Assessment of Knowledge and Belief of Pregnant Women Attending Maternal and Child Care Unit in Primary Health Center of Sulaimani City Regarding Exercise During Pregnancy

Background: given the positive physical and mental health outcomes associated with participating in regular exercise, promoting exercise during pregnancy needs to remain a crucial objective among health promoters. Objectives: to determine the knowledge level and document self-reported beliefs about physical exercise during pregnancy. Method: a descriptive study was carried out on 197 pregnant women who attended the maternal and child care units in two primary health care centers of Sulaimani city.The study was carried out for the period of (April, 2013 – February, 2014 ). Data was analyzed with SPSS (16.0) program. Chi-Square (Fishers' Exact) test was used in the statistical assessment and the figure of p<0.05 was considered as the statistically significant. Results: majority 81.2 % of participants had inadequate knowledge regarding effect of exercise during pregnancy and only 13.7% of participants believed that exercises had positive effect on pregnancy. Level of knowledge and belief increase with increasing level of education, employment, better financial status, extended family type, and women who had no abortion while age, gestational age, pregnancy and delivery number were not associated with knowledge and belief level. Kirkuk University Journal /Scientific Studies (KUJSS) Volume 10, Issue 1, March 2015 , p.p(158-172) ISSN 1992 0849 Web Site: www.kujss.com Email: kirkukjoursci@yahoo.com, kirkukjoursci@gmail.com 859 Conclusions: researchers conclude that the knowledge of pregnant women in Sulaimani regarding exercise during pregnancy is inadequate. Women's education, occupation, family type, financial status and pervious abortion had a positive effect on pregnant women's knowledge and beliefs.


1.INTRODUCTION
Exercise is a safe and effective way to gain many physical and mental health benefits, pregnancy is a good time to develop healthy lifestyle habits including regular exercise and good nutrition [1].Improving the quantity and quality of information related to physical exercise has the potential to correct inaccurate perceptions and confer several benefits on maternal and fetal health. Effective intervention strategies should focus not only on the pregnant woman but also extend to her family, friends and exercise provider [2].
The American Congress of Obstetricians and Gynecologists (ACOG 2002) [3] and the American College of Sports Medicine (ACSM) [4]recommend 30 minutes or more of moderate to vigorous exercise a day on most of the week during pregnancy. More recently,the United States Department of Health and Human Services (USDHH) [5] released exercise guidelines for pregnant women. According to the guidelines, at least 150 minutes of moderate-intensity aerobic activity per week is advised for those who have not been engaged in regular exercise before pregnancy. Further, under a health-care provider's recommendations and adjustments, healthy women who have been engaged in regular exercise may continue to do so throughout the pregnancy and postpartum [6].
Research indicates that the exercise during pregnancy is determined by several belief factors, the safety issue is an important belief factor for exercising during pregnancy. In a study of British pregnant women [7], one third of the participants chose the risk of health to an unborn baby as a primary reason for not being active during pregnancy.
Guszkowskaexamined pregnant women's belief about the safety of exercise during pregnancy and stated that the majority of pregnant women had safety concerns about their own and baby's health, regardless of the intensity and frequency of exercise, and normseems to be a prominent determinant of women's exercise participation during pregnancy [8].
Given the positive physical and mental health outcomes associated with participating in regular exercise, promoting exercise during pregnancy needs to remain a crucial objective among health promoters [9]. Now a day, information about the physical exercise and activity level of the community is inadequate, adopted an increasingly sedentary lifestyle, in particular the low level of awareness about exercise during pregnancy is observed. This study provides information to create more successful interventions to help women get correct information and understand concepts regarding the safety and benefits of physical activity during pregnancy.

Objective of the study
The objectives of this study were to determine the knowledge level, to document selfreported beliefs about physical exercise among pregnant women, and to explore association between some socio-demographic and obstetric characteristics with knowledge and belief levels.

Methodology
A cross-sectional study was carried out during the period of (April, 2013 to February, 2014).A purposive "non-probability" sample of (197) pregnant women who have been This study was approved by ethical committee of the School of Nursing at University of Sulaimani. A pilot study was conducted for the determination of the reliability and a panel of experts for the content validity of the assessment tool. The data were collected through the interview techniques. A score of (1) was given to all "agree" answers, while a score of zero given to all "disagree" answer for a positive statement and vice-versa. Regarding knowledge for the women who answered questions correctly considered as (adequate knowledge), for whom did not answered considered as (inadequate knowledge) and the same applied for belief. Statistical analyses were performed using SPSS (16.0) with the significance level set at (0.05). Factors associated with levels of knowledge and belief examined by chi-square and Fishers' Exact tests.

2.RESULT & DISCUSSION
The population consisted of young women, nearly one third (23-27 years) and (29.4%) of them (28-32 years). Nearly half (42.7%) had at least some high school education such as institute or college certificate. More than half of them were housewives, and (58.4%) were barely financially sufficient as presented in Table.(1) . These characteristics are similar to those found in regional study in Iran by [11], who evaluated knowledge and performance of pregnant women referring to a hospital on exercises during pregnancy and postpartum periods. As for obstetric characteristics (44.7%) were in (29-38 weeks) of gestations, more than half were prime pregnancy with nulliparas, and more than two third of them had no abortion.    Figure.(2) .  Figure.(1) .These findings are in agreement with the results that reported in other regional countries study by others [11]who found that the (22%) of women in their study had good knowledge regarding exercise during pregnancy. More recent study in Turkey [12] researchers found majority of the pregnant women heard about the exercises performed during pregnancy but they do not have sufficient and true knowledge about the exercises performed in pregnancy.

Kirkuk University Journal /Scientific Studies (KUJSS)
Based on the findings, only (13.7%) of participant believes that exercises have positive effect on pregnancy, and the rest do not believe or believe that exercise has negative effect on pregnant women, fetus and pregnancy outcome, Figure.(2) .While Evenson & Braddly [13] found different result in their study on belief about exercise and physical activity among pregnant women and they reported that the (68%) of women agreed that most women who never exercised could begin an exercise program during pregnancy. Most (89%) agreed that regular exercise was better than irregular exercise during pregnancy. While almost all women agreed with the benefits of light activity (98. A study that evaluated factors associated with women's perceptions of the safety of physical activity in pregnancy found that women perceive physical exercise as beneficial because they believe it helps control blood glucose levels, minimizes weight gain, improves energy efficiency and mood, makes childbirth easier and contributes towards fetal health [14]. Nevertheless, although these women recognized these advantages, they believed that it was more important to rest and relax during pregnancy than to exercise.
These findings of previous study that mentioned before are not in agreement with the results of the present study, a lack of knowledge and belief concerning the benefits of exercise during pregnancy was main finding of present study results .The difference may have resulted from different factors such as; culture difference, most studies regarding belief in exercise in pregnancy carried out western society, according to our knowledge there is no regional study to evaluate women belief regarding exercise during pregnancy, Krans & Chang [15] found that the culture as a major contributing factor in knowledge and belief in exercise and concluded that the health care provider should be aware of cultural myth that prevent women from believing and performing some activities during pregnancy. Maternity and child health care and follow up system also may influence in the levels of knowledge and belief of pregnant women, information of benefit of exercises are absence in the program that apply in the maternity and child health care in the primary health care centers, shortage of health knowledge generally may be other factors affected women knowledge and belief.
Except age group the association was significant between all others socio-demographic variables and each of knowledge and belief levels, (p) value is (> 0.05). Level of knowledge and belief increase with increasing level of education, employment, good financial status, and extended family type while they decrease in housewife, poor financial and nuclear family type, as demonstrated in Table.(2) .  18  Present study evaluated factors associated with women's knowledge and belief, and showed that knowledge and belief in positive effect of physical exercise in pregnancy was significantly higher among the women with better education, being in paid employment, lives in extended family and had sufficient income, nevertheless, no statistically significant association was found between the pregnant women age and neither knowledge or belief.

N (%)
Regarding association of socio-demographic data previous study [16] found that the knowledge level of the pregnant women who are between the age of (31-39), university graduates pregnant was higher than the others, the researcher did not found association between level of knowledge and obstetrics factors such as delivery and pregnancy number. Furthermore they reported that socio-economic status as a significant predictor of different physical activity levels during pregnancy.
Socio-demographic factors such as education, income, and ethnicity, play a significant role in physical activity level knowledge and performance during pregnancy. A positive relationship between the level of education and exercise during pregnancy was consistent across different populations [17]. Women with higher education and level tend to engage in regular exercise more frequently as compared to those with lower education level. Ethnicity also plays a significant role in exercise during pregnancy. Research shows that whites exercise more than the non-white population [16].Differences in beliefs were most notable by educational level, race/ethnicity, and whether they participated in regular exercise during pregnancy [13].
The knowledge and belief of physical exercise during pregnancy was, however, significantly higher among women who had no previous abortion as showed in Table.(3) , this may result from wrong belief in our society that exercises and physical activities cause abortion while there was no association between number of pregnancy, gestation age and parity with each of knowledge and belief of physical exercises during pregnancy. Hegaard et al [18] found no significant association between parity and exercise.

3.CONCLUSIONS
Our results suggest that women's knowledge concerning the practice of physical exercise during pregnancy is inadequate and their belief is doing not believe in positive effect of exercises during pregnancy. The levels of knowledge and belief increase with increasing income, education, paid employment, and extended family, the history of previous abortion influence negatively the level of knowledge and belief. Maternal age, gestational age number of pregnancy had no effect on levels of knowledge and belief of pregnant women regarding exercises during pregnancy 4.RECOMMENDATIONS 1. Implement exercises and information regarding exercises and physical activities during pregnancy in the maternal child health program that provide health care and follow up care for pregnant women in the primary care health centers.

2.
Since women's activities are affected by medical recommendations, doctors, nurse and midwives should provide the necessary information about physical activity and exercises and its benefits during prenatal care.

3.
Health care providers should be aware of cultural myths that may prevent many women from performing certain activities during pregnancy.

4.
We recommend that this population should be given information about the benefits of the practice of simple, regular physical exercise such as supervised walking preceded by stretching exercises. Negative side effects would be insignificant and the return in terms of gestational well-being and health would be considerable.