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 Table of Contents 
Year : 2021  |  Volume : 10  |  Issue : 4  |  Page : 1628-1632  

Knowledge, attitudes and practice of primary care physicians in eastern provinces of Saudi Arabia towards exercise during pregnancy

1 Family Medicine Department, Family Medicine Academy in First Health Cluster in Eastern, Qatif, Eastern Province, Saudi Arabia
2 Family Medicine Department, First Health Cluster in Eastern Province, Qatif, Eastern Province, Saudi Arabia
3 Prince Sultan Military Medical City, Sulimania, Riyadh, Saudi Arabia
4 Family Medicine Department, Family Medicine Academy in First Health Cluster in Eastern, Aqrabiah, Khobar, Eastern Province, Saudi Arabia

Date of Submission16-Oct-2020
Date of Decision08-Dec-2020
Date of Acceptance01-Jan-2021
Date of Web Publication29-Apr-2021

Correspondence Address:
Dr. Eman H Albahhar
Family Medicine Department, Family Medicine Academy In First Health Cluster In Eastern, Riyadh Street, Qatif, Eastern Province 32613
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jfmpc.jfmpc_2135_20

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Context: Physical activity is well known to have enormous benefits for women in all phases of life, including pregnancy. Aims: The purpose of this study was to assess the knowledge, attitude, and practices of primary care physicians towards exercise during pregnancy in the eastern provinces of Saudi Arabia: Qatif, Dammam, and Al-Khobar. Methods and Material: A descriptive cross-sectional study was conducted between January and June 2019 among primary care physicians, based on a 32-item self-administered questionnaire distributed through e-mails and SMS messaging. Statistical Analysis Used: Descriptive statistics and Chi-square analysis were used to compare groups. Results: The majority of participants (97.3%) believed that exercise during pregnancy is beneficial and showed fair knowledge; however, most of them (86.5%) were unaware of the guidelines and nearly half of them (55.2%) did not give advice on exercise to their patients. Conclusions: Primary care physicians demonstrate fair knowledge and positive attitude towards exercise in pregnancy; however, their practice and recommendations did not align with the guidelines. Thus, we need to bridge this gap by providing well-structured evidence based continuous educational programs and activities to all physicians providing maternal care.

Keywords: Maternal care, physical activity, pregnancy, questionnaire

How to cite this article:
Albahhar EH, Albahhar ZH, Alqumber NA, Aljanahi E. Knowledge, attitudes and practice of primary care physicians in eastern provinces of Saudi Arabia towards exercise during pregnancy. J Family Med Prim Care 2021;10:1628-32

How to cite this URL:
Albahhar EH, Albahhar ZH, Alqumber NA, Aljanahi E. Knowledge, attitudes and practice of primary care physicians in eastern provinces of Saudi Arabia towards exercise during pregnancy. J Family Med Prim Care [serial online] 2021 [cited 2021 May 18];10:1628-32. Available from: https://www.jfmpc.com/text.asp?2021/10/4/1628/314921

  Introduction Top

Physical activity is well known to have enormous benefits for women in all phases of life, including pregnancy.[1] Since pregnant women have relatively frequent health care access, the antenatal period provides women the opportunity to modify their behavior and pursue healthier habits.

Physical activity has been included in several pregnancy care guidelines.[2] Despite its importance, most pregnant women demonstrate low levels of knowledge regarding safe exercise during pregnancy.[3],[4],[5],[6] Primary care providers play an integral role in promoting mothers and children health through effective preventive strategies, including physical activity encouragement during pregnancy

  Subjects and Methods Top

A descriptive cross-sectional study was conducted to assess the knowledge, attitude, and practice of exercise during pregnancy among primary care physicians in primary healthcare centers in three major cities Qatif, Dammam, and Al-Khobar, which represent the majority of primary care physicians in the Eastern Province of Saudi Arabia. The number of primary healthcare centers in Dammam, Khobar, and Qatif is 30, 16, and 31, respectively. The total number of physicians working in the three sectors is 310. Ethical approval obtained from Ministry of health committee 2019, January 1st.

All working physicians in the three sectors were included; however, dentists and physicians with only administrative work were excluded from the study.

After an extensive review of the literature, the questionnaire was adopted from similar studies conducted by Bauer et al.[7] The questionnaire was piloted for content, construct validity, and functionality. It consisted of five sections with 32 questions in total, including questions of physician demographic data and knowledge, attitude, practice, and barriers affecting antenatal physical activity prescription. The online questionnaire was set up to include 4–10 items per page and five screens in total. It was self-administered and sent electronically using Google forms through mobile phones and e-mails using the official list of the physician numbers and e-mails provided by the Ministry of Health.

The Checklist for Reporting Results of Internet E-Surveys (CHERRIES) was followed[8]; ethical approval was obtained from the ministry of health ethics committee. A questionnaire included an introduction explaining: the target population, study purpose and design, investigator contacts for any clarifications, and the time required for completing the questionnaire (7 minutes). Participants' consent was indicated by voluntarily completing the questionnaire. Personal data and information from the questionnaire were kept anonymous and confidential, and no incentives for participation were provided. The participants could only fill the questionnaire once using their e-mail to log in. Each part of the questionnaire was mandated to answer before going to the next part, to ensure completeness.

The completeness rate was calculated at 0.72 at the end of 4 month-period. Participants were grouped by the age, gender, practice location, degree, and years of experience. Frequency tables and descriptive statistics for all questions were calculated using IBM SPSS Statistics Base 23.0. Chi-square analysis was used to compare the groups. Statistical significance was noted when P < 0.05.

  Results Top

Demographic information of the participants is shown in [Table 1]. Most participants were females (75.8%) and aged between 31 and 40 years (56%). The results showed that 46.6%, 35%, and 18.4% of participants were practicing in Qatif, Al-Khobar, and Dammam sectors, respectively, and around half of them (54.3%) were in family medicine residency program.
Table 1: Participant demographic data

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The knowledge and attitude answers of the respondents are displayed in [Table 2], and they were largely positive. The majority of respondents (97.3%) believed that the exercise during pregnancy is beneficial. Eighty-six percent of them believed that pregnant women should participate in moderate-intensity exercise and (92.3%) encouraged long-term exercisers to continue it throughout the pregnancy. However, 86.5% were not aware of ACOG guidelines and 45.9% believed that pregnant women should not embark in strength training programs. [Figure 1] depicts the physician's opinion towards the benefit of exercise.
Figure 1: Benefits of exercise during pregnancy as perceived by primary care physicians

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Table 2: Knowledge and Attitudes of practitioners to key questions (n=223)

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Thirty-seven percent of the participants a were not confident about exercise counseling during pregnancy; however, they reported interest in attending workshops (95.5%) and local educational sessions (96%) on prenatal physical activity. [Table 3] and [Table 4] provide key statements regarding practice and barriers towards exercise during pregnancy. Despite the participant positive attitude and good knowledge, their practice was not aligned with the guidelines. Sixty-three percent did not obtain exercise histories and nearly half of them (55.2%) did not give exercise advice to their patients.
Table 3: Response of practitioners to key questions (n=223)

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Table 4: Response of practitioners to key questions (n=223)

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Nearly all the participants (95.5%) did not provide any informational pamphlets or written advice to their patients. Furthermore, quarter of participants (24.7%) did not recommend their patients to avoid certain types of exercises, and half of them (47.1%) believed that low-intensity exercise is sufficient to achieve maternal and fetal exercise benefits.

Approximately three-quarters of participants agreed that cultural beliefs (80.3%), time lacking in the clinic (82.1%), and incompetency (93.7%), in addition to anticipated fear of maternal and fetal harm (82.5%), were barriers affecting prenatal exercise prescription. Females appeared to be more aware of the current guidelines (15%) compared with males (5%), although this was not statistically significant (p = 0.051). Practitioners with higher levels of medical education were more likely to recommend moderate-intensity exercise (82.3%) compared with practitioners who discontinued further study after medical school (p = 0.000). No association was found between age and awareness of guidelines or exercise prescription (p = 0.14).

  Discussion Top

The studies have shown that exercise has enormous maternal and fetal benefits. The benefits include the reduction of excessive weight gain,[9] enhancement of psychological wellbeing, lowering of risk for depression and anxiety,[5] and improvement of sleep.[10] Furthermore, it has been found to prevent urinary incontinence during the pregnancy and postpartum period[11] and to decrease the chance of cesarean delivery and preterm birth.[12] It reduces the incidence of gestational hypertension and gestational diabetes mellitus (DM),[13] prevents osteoporosis, and improves cardiovascular and metabolic function.[1] Physical activity has been shown to be beneficial for pregnant women with comorbidities as well. For example, it is clearly evident that physical activity helps to achieve glycemic target in women with gestational DM and reduce the incidence of gestational DM in obese pregnant women.[14]

Physical activity has been included in several pregnancy care guidelines.[2] The World Health Organization recommends that adults aged 18 to 64 years should practice at least 150 minutes of moderate-intensity aerobic activity throughout the week, at least 75 minutes of vigorous-intensity aerobic activity, or an equivalent combination of the two.[15] In 2015, the American College of Obstetricians and Gynaecologists (ACOG) stated that women with uncomplicated pregnancies should engage in at least 150 minutes of exercise per week and should be physically active before, during, and after the pregnancy.[16] The 2019 Canadian Guideline for Physical Activity Throughout Pregnancy recommends that all women without contraindications should be physically active throughout pregnancy.[17]

Exercise is enforced by the Saudi Arabia Ministry of Health. In the mother and child health passport,[18] designed to guide maternal care, the exercise has been included as one of the components for health counseling, encouraging primary care physicians to advise moderate-intensity exercise to all healthy pregnant women.

Worldwide, sedentary lifestyle has been ranked as the fourth major cause of death.[15] Primary care physicians are essential in the health care system providing comprehensive, continuous care for the whole family, including women, in all stages of life. They play an integral role in educating patients and promoting the health of mothers and children through effective preventive strategies, including physical activity encouragement during pregnancy. In spite of the importance of exercise in pregnancy, to the best of our knowledge, no studies have been conducted in Saudi Arabia to assess the knowledge and practice of primary care physicians in antenatal exercise prescription.

Similar studies have highlighted the lack of healthcare practitioner knowledge and awareness of the guidelines.[7],[19],[20] Our study showed similar findings, although the majority of responses were positive regarding exercising during pregnancy, most of the participants regardless of the degree level were unaware of the current recommendations and guidelines, and nearly half of them believe that sedentary women should not practice exercise in pregnancy, and this was considered as a significant finding. Healthcare providers showed good knowledge of most exercise benefits during pregnancy; for example, over a half of the responders believed that exercise is beneficial in decreasing gestational DM, gestational hypertension, and weight gain and improving the self-image. However, the results showed that the majority were unaware of other benefits. Exercise has been shown to reduce the risk of preeclampsia.[6] In addition, pelvic floor exercise has an important role in the reduction of urinary and anal incontinence[3]; only a minority of responders were aware of this, therefore, their knowledge of these benefits should be improved. The study found a discrepancy between physician knowledge and practice, most of them did not obtain an exercise history, and almost all the participants did not prescribe exercises or provide pamphlets to their patients, and a large portion of them recommend low-intensity exercise. This could be attributed to their lack of awareness of the current guidelines, and some of may be afraid of judgment by members of their society if any maternal or fetal harm occurred, in comparison to the overseas countries, which showed similar findings.[15],[18],[19]

Healthcare providers should be aware that a normal pregnancy is a physiological state and pregnant women should be encouraged to initiate or continue moderate-intensity exercise throughout the pregnancy. Primary care physicians showed positive attitude and good knowledge towards exercise during pregnancy, thus we need to bridge the gap between the knowledge and practice by providing well-structured evidence based continuous educational programs and activities to all physicians providing maternal care and to organize assigned clinic days for prenatal care consultations so that the physician can focus on all the aspects of prenatal care.

Study strengths and limitations

This study provides the fundamental basis for future effective strategies of the promotion of antenatal physical activity in primary care clinics. From this study we put forward the recommendation that well-structured, evidence based continuous educational programs and activities should be provided to all physicians providing maternal care, as well as the organization of assigned clinic days for prenatal care consultations so that the physician can focus on all the aspects of prenatal care.

Similar studies have been done in other countries.[15],[18],[19] This is the first study conducted in Saudi Arabia. Several guidelines are available and primary care physicians play an integral role in prenatal care. This study assessed the application of these guidelines to pregnant women at the primary care level. However, it has some limitations. It was conducted in certain cities Qatif, Dammam, and Al-Khobar in the eastern region of Saudi Arabia. Therefore, it may not reflect the entire Saudi Arabian primary care physician practice. Such research should expand to include other cities and regions of the country to closely reflect the family physician knowledge and attitude towards physical activities. In the future, we hope to conduct a qualitative study design to truly reflect the clinical practice.


Many thanks to all physicians who gave their time and participated in this study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Prather H, Spitznagle T, Hunt D. Benefits of exercise during pregnancy. PM R 2012;4:845-50.  Back to cited text no. 1
Evenson K, Barakat R, Brown W, Dargent-Molina P, Haruna M, Mikkelsen E, et al. Guidelines for physical activity during pregnancy. Am J Lifestyle Med 2013;8:102-21.  Back to cited text no. 2
Hesketh KR, Evenson KR. Prevalence of US pregnant women meeting 2015 ACOG physical activity guidelines. Am J Prev Med 2016;51:e87-9.  Back to cited text no. 3
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:e0128953.  Back to cited text no. 4
Harrison AL, Taylor NF, Shields N, Frawley HC. Attitudes, barriers and enablers to physical activity in pregnant women: A systematic review. J Physiother 2018;64:24-32.  Back to cited text no. 5
Al-Youbi GM, Elsaid T. Knowledge, attitude, and practices on exercise among pregnant females attending Al-Wazarat Health Center, Riyadh, Saudi Arabia. J Family Med Prim Care 2020;9:3905-15.  Back to cited text no. 6
  [Full text]  
Bauer P, Broman C, Pivarnik J. Exercise and pregnancy knowledge among healthcare providers. J Womens Health (Larchmt) 2010;19:335-41.  Back to cited text no. 7
Eysenbach G. Improving the Quality of Web Surveys: The Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res 2004;6:e34.  Back to cited text no. 8
Nascimento SL, Surita FG, Cecatti JG. Physical exercise during pregnancy. Curr Opin Obstet Gynecol 2012;24:387-94.  Back to cited text no. 9
Youngstedt SD. Effects of exercise on sleep. Clin Sports Med 2005;24:355-65.  Back to cited text no. 10
Stafne SN, Salvesen KA, Romundstad PR, Torjusen IH, Mørkved S. Does regular exercise including pelvic floor muscle training prevent urinary and anal incontinence during pregnancy? A randomised controlled trial. BJOG 2012;119:1270-80.  Back to cited text no. 11
Di Mascio D, Magro-Malosso ER, Saccone G, Marhefka GD, Berghella V. Exercise during pregnancy in normal-weight women and risk of preterm birth: A systematic review and meta-analysis of randomized controlled trials. Am J Obstet Gynecol 2016;215:561-71.  Back to cited text no. 12
Magro-Malosso E, 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;96:921-31.  Back to cited text no. 13
Cremona A, O'Gorman C, Cotter A, Saunders J, Donnelly A. Effect of exercise modality on markers of insulin sensitivity and blood glucose control in pregnancies complicated with gestational diabetes mellitus: A systematic review. Obes Sci Pract 2018;4:455-67.  Back to cited text no. 14
WHO | Global recommendations on physical activity for health [Internet]. Who.int. 2018 [cited 5 November 2018]. Available from: http://www.who.int/dietphysicalactivity/factsheet_recommendations/en/.  Back to cited text no. 15
ACOG Committee opinion no. 650 summary: Physical activity and exercise during pregnancy and the postpartum period. Obstet Gynecol 2015;126:e135-42.  Back to cited text no. 16
Mottola M, Davenport M, Ruchat S, Davies G, Poitras V, Gray C, et al. No. 367-2019 Canadian guideline for physical activity throughout pregnancy. J Obstet Gynaecol Can 2018;40:1560-70.  Back to cited text no. 17
2020. Ministry of Health.Child Health Mother and Child Health Passport. [online] Moh.gov.sa. Available from: https://www. moh.gov.sa/en/HealthAwareness/EducationalContent/ BabyHealth/Pages/BabyHealthPassport.aspx. [Last accessed 2020 Sep 26].  Back to cited text no. 18
Watson ED, Oddie B, Constantinou D. Exercise during pregnancy: Knowledge and beliefs of medical practitioners in South Africa: A survey study. BMC Pregnancy Childbirth 2015;15:245.  Back to cited text no. 19
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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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