women do not feel motivated or actively engage in exercises.
The results of this study also revealed that only 30% of the participants had adequate knowledge of the benefits of antenatal exercise. However they were not influenced by maternal sociodemographic characteristics. We state that there is a urgent need for the management of hospitals and physiotherapists themselves to put in more effort to create an awareness of the need for antenatal exercises among Indian women. This vital service will then be utilized and benefit many mothers to be.
Recommendations
The outcome of this study from India underscores the need for interaction of physiotherapist with other health care professionals in order to ensure that the antenatal exercises performed by pregnant women. The study also indicated that positive role played by health education programmes in motivating pregnant women to engage actively in physical exercises. Further these implemented measures should be analyzed for their impact on pregnancy in both pre and postnatal outcome.
Limitations
The outcome of this study is limited in its generalizability and needs to be validated in other settings. This study does not take into account available knowledge of contraindications to exercise during pregnancy. Our community in Mangalore is a multilingual community (Malayalam, Tulu, Konkani) however we limited our samples to those who knew either English or Kannada and to the upper and middle socio-economic classes of society.
Conclusion:
Our results suggest that the pregnant Indian woman’s attitude towards the role of physiotherapy during pregnancy is favorable; however, the knowledge of the different antenatal exercises and their benefits is inadequate.
Conflict of Interests
The authors declare that they have no conflict of interests regarding the publication of this paper.
Acknowledgments
The authors gratefully acknowledge all the women who volunteered for this study. Also, they are grateful to the administrative and nursing staff of the hospitals.
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