# Profile of pregnant women complying or not with physical activity recommendations during the second trimester of pregnancy: a French pilot study

Marie Gerard, Rémi Béranger, Bruno Pereira, Nathalie Boisseau

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Marie Gerard, Rémi Béranger, Bruno Pereira, Nathalie Boisseau. Profile of pregnant women complying or not with physical activity recommendations during the second trimester of pregnancy: a French pilot study. Journal of Gynecology Obstetrics and Human Reproduction, 2025, 54 (9), pp.103007. 10.1016/j.jogoh.2025.103007. hal-05213549

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Original Article

# Profile of pregnant women complying or not with physical activity recommendations during the second trimester of pregnancy: A French pilot study

M. Gerard<sup>a</sup>, R. Beranger<sup>b</sup>, B. Pereira<sup>c</sup>, N. Boisseau<sup>d, *, e</sup>

<figure><img src="image_3.png" /></figure>

ARTICLE INFO

Keywords:

Pregnancy

Physical activity

Sedentary behaviour

Guideline adherence

Public health

ABSTRACT

**Introduction:** Insufficient physical activity (PA) during pregnancy is a global public health concern. The aims of this study were: i) to determine retrospectively PA and sedentary time in women in the second trimester of pregnancy, and ii) to identify factors that influence adherence to the French National College of Midwives guidelines on PA (≥150 minutes of moderate to high-intensity PA per week).

**Methods:** This cross-sectional, single-centre study, conducted at the University Hospital of Rennes, included 195 pregnant women. PA levels and sedentary time before and during the second trimester of pregnancy were determined using an anonymous self-report questionnaire. The self-reported PA levels were compared to the guidelines on PA. Bivariate analyses and Poisson generalized linear regression models were used to identify factors associated with non-compliance to such guidelines.

**Results:** Only 30.7 % of pregnant women reported the recommended PA levels in the second trimester of pregnancy. Sedentary time and adherence to the PA guidelines were not associated. Fatigue was the most frequently cited reason for insufficient PA (71.6 %). Preconception PA level was the strongest predictor of adherence. Body mass index >25 kg/m², <2 years of higher education, limited access to transportation and sports facilities, and living in a town with <2.000 inhabitants also were associated with lower PA levels.

**Conclusion:** Adherence to the PA recommendations is low among French pregnant women. Public health initiatives should emphasize PA importance before pregnancy and provide tailored support throughout gestation. Future studies should explore the interplay between PA, sedentary time and pregnancy outcomes.

Introduction

According to the World Health Organization (WHO) guidelines, physical activity (PA) refers to any bodily movement produced by skeletal muscles that requires energy expenditure, whereas sedentary behaviour is defined as any waking activity with energy expenditure ≤1.5 Metabolic Equivalent of Task (MET) in a sitting, reclining, or lying posture [1]. These are two distinct behavioural constructs that can independently influence health outcomes [1]. Insufficient PA is a global public health concern that contributes to the increased risk of

noncommunicable diseases, such as type 2 diabetes, cardiovascular conditions, cancers and musculoskeletal disorders [2-4]. Reducing sedentary time and increasing PA are important strategies to decrease the overall mortality risk [2-4]. Insufficient PA is an issue also in pregnant women who may face additional barriers to remain physically active.

The 2016 survey by the French Agency for Food, Environmental and Occupational Health & Safety (ANSES) showed that only 26.2 % of French women participate in regular PA during pregnancy [5]. Additionally, their PA patterns fluctuate throughout pregnancy. According to

<footnote><sup>a</sup> CHU de Rennes, School of Midwifery, 2 Rue Henry Guilloux Rennes, France</footnote>

<footnote><sup>b</sup> Univ Rennes, CHU Rennes, Inserm, Irset (Research Institute for Environmental & Occupational Health), UMR 1085, F-35000 Rennes, France</footnote>

<footnote><sup>c</sup> CHU de Clermont-Ferrand, Biostatistics Unit (Clinical Research and Innovation Department), F-63000 Clermont-Ferrand, France</footnote>

<footnote><sup>d</sup> Laboratoire des Adaptations Métaboliques à l'Exercice en conditions Physiologiques et Pathologiques (AME2P), Université Clermont Auvergne, EA 3533, 63171</footnote>

<footnote>Clermont-Ferrand, France</footnote>

<footnote>* Corresponding author at: Pr Nathalie BOISSEAU. Laboratoire AME2P (Adaptations Métaboliques à l'Exercice en conditions physiologiques et pathologiques), Université Clermont Auvergne, Campus des Cézeaux, 3 rue de la Chébarde, 63178, Aubière Cedex</footnote>

<footnote>E-mail addresses: marie.gerard@ifchurennes.fr (M. Gerard), remi.beranger@univ-rennes.fr (R. Beranger), bpereira@chu-clermontferrand.fr (B. Pereira), nathalie.boisseau@uca.fr (N. Boisseau).</footnote>
the French National Authority for Health (HAS), PA generally decreases (duration and intensity) during pregnancy and in the first 6 weeks postpartum. Then, PA levels gradually increase again from the third month postpartum [6].

Historically, pregnancy has been perceived as a barrier to initiating or maintaining PA. This misconception stems from the erroneous belief that PA might compromise pregnancy progression and pose risks to foetal development and maternal health [7]. Despite growing scientific evidence, these concerns persist among women, their social circles, and even some perinatal healthcare professionals, resulting in recommendations to reduce or suspend PA during pregnancy, even for women who were physically active before conception. However, it is well established that physical inactivity during pregnancy may increase the risk of adverse maternal and foetal outcomes, including excessive weight gain, gestational diabetes, and preeclampsia [8]. The hormonal, anthropometric, physiological, and biomechanical changes that occur during pregnancy do not hinder regular PA [8]. On the contrary, a growing body of scientific evidence consistently demonstrated that engaging in regular PA during pregnancy poses minimal risk and provides substantial benefits for both mother and child, as well as for the overall course of pregnancy and childbirth [7,8].

Given the persistent misconceptions about the potential risks of PA during pregnancy, it is crucial to emphasize the substantial and well-documented benefits of maintaining regular PA throughout gestation. PA during pregnancy helps to reduce excessive weight gain, the incidence of gestational diabetes, lower back pain, and high blood pressure, thereby decreasing the risk of pre-eclampsia and its complications, including HELLP syndrome [8,9]. PA is also associated with a reduced risk of prenatal depression, partly by enhancing self-esteem [10], as well as with shorter labour duration and greater pain tolerance [5,8], lower caesarean section rates and decreased risk of preterm delivery [7]. Many benefits have been documented also for the foetus, including on neurodevelopment, growth, autonomous regulation of foetal myocardium, postnatal behavioural outcomes (e.g., emotional regulation, attention, and social interaction), language development, and lower risk of long-term metabolic disorders and hormone-dependent cancers [7,11].

In line with international recommendations, the latest French guidelines by the French National College of Midwives (CNSF) [8] advocate for pregnant women: i) to initiate or maintain moderate to high-intensity PA for a minimum of 150 minutes per week (min week⁻¹), with at least three sessions lasting more than 30 minutes; ii) to initiate or maintain muscle strengthening exercises once/twice per week; and iii) to minimize sedentary time, possibly less than 7 h per day, irrespective of the pregnancy trimester [8].

The aims of this study carried out at Rennes University Hospital, France, were to determine the proportion of French women who meet the recommended levels of moderate to high-intensity PA during pregnancy and to identify factors that influence adherence to the CNSF guidelines in order to improve understanding and pregnancy monitoring practices. As body mass and abdominal volume increase during the third trimester of pregnancy, often leading to decreased PA levels [12], this study specifically focused on PA in women in the second trimester of pregnancy.

## Materials and methods

### *Study type*

This quantitative, observational, cross-sectional, and single-centre study was conducted by a fifth-year midwifery student and two supervisors at Rennes University Hospital Centre (CHU), France. This study was approved by the Ethics Research Committee in Obstetrics and Gynaecology in October 2023 (number: 2023-OBS-0904 IRB).

### *Study population*

Women in their 8th or 9th month of pregnancy were recruited at Rennes University Hospital. Exclusion criteria were: having initiated the pregnancy follow-up elsewhere and having had the first prenatal consultation at Rennes University Hospital after the first trimester of pregnancy; being younger than 18 years; not understanding French, or refusing to participate. Women with preconception or pregnancy-related medical conditions that restricted PA (e.g., multiple pregnancy, premature rupture of membranes, risk of preterm labour, history of at least two preterm births, low-lying placenta, unexplained persistent vaginal bleeding, intrauterine growth retardation, hypertension with proteinuria, severe cardiac or respiratory diseases) also were excluded. Lastly, participants with unclear or inconsistent questionnaire responses were excluded. After applying these criteria, 195 of the 218 included women (and thus questionnaires) were retained for analysis (see flow-chart in supplementary data).

### *Methodology*

#### *Questionnaire*

Pregnant women were recruited from June 15, 2022 to August 20, 2022. Obstetric secretaries distributed an anonymous self-report questionnaire to all women who met the inclusion criteria (~300 per month) helped by a midwifery student. To ensure comprehensive coverage of eligible pregnant women, the midwifery student regularly reviewed consultation schedules and marked the records of women in their 8th to 9th month of pregnancy to whom the questionnaire was given during a prenatal visit. Confidentiality was guaranteed by not collecting names or medical record identifiers. All questionnaires were in paper form and stored in a locked cabinet accessible only to the research team.

The self-report questionnaire was divided in three parts. In the first part, pregnant women reported their sociodemographic data [age, education level, preconception body mass index (BMI), marital status, number of children, and pathologies before and during pregnancy]. In the second part, their reported their sedentary time (min.day⁻¹) and time spent in moderate-to-vigorous intensity PA (min.week⁻¹) during the preconception period. They were also required to specify the time dedicated to “sporting” activities (recreational or competitive sport, institutionalized or not) and the type of sport practiced. In the third section, pregnant women retrospectively evaluated their PA levels during the first and second trimesters of pregnancy. Specifically, they were asked whether their PA level in the first trimester was similar to, higher than, or lower than in the preconception period and in the second trimester. For the second trimester, pregnant women were asked to specify their sedentary time (min.day⁻¹) and time spent in moderate-to-vigorous intensity PA (min.day⁻¹). This section also explored the reasons for changes in PA levels during the second trimester compared with the preconception period.

#### *Definitions and recommendations*

Before completing the questionnaire, definitions were given to women:

- *The preconception period* was defined as the year before the start of the current pregnancy. The first trimester included the first, second and third month of pregnancy and the second trimester included the fourth, fifth and sixth month.

- *Moderate to high-intensity PA* was defined as any skeletal muscle movement leading to energy expenditure and of moderate intensity (slight breathlessness allowing conversation) (i.e., Borg CR10 rating: 5-6) and high intensity (speech difficult) (i.e., Borg CR10 rating: ≥7-8) [13]. PA included activities across work, transportation, household chores and leisure, such as exercise, sports and informal activities.
- Sedentary time was defined as waking hours with energy expenditure at or below resting levels in a seated or supine position, including car travel, sitting idle, watching TV, reading, writing, computer work or resting activities (reading or phone calls while lying down).

## Statistical analysis

Variables were expressed as mean ± standard deviation (SD), percentages, or median [25th-75th percentiles]. The Chi-square and Fisher's exact tests, Kruskal-Wallis's test and Spearman correlations were used to analyse relationships between variables. To identify factors associated with non-adherence to the CNSF PA guidelines (i.e., not meeting the 150 min.week⁻¹ recommendation), relative risks (RR) with 95 % confidence intervals (CI) were computed using Poisson generalized linear model regression with robust variance. Multiple correspondence analysis (MCA), a useful tool to uncover relationships among categorical variables, followed by hierarchical classification, was also used to (i) study the relationships between the variable modalities, and (ii) determine the pregnant women's profiles (groups of pregnant women sharing similar characteristics). Statistical analyses were done with Stata version 15 (StataCorp, College Station, TX, USA) and a two-sided Type I error of 5 %. The R software was used for the MCA.

## Results

### Population characteristics

Table 1 summarizes the study population (N = 195 women in their 8th to 9th month of pregnancy, mean age 30±6.5 years). Based on the preconception BMI, 53.1 % of pregnant women had normal weight, 23.2 % were overweight, and 19 % were living with obesity (mean preconception BMI: 25.1 ± 5.8 kg/m²). Moreover, 94.5 % were in a couple, 47.6 % were nulliparous, 38.2 % lived in towns with >10,000 inhabitants, 29.0 % had a university or higher diploma, and 20.7 % had completed high school. Based on their own perception of proximity, 70.8 % and 55.9 % of pregnant women thought that they lived far from sports facilities and had limited access to public transport, respectively. Pre-pregnancy and pregnancy-related pathologies were reported by 3.1 % and 5.7 % of pregnant women, respectively.

### Physical activity levels during the second trimester of pregnancy

PA data were available for 189/195 pregnant women. Overall, 30.7 % (N = 58) of pregnant women met the PA recommendations (≥150 min.week⁻¹) among whom 90 % engaged in 150-300 min.week⁻¹ and 10 % in >300 min.week⁻¹. The other pregnant women performed <150 min.week⁻¹. Overall, 29.0 % engaged in sports during pregnancy, with similar rates in both groups. The most common sports in the second trimester of pregnancy were swimming (48.1 %), active walking (36.5 %), and yoga (25.0 %). Less frequent activities included outdoor cycling (5.8 %), running (5.8 %), stationary cycling (3.8 %), dancing (3.8 %), Pilates (1.9 %), weight training (1.9 %), badminton (1.9 %), and fitness (1.9 %).

### Distribution of physical activity levels according to the daily sedentary time during the second trimester of pregnancy

Concerning sedentary time during the second trimester of pregnancy, pregnant women reported they had been sedentary for >7 h per day (30 %), for 5-7 h (18 %), for 2-5 h (35 %), and for <2 h per day (17 %). Sedentary behaviour and PA levels were not correlated (r = 0.06, p >0.05) (Fig. 1).

<caption>Table 1</caption>

Characteristics and sociodemographic data of the study population (N = 195). Categorical variables are presented as numbers (percentages) and continuous variables as mean ± standard deviation (SD). BMI: Body Mass Index (kg/m²).

<table><thead><tr><th></th><th>N (%)</th><th>Mean ± SD</th></tr></thead><tbody><tr><td><strong>Age (years)</strong></td><td><strong>N = 195</strong></td><td><strong>30 ± 6.5</strong></td></tr><tr><td>≤20</td><td>4 (0.5 %)</td><td></td></tr><tr><td>21 to 25</td><td>23 (11.7 %)</td><td></td></tr><tr><td>26 to 30</td><td>66 (33.8 %)</td><td></td></tr><tr><td>31 to 35</td><td>70 (35.9 %)</td><td></td></tr><tr><td>36 to 40</td><td>27 (13.8 %)</td><td></td></tr><tr><td>>40</td><td>5 (2.6 %)</td><td></td></tr><tr><td><strong>Preconception BMI (kg/m²)</strong></td><td><strong>N = 190</strong></td><td><strong>25.1 ± 5.8</strong></td></tr><tr><td>Thinness (&lt;18.5)</td><td>9 (4.7 %)</td><td></td></tr><tr><td>Normal weight (18.5 to 24.9)</td><td>101 (53.1 %)</td><td></td></tr><tr><td>Overweight (25 to 29.9)</td><td>44 (23.1 %)</td><td></td></tr><tr><td>Obesity (≥30)</td><td>36 (18.9 %)</td><td></td></tr><tr><td><strong>Level of education</strong></td><td><strong>N = 193</strong></td><td></td></tr><tr><td>No high school diploma</td><td>35 (18.1 %)</td><td></td></tr><tr><td>High school diploma</td><td>40 (20.7 %)</td><td></td></tr><tr><td>Two-year undergraduate course</td><td>32 (16.5 %)</td><td></td></tr><tr><td>Three-year undergraduate course</td><td>30 (15.5 %)</td><td></td></tr><tr><td>Bachelor's degree and more</td><td>56 (29.0 %)</td><td></td></tr><tr><td><strong>Marital situation</strong></td><td><strong>N = 183</strong></td><td></td></tr><tr><td>Alone</td><td>10 (5.5 %)</td><td></td></tr><tr><td>In couple</td><td>173 (94.5 %)</td><td></td></tr><tr><td><strong>Number of children</strong></td><td><strong>N = 187</strong></td><td></td></tr><tr><td>0</td><td>89 (47.6 %)</td><td></td></tr><tr><td>1</td><td>63 (33.7 %)</td><td></td></tr><tr><td>2</td><td>25 (13.4 %)</td><td></td></tr><tr><td>3</td><td>7 (3.7 %)</td><td></td></tr><tr><td>≥4</td><td>3 (1.6 %)</td><td></td></tr><tr><td><strong>Town</strong></td><td><strong>N = 131</strong></td><td></td></tr><tr><td>&lt;2,000 inhabitants</td><td>23 (17.6 %)</td><td></td></tr><tr><td>2,000-5,000 inhabitants</td><td>35 (26.7 %)</td><td></td></tr><tr><td>5,000-10,000 inhabitants</td><td>23 (17.6 %)</td><td></td></tr><tr><td>>10,000 inhabitants</td><td>50 (38.2 %)</td><td></td></tr><tr><td><strong>Proximity to transports</strong></td><td><strong>N = 195</strong></td><td></td></tr><tr><td>Yes</td><td>86 (44.1 %)</td><td></td></tr><tr><td>No</td><td>109 (55.9 %)</td><td></td></tr><tr><td><strong>Nearby sports facilities</strong></td><td><strong>N = 195</strong></td><td></td></tr><tr><td>Yes</td><td>57 (29.2 %)</td><td></td></tr><tr><td>No</td><td>138 (70.8 %)</td><td></td></tr><tr><td><strong>Pre-pregnancy pathology</strong></td><td><strong>N = 193</strong></td><td></td></tr><tr><td>Yes</td><td>6 (3.1 %)</td><td></td></tr><tr><td>No</td><td>187 (96.9 %)</td><td></td></tr><tr><td><strong>Pregnancy-related pathology</strong></td><td><strong>N = 194</strong></td><td></td></tr><tr><td>Yes</td><td>11 (5.7 %)</td><td></td></tr><tr><td>No</td><td>174 (89.7 %)</td><td></td></tr><tr><td>Do not know</td><td>9 (4.6 %)</td><td></td></tr></tbody></table>

### Comparison of physical activity levels in preconception, first and second trimesters

Preconception PA (N = 184) ranged from <150 min.week⁻¹ (51.0 % of pregnant women) to 150-300 min.week⁻¹ (43.5 %) and >300 min. week⁻¹ (5.4 %). PA levels (min.week⁻¹) in the preconception period and the second trimester of pregnancy were significantly correlated (r = 0.6; p < 10⁻³). Among the pregnant women who met the PA recommendations in the second trimester, 80.4 % already did it before pregnancy (64.3 % engaged in 150-300 min.week⁻¹, and 16.1 % >300 min.week⁻¹). Conversely, 66.4 % of pregnant women who did not meet the guidelines performed <150 min.week⁻¹ of PA also during the preconception period.

During the first trimester of pregnancy, 59.0 % of participants reduced, 34.0 % did not change, and 7.0 % increased their PA level compared with the preconception period. Between the first and second trimester, 34.8 % of pregnant women maintained the same PA level. PA levels during the first trimester did not significantly influence adherence to the PA recommendations in the second trimester (p >0.05). The proportion of participants who reported a PA decrease in the first trimester was similar between women who did (58.0 %) and who did not adhere (60.0 %) to the guidelines in the second trimester.
<figure><img src="image_4.png" /><figcaption>Fig. 1. Distribution of the self-reported physical activity levels in the second trimester of pregnancy (N = 177) in function of the self-reported daily sedentary time (<2 h, 2–5 h, 5–7 h, >7 h). The Y axis shows the percentage of pregnant women in each physical activity level group (<150, ≥150 to <300, ≥300 min.week⁻¹).</figcaption></figure>

## Factors influencing physical activity reduction in the second trimester

Fatigue was cited by 71.6 % of pregnant women as the primary reason for reducing PA in the second trimester (Table 2). Other common reasons included lack of motivation (33.6 %), fears related to pregnancy (26.1 %), and lack of time (25.4 %). Less than 20 % of pregnant women reduced their PA level due to other factors, such as fears for their foetus' health, lack of interest in PA, presence of children at home, opinions of relatives, financial reasons, being advised against PA.

<caption>Table 2</caption>

Self-reported factors that contributed to the reduction in physical activity during the second trimester of pregnancy compared to the preconception period (N = 134).

<table><thead><tr><th></th><th>Reduced physical activity (%)</th><th>Maintained physical activity (%)</th></tr></thead><tbody><tr><td>Lack of information</td><td>3 (2.2 %)</td><td>131 (97.8 %)</td></tr><tr><td>Ignorance</td><td>11 (8.2 %)</td><td>123 (91.8 %)</td></tr><tr><td>Fears for the baby's health</td><td>25 (18.7 %)</td><td>109 (81.3 %)</td></tr><tr><td>Fears for the pregnancy</td><td>35 (26.1 %)</td><td>99 (73.9 %)</td></tr><tr><td>Lack of time</td><td>34 (25.4 %)</td><td>100 (74.6 %)</td></tr><tr><td>Lack of motivation</td><td>45 (33.9 %)</td><td>89 (66.4 %)</td></tr><tr><td>Fatigue</td><td>96 (71.6 %)</td><td>38 (28.4 %)</td></tr><tr><td>Limited interest in physical activity</td><td>18 (13.4 %)</td><td>116 (86.6 %)</td></tr><tr><td>Opinions of relatives</td><td>6 (4.5 %)</td><td>128 (95.5 %)</td></tr><tr><td>Presence of children at home</td><td>17 (12.7 %)</td><td>117 (87.3 %)</td></tr><tr><td>Physical activity not recommended</td><td>13 (9.7 %)</td><td>121 (90.3 %)</td></tr><tr><td>Financial reasons</td><td>7 (5.2 %)</td><td>127 (94.8 %)</td></tr><tr><td>Other</td><td>16 (11.9 %)</td><td>118 (88.1 %)</td></tr></tbody></table>

Values are presented as number and percentages (%) of pregnant women. Pregnant women were categorized based on whether they reduced or maintained their physical activity (PA). Each factor could be selected from a multiple-choice list.

## Determinants of physical activity in the second trimester of pregnancy: bivariate analyses

In the second trimester, the mean and median PA levels were 106.8 ± 107.1 min.week⁻¹ and 80 min.week⁻¹ [25th; 75th percentile: 25; 175] (Table 3). PA level in the second trimester was not associated with age (p = 0.718), number of children, marital status, and preconception sedentary time. Pregnant women with overweight/obesity were less active than those with lower BMI (p = 0.017). PA adherence tended to increase with education (p = 0.06), particularly in pregnant women with >2 years of higher education (p = 0.004). Conversely, pregnant women living in towns with <2,000 inhabitants and to a lesser extent, with 2,000-5,000 inhabitants were less active (p = 0.015). Access to public transport (p = 0.017), but not to sports facilities, was linked to higher PA. PA advice from healthcare professionals had no effect (p = 0.422).

## Determinants of non-adherence to the physical activity guidelines

Several factors were associated with higher risk of not adherence to the PA recommendations during pregnancy (Fig. 2). The strongest risk factor was <150 min.week⁻¹ of PA per week before pregnancy (RR = 7.23, 95 % CI: 3.47–15.05, p <0.00001). Overweight (RR = 1.36, 95 % CI: 1.12–1.66, p = 0.002) and having ≥2 children (RR = 1.28, 95 % CI: 1.02–1.61, p = 0.029) also were associated with higher risk of insufficient PA. Conversely, several factors were protective: higher education level, particularly having a 3-year undergraduate degree (RR = 0.67, 95 % CI: 0.47–0.97, p = 0.035) or a bachelor's degree (RR = 0.74, 95 % CI: 0.57–0.97, p = 0.027), living in a town with >10,000 inhabitants (RR = 0.70, 95 % CI: 0.53–0.93, p = 0.014), and self-reported access to public transport (RR = 0.78, 95 % CI: 0.64–0.96, p = 0.016). Being in a couple also was associated with a lower risk of non-adherence (RR = 0.23, 95 % CI: 0.03–1.85, p = 0.016), although the wide confidence interval suggests a high level of uncertainty. Access to sports facilities was not associated with adherence to the guidelines (RR = 0.83, 95 % CI: 0.67–1.05, p = 0.126).
<caption>**Table 3**</caption>

Determinants of physical activity levels during the second trimester of pregnancy.

<table><caption>**Table 3 (continued)**</caption><thead><tr><th></th><th>Physical activity level median ± [25<sup>th</sup>; 75<sup>th</sup> percentile]</th><th>Suboptimal practice in the 2<sup>nd</sup> trimester (&lt;150 min. week<sup>-1</sup>)</th><th>Optimal practice in the 2<sup>nd</sup> trimester (≥150 min. week<sup>-1</sup>)</th><th>P value</th></tr></thead><tbody><tr><td>Population (N =189)</td><td></td><td>131 (69.3 %)</td><td>58 (30.7 %)</td><td></td></tr><tr><td>Age (years)</td><td></td><td></td><td></td><td>0.718</td></tr><tr><td>≤25 (N = 27)</td><td>60 [0; 210]</td><td>19 (70.4 %)</td><td>8 (29.6 %)</td><td></td></tr><tr><td>26 to 30 (N = 65)</td><td>60 [30; 150]</td><td>47 (72.3 %)</td><td>18 (27.9 %)</td><td></td></tr><tr><td>31 or 35 (N = 67)</td><td>100 [40; 189]</td><td>43 (64.2 %)</td><td>24 (35.9 %)</td><td></td></tr><tr><td>≥36 (N = 30)</td><td>85 [25; 150]</td><td>22 (73.3 %)</td><td>8 (26.7 %)</td><td></td></tr><tr><td>Total N = 189</td><td></td><td></td><td></td><td></td></tr><tr><td>Preconception BMI (kg/m<sup>2</sup>)</td><td></td><td></td><td></td><td>0.017</td></tr><tr><td>Thinness (&lt;18.5) (N = 8)</td><td>107 [30; 189]</td><td>66 (61.7 %)</td><td>41 (38.3 %)</td><td></td></tr><tr><td>+ Normal weight (18.5 to 24.9) (N = 99)</td><td></td><td></td><td></td><td></td></tr><tr><td>Overweight (25 to 29.9) (N = 42)</td><td>60 [0; 120]</td><td>37 (84.1 %)</td><td>7 (15.9 %)</td><td></td></tr><tr><td>Obesity (≥30) (N = 30)</td><td>60 [0; 130]</td><td>25 (75.8 %)</td><td>8 (24.2 %)</td><td></td></tr><tr><td>Total N = 184</td><td></td><td></td><td></td><td></td></tr><tr><td>Number of children</td><td></td><td></td><td></td><td>0.159</td></tr><tr><td>0 (N = 88)</td><td>94 [33; 175]</td><td>56 (63.6 %)</td><td>32 (36.4 %)</td><td></td></tr><tr><td>1 (N = 60)</td><td>68 [30; 177]</td><td>41 (68.3 %)</td><td>19 (31.7 %)</td><td></td></tr><tr><td>≥2 (N = 33)</td><td>75 [0; 174]</td><td>27 (81.8 %)</td><td>6 (18.2 %)</td><td></td></tr><tr><td>Total N = 181</td><td></td><td></td><td></td><td></td></tr><tr><td>Education level</td><td></td><td></td><td></td><td>0.066</td></tr><tr><td>No high school diploma (N = 33)</td><td>74 [0; 110]</td><td>27 (81.8 %)</td><td>6 (18.2 %)</td><td></td></tr><tr><td>High school diploma (N = 40)</td><td>60 [0; 133]</td><td>31 (77.5 %)</td><td>9 (22.5 %)</td><td></td></tr><tr><td>Two-year undergraduate course (N = 29)</td><td>90 [30; 140]</td><td>22 (75.9 %)</td><td>7 (24.1 %)</td><td></td></tr><tr><td>Three-year undergraduate course (N = 29)</td><td>120 [60; 177]</td><td>16 (55.2 %)</td><td>13 (44.8 %)</td><td></td></tr><tr><td>Bachelor's degree and more (N = 56)</td><td>110 [40; 193]</td><td>34 (60.7 %)</td><td>22 (39.3 %)</td><td></td></tr><tr><td>Total N = 187</td><td></td><td></td><td></td><td></td></tr><tr><td>Education level</td><td></td><td></td><td></td><td>0.004</td></tr><tr><td>&lt;2 years of undergraduate studies (N = 102)</td><td>63 [0; 134]<sup>a</sup></td><td>80 (78.4)</td><td>22 (21.6)</td><td></td></tr><tr><td>≥2 years of undergraduate studies (N = 85)</td><td>80 [25; 175]</td><td>50 (58.8)</td><td>35 (41.2)</td><td></td></tr><tr><td>Total N = 187</td><td></td><td></td><td></td><td></td></tr><tr><td>Marital status</td><td></td><td></td><td></td><td>0.174</td></tr><tr><td>Alone (N = 10)</td><td>45 [0; 100]</td><td>9 (90.0 %)</td><td>1 (10.0 %)</td><td></td></tr><tr><td>Couple (N = 168)</td><td>80 [25; 175]</td><td>113 (67.3 %)</td><td>55 (32.7 %)</td><td></td></tr><tr><td>Total N = 178</td><td></td><td></td><td></td><td></td></tr><tr><td>Physical activity suggestion by professionals</td><td></td><td></td><td></td><td>0.422</td></tr><tr><td>Yes (N = 78)</td><td>60 [0; 174]<sup>b</sup></td><td>56 (71.8 %)</td><td>22 (28.2 %)</td><td></td></tr><tr><td>No (N = 104)</td><td>94 [37; 179]</td><td>68 (65.4 %)</td><td>36 (34.6 %)</td><td></td></tr><tr><td>Total N = 182</td><td></td><td></td><td></td><td></td></tr></tbody></table>

<table><thead><tr><th></th><th>Physical activity level median ± [25<sup>th</sup>; 75<sup>th</sup> percentile]</th><th>Suboptimal practice in the 2<sup>nd</sup> trimester (&lt;150 min. week<sup>-1</sup>)</th><th>Optimal practice in the 2<sup>nd</sup> trimester (≥150 min. week<sup>-1</sup>)</th><th>P value</th></tr></thead><tbody><tr><td>Preconception physical activity level</td><td></td><td></td><td></td><td>&lt;0.001</td></tr><tr><td>&lt;150 min. week<sup>-1</sup> (N = 98)</td><td>40 [0; 105]</td><td>85 (86.7 %)</td><td>13 (13.3 %)</td><td></td></tr><tr><td>≥150 min. week<sup>-1</sup> (N = 87)</td><td>150 [60; 210]</td><td>42 (48.3 %)</td><td>45 (51.7 %)</td><td></td></tr><tr><td>Total N = 185</td><td></td><td></td><td></td><td>0.847</td></tr><tr><td>Preconception sedentary time</td><td></td><td></td><td></td><td></td></tr><tr><td>&lt;7 hours.day<sup>-1</sup> (N = 127)</td><td>80 [15; 175]</td><td>88 (69.3 %)</td><td>39 (30.7 %)</td><td></td></tr><tr><td>≥7 hours.day<sup>-1</sup> (N = 56)</td><td>73 [30; 176]</td><td>38 (67.9 %)</td><td>18 (32.1 %)</td><td></td></tr><tr><td>Total N = 183</td><td></td><td></td><td></td><td>0.015</td></tr><tr><td>Town (population)</td><td></td><td></td><td></td><td></td></tr><tr><td>&lt;2,000 (N = 22)</td><td>38 [0; 90]<sup>a</sup></td><td>20 (90.9 %)</td><td>2 (9.1 %)</td><td></td></tr><tr><td>2,000-5,000 (N = 33)</td><td>90 [30; 150]</td><td>24 (72.7 %)</td><td>9 (27.3 %)</td><td></td></tr><tr><td>5,000-10,000 (N = 23)</td><td>125 [60; 210]</td><td>13 (56.5 %)</td><td>10 (43.5 %)</td><td></td></tr><tr><td>&gt;10,000 (N = 48)</td><td>121 [30; 183]</td><td>27 (56.3 %)</td><td>21 43.88 %</td><td></td></tr><tr><td>Total N = 126</td><td></td><td></td><td></td><td>0.017</td></tr><tr><td>Transport facilities</td><td></td><td></td><td></td><td></td></tr><tr><td>No (N = 104)</td><td>70 [0; 140]</td><td>80 (76.9 %)</td><td>24 (23.1 %)</td><td></td></tr><tr><td>Yes (N = 85)</td><td>90 [30; 189]</td><td>51 (60.0 %)</td><td>34 (40.0 %)</td><td></td></tr><tr><td>Total N = 189</td><td></td><td></td><td></td><td>0.096</td></tr><tr><td>Sports facilities</td><td></td><td></td><td></td><td></td></tr><tr><td>No (N = 133)</td><td>75 [0; 164]</td><td>97 (72.9 %)</td><td>36 (27.1 %)</td><td></td></tr><tr><td>Yes (N = 56)</td><td>90 [33; 183]</td><td>34 (60.7 %)</td><td>22 (39.3 %)</td><td></td></tr><tr><td>Total N = 189</td><td></td><td></td><td></td><td></td></tr></tbody></table>

Physical activity levels are expressed as median [25<sup>th</sup>; 75<sup>th</sup> percentile] in minutes per week. Pregnant women were categorized as having suboptimal (&lt;150 min. week<sup>-1</sup>) or optimal (≥150 min. week<sup>-1</sup>) physical activity levels, based on the current guidelines.

The p-value column shows the comparisons between the suboptimal and optimal activity groups. Superscript symbols indicate significant differences in the weekly physical activity levels between specific subgroups: *p <0.05 between the 'thinness + normal weight' and 'overweight' Body Mass Index (BMI, kg/m<sup>2</sup>) categories; α: p <0.01 between pregnant women with &lt;2 years of undergraduate education and those with ≥2 years; β: p <0.05 between pregnant women who reported receiving professional advice on physical activity and those who did not; Δ: p <0.05 between pregnant women living in towns with &lt;2,000 inhabitants and with 2,000-5,000 and 5,000-10,000 inhabitants.

### Determination of pregnant women profiles by multiple correspondence analysis

For the factor analysis, data of 189 respondents were used, but not 'town size' due to the insufficient number of responses (N = 126). Two participant profiles emerged (Fig. 3):

- Cluster 1 (Active Profile): pregnant women who met the 150 min. week<sup>-1</sup> PA recommendation, age between 26 and 35 years, BMI <25 kg/m<sup>2</sup>, no children, at least 2 years of higher education, easy access to transport and sports facilities, healthcare encouragement for PA, and preconception adherence to the PA guidelines.

- Cluster 2 (Inactive Profile): pregnant women who did not meet the PA recommendations, younger than 25 or older than 35 years, >1
<figure><img src="image_5.png" /><figcaption>**Fig. 2.** Risk of not meeting the physical activity recommendation (150 min. week⁻¹) in the second trimester of pregnancy (univariate analyses). The Forest plot shows the relative risk and 95 % confidence intervals (CI) of non-compliance with the physical activity guidelines. The X-axis displays the effect sizes (RR; black squares) with their 95 % CI (horizontal lines). Values ≥1 indicate higher risk of not meeting the recommended physical activity guidelines, and values <1 suggest a lower risk. The corresponding numerical RR, 95 % CI, and p-values are reported on the right for each variable.</figcaption></figure>

child, BMI >25 kg/m², lower education level, limited access to transport/sports facilities, no healthcare encouragement for PA, and preconception non-adherence to the PA guidelines.

Discussion

In our study, only 30.7 % of French pregnant women reported to engage in at least 150 min. week⁻¹ of moderate-to-vigorous intensity exercise (i.e., the current CNSF guidelines) during the second trimester of pregnancy. PA levels during pregnancy were associated with the preconception PA levels, but not with the sedentary time during or before pregnancy. Several factors were associated with the risk of lower PA levels during pregnancy, particularly BMI >25 kg/m², lower education level, limited access to transportation and sports facilities, living in a town with <2,000 inhabitants, and receiving minimal or no encouragement from healthcare professionals to engage in PA.

In line with other international guidelines [6,13–17], the latest French guidelines by the CNSF [8] encourage pregnant women to initiate or maintain moderate-to-high-intensity PA (at least 150 min.

week⁻¹) and simultaneously to reduce sedentary time. Yet, these recommendations appear to be difficult to follow worldwide. Previous studies indicate that PA generally decreases as pregnancy progresses, particularly in the second and third trimesters, and that many women feel less confident in their ability to remain active as pregnancy advances [12,18]. This decline is often attributed to increased physical discomfort, societal expectations, and lack of encouragement by healthcare providers [12,18–20]. PA levels during the second trimester of pregnancy strongly vary among countries. These differences are influenced by cultural, socioeconomic and health-related factors. In a population survey (N = 247) in the United States, most pregnant women reported leisure-time PA (LTPA, defined as moderate or vigorous intensity for ≥10 minutes) levels below the recommended 150 min. week⁻¹ [21]. Only 23.4 % of pregnant women reported 150 min. week⁻¹ of LTPA, and 60 % did not perform any LTPA. Similarly, Smith et al. found that only 16 % of American pregnant women met the recommended PA levels [22]. Likewise, a study in Poland found that 55.9 % of pregnant women did not exercise at all during pregnancy, and only 10 % met the minimum PA recommendations [23].
<figure><img src="image_6.png" /><figcaption>**Fig. 3.** Multiple correspondence analysis (MCA) to explore the relationships among categorical variables (a), and distribution of pregnant women in the two identified clusters (b). (a) Projection of categorical variables in the first two dimensions of the MCA. (b) Individual pregnant women (dots) separated into Cluster 1 (black dots) and Cluster 2 (white dots) based on their variable profiles. Age Cat 1: ≤25 years; Age Cat 2: 26 to 30 years; Age Cat 3: 31 to 35 years; Age Cat 4: >36 years. Body Mass Index (BMI): BMI Cat 1: <25 kg/m² and BMI Cat 2 ≥ 25 kg/m². Education level 1: less than two years undergraduate course; Education level 2: at least two years undergraduate course.</figcaption></figure>

The factors contributing to low PA levels during pregnancy are shaped by country-specific socioeconomic, cultural, and demographic factors. Nevertheless, several common recurring barriers have been identified. For instance, a recent study by Suberu et al. in Nigeria highlighted insufficient knowledge, perceived barriers, lack of social support, limited perceived benefits, and inadequate guidance from healthcare professionals as key determinants of physical inactivity during pregnancy [24]. These factors are frequently reported also in high-income countries, but comparisons should be made with caution. Structural differences, including healthcare systems, cultural norms surrounding pregnancy, and socioeconomic inequalities, can significantly influence PA behaviours and their underlying determinants. Despite these contextual variations, cross-cultural findings can provide valuable insights by revealing shared barriers and help to shape relevant public health strategies, while avoiding overgeneralizations to national contexts. Commonly cited barriers include cultural beliefs about exercise, limited awareness of its benefits, and insufficient support from healthcare providers [25,26]. Lack of time and energy also are frequently cited as major obstacles [21,27]. In our study, fatigue was the most frequently reported barrier (71.6% of pregnant women) and lack of time was mentioned by 25.4% of inactive pregnant women. Moreover, 26.1% of inactive women identified fear related to pregnancy (particularly concerns about harming the baby) as a major reason for not engaging in PA. Lack of information was not spontaneously mentioned, but 65.4% of pregnant women who did not meet the recommendations said that they had not received any guidance from healthcare professionals. Environmental and geographical factors also emerged as important determinants. Urbanization is often associated with better access to recreational infrastructure, which may facilitate PA during pregnancy [28]. Infrastructure in the living environment, such transportation and availability of sports facilities, may play a critical role in shaping PA engagement during pregnancy [28]. Although these factors were not explicitly reported as barriers, access to public transport was strongly associated with PA adherence in our study, suggesting an indirect but significant influence on the women's ability to meet the recommendations.

Preconception PA level was the factor most strongly associated with

PA levels during pregnancy. Women who are physically active before conception are significantly more likely to continue exercising during pregnancy [29]. This is consistent with the Stages of Change Model according to which prior behaviour is a strong predictor of future behaviour, particularly in the context of PA [29]. Like in the present study, a previous systematic review with meta-analysis reported that women with an active lifestyle before pregnancy are more likely to adhere to the recommended PA guidelines during gestation, thus improving their overall health and well-being [30].

One of the distinctive features of our study was the assessment of the relationship between PA and sedentary time. Surprisingly, sedentary time (before conception, during the first trimester and also the second trimester) was not associated with adherence to the PA recommendations in the second trimester of pregnancy. This is in line with the idea that PA and sedentary behaviour are two distinct behavioural constructs that may independently influence health outcomes. This distinction is well established in recent theoretical frameworks and public health guidelines, including those by the WHO, according to which reducing sedentary time and increasing PA should be pursued through separate and complementary strategies [1]. In agreement, the absence of a correlation in our study suggests that sedentary behaviour may not merely be the inverse of PA, but rather a separate behavioural dimension requiring specific interventions and measurement approaches. These results underscore the importance of addressing both behaviours independently in the design of pregnancy-related health promotion programmes.

Our analysis also revealed distinct behavioural profiles among pregnant women. These profiles represent clusters of characteristics that can inform more targeted and effective prevention strategies. Women in the “Inactive Profile” were more likely to be younger than 25 or older than 35 years, have a BMI >25 kg/m², live in smaller towns with limited access to transportation or sports facilities, have children, and receive little encouragement by healthcare professionals. These factors may limit the time and opportunity for engaging in PA. Conversely, the “Active Profile” included pregnant women with higher education level, living in more urbanized settings, and with preconception adherence to the PA recommendations. These profiles could allow healthcare
providers and policymakers to tailor prevention and intervention efforts more precisely, by identifying the women most at risk of inactivity and addressing their specific barriers. This person-centred approach may enhance the effectiveness of public health messages and support systems to promote PA during pregnancy.

Despite the originality and relevance of our findings, several limitations must be acknowledged. First, although the questionnaire was carefully developed based on the existing recommendations and expert input, it was not formally validated. At the study time, no validated questionnaire specific to the French context for assessing PA and sedentary time during pregnancy was available. To ensure contextual appropriateness, we developed our own tool that was pilot tested with eight pregnant women (not included in the main sample) to assess its clarity and comprehensibility. Follow-up interviews were also conducted to check the response consistency. In addition, although the French guidelines recommend at least three sessions of ≥30 min.week⁻¹, our questionnaire only assessed the total weekly PA duration. Consequently, we were unable to determine whether participants met the recommended frequency. Second, as data were self-reported, we cannot fully exclude the possibility of over- or under-estimation of PA and sedentary behaviour. Nevertheless, the questionnaire was based on factual questions (e.g., minutes of PA per week), developed under the supervision of a PA assessment expert, in order to reduce the risk of measurement bias. Moreover, any such bias would likely be non-differential (affecting all participants similarly), thus potentially attenuating the observed associations and reducing the statistical power rather than introducing spurious results [31]. Third, the response rate was ~30 %, which is in line with what expected for observational studies that rely on self-administered questionnaires. Nevertheless, we cannot entirely rule out a selection bias. It is well established that participation is often associated with socioeconomic status and personal interest in the topic, potentially leading to overrepresentation of more health-conscious individuals.

## Conclusion

Our study highlights that only 30.7 % of French pregnant women performed the recommended 150 min.week⁻¹ of moderate-to-vigorous PA during the second trimester (without specification on frequency). Preconception PA emerged as the most important adherence predictor during pregnancy, but not sedentary time. These results emphasize the importance of promoting active lifestyles well before conception, particularly among women with risk factors, such as high BMI, low education, or limited access to facilities. For healthcare providers, the early identification of these women and the provision of brief, personalized counselling during antenatal care could be crucial to improve their PA levels. Consequently, it is essential to increase the healthcare professionals' awareness and training on PA benefits and safety during pregnancy. Structured PA counselling, systematic PA prescription, and the development of supervised prenatal exercise programmes, in healthcare or community settings, could contribute to improve adherence to the PA guidelines. Although these findings should be confirmed in a larger population, they offer a solid basis for developing targeted, practical strategies to support women with low baseline PA throughout their pregnancy journey.

## Declaration of competing interest

The authors declare that they have no conflicts of interest to disclose regarding the publication of this article. Specifically, they confirm that no financial support or grants from any organization or entity have been received in connection with the research or preparation of this manuscript.

## Supplementary materials

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.jogoh.2025.103007.

## References

[1] Organization WH. WHO Guidelines on Physical Activity and Sedentary Behaviour. Geneva; 2020.

[2] Guthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1.9 million participants. Lancet Glob Health 2018;6(10):e1077-e86.

[3] Owen N, Healy GN, Dempsey PC, Salmon J, Timperio A, Clark BK, et al. Sedentary behavior and public health: integrating the evidence and identifying potential solutions. Annu Rev Public Health 2020;41:265-87.

[4] Piercy KL, Troiano RP, Ballard RM, Carlson SA, Fulton JE, Galuska DA, et al. The physical activity guidelines for Americans. JAMA 2018;320(19):2020-8.

[5] ANSES. Actualisation des repères du PNNS - Révisions des repères relatifs à l'activité physique et à la sédentarité. 2016.

[6] HAS. Prescription d'activité physique et sportive pendant la grossesse et en postpartum [Internet], 2019.

[7] Guinhouya BC, Duclos M, Enea C, Storme L. Beneficial Effects of Maternal Physical Activity during Pregnancy on Fetal, Newborn, and Child Health: Guidelines for Interventions during the Perinatal Period from the French National College of Midwives. J Midwifery Womens Health 2022;67(Suppl 1):S149-S57.

[8] Boisseau N. Physical activity during the perinatal period: guidelines for interventions during the perinatal period from the french national college of midwives. J Midwifery Womens Health 2022;67(Suppl 1):S158-S71.

[9] Bellamy L, Casas JP, Hingorani AD, Williams D. Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis. Lancet 2009;373(9677):1773-9.

[10] De Moor MH, Beem AL, Stubbe JH, Boomsma DI, De Geus EJ. Regular exercise, anxiety, depression and personality: a population-based study. Prev Med 2006;42(4):273-9.

[11] Jones MA, Catov JM, Jeyabalan A, Whitaker KM. Barone Gibbs B. Sedentary behaviour and physical activity across pregnancy and birth outcomes. Paediatr Perinat Epidemiol 2021;35(3):341-9.

[12] Haakstad LA, Voldner N, Henriksen T, Bo K. Why do pregnant women stop exercising in the third trimester? Acta Obstet Gynecol Scand 2009;88(11):1267-75.

[13] ACOG. ACOG Committee Opinion No. 650: physical activity and exercise during pregnancy and the postpartum period. Obstet Gynecol 2015;126(6):e135-ee42.

[14] Dipietro L, Evenson KR, Bloodgood B, Sprow K, Troiano RP, Piercy KL, et al. Benefits of physical activity during pregnancy and postpartum: an umbrella review. Med Sci Sports Exerc 2019;51(6):1292-302.

[15] Mottola MF, Davenport MH, Ruchat SM, Davies GA, Poitras VJ, Gray CE, et al. 2019 Canadian guideline for physical activity throughout pregnancy. Br J Sports Med 2018;52(21):1339-46.

[16] US. Physical activity guidelines for Americans. 2nd edition. US Department of Health and Human Services; 2018.

[17] Bull FC, SS Al-Ansari, Biddle S, Borodulin K, Buman MP, Cardon G, et al. World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Br J Sports Med 2020;54(24):1451-62.

[18] 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.

[19] Cioffi J, Schmied V, Dahlen H, Mills A, Thornton C, Duff M, et al. Physical activity in pregnancy: women's perceptions, practices, and influencing factors. J Midwifery Womens Health 2010;55(5):455-61.

[20] Santo EC, Forbes PW, Oken E, Belfort MB. Determinants of physical activity frequency and provider advice during pregnancy. BMC Pregnancy Childbirth 2017;17(1):286.

[21] Hesketh KR, Evenson KR. Prevalence of U.S. pregnant women meeting 2015 ACOG physical activity guidelines. Am J Prev Med 2016;51(3):e87-9.

[22] Smith KM, Foster RC, Campbell CG. Accuracy of physical activity assessment during pregnancy: an observational study. BMC Pregnancy Childbirth 2011;11:86.

[23] Rzeźnicki A, Michalik K, Cichonska-Rzeźnicka D, Tchórzewska K, Tchórzewski J, Szpak A, et al. Knowledge about physical activity and taking up physical activity by pregnant women covered by obstetric and gynecological care in selected facilities in the lodz voivodeship. J Health Study Medic 2022;2022(4):5-21.

[24] Suberu F, Adeoye IA. Barriers, attitudes and perceptions to physical activity among pregnant women in Ibadan, Nigeria and the associated factors: a mixed method study. Reprod Health 2024;21(1):166.

[25] Whitaker KM, Wilcox S, Liu J, Blair SN, Pate RR. Patient and provider perceptions of weight gain, physical activity, and nutrition counseling during pregnancy: a qualitative study. Womens Health Issues 2016;26(1):116-22.

[26] Sitzberger C, Hansl J, Felberbaum R, Brossner A, Oberhoffer-Fritz R, Wacker-Gussmann A. Physical activity in high-risk pregnancies. J Clin Med 2022;11(3).

[27] Stengel MR, Kraschnewski JL, Hwang SW, Kjerulf KH, Chuang CH. What my doctor didn't tell me: examining health care provider advice to overweight and obese pregnant women on gestational weight gain and physical activity. Womens Health Issues 2012;22(6):e535-40.

[28] Okafor UB, Goon DT. Physical activity advice and counselling by healthcare providers: a scoping review. Healthcare (Basel) 2021;9(5).
[29] Haakstad LA, Voldner N, Bo K. Stages of change model for participation in physical activity during pregnancy. J Pregnancy 2013;2013:193170.

[30] Kasahun AW, Shitu S, Mekonnen BA, Hawlet M, Zewdie A. Knowledge, attitude and practice towards antenatal physical exercise among pregnant women in

Ethiopia: A systematic review and meta-analysis. PLoS One 2023;18(12): e0295275.

[31] Armstrong BG. Effect of measurement error on epidemiological studies of environmental and occupational exposures. Occup Environ Med 1998;55(10): 651-6.