“Just because you’re pregnant, doesn’t mean you’re sick!” A qualitative study of beliefs regarding physical activity in black South African women

Pregnant (29–33 weeks gestation) participants were recruited from the MRC/Wits Developmental Pathways for Health Research Unit (DPHRU), based at Chris Hani Baragwaneth Hospital (CHBH), Soweto, South Africa. Soweto, an English abbreviation for South Western Township, is one of the largest urban areas in South Africa, with over one million inhabitants. Although the majority of its inhabitants come from low-income households, it also has a rising middle class and this, combined with historical apartheid-related poverty, makes it a complex mix for social inequalities and health care issues (www.​soweto.​co.​za).​

A purposive sampling approach was used to include a homogenous group of singleton, black pregnant women with non-complicated pregnancies in the third trimester [20]. Women were purposively recruited from a public antenatal hospital, as this is a proxy for low to middle socioeconomic status in South Africa. A sample matrix [20] was designed to include a sample size of 15 women; however, data saturation was reached after 13 interviews. The women attended the DPHRU for non-clinical, research purposes every 4–6 weeks during their pregnancy as part of a larger study (Soweto First 1000 Days study). Reporting of methods has been based on the Relevance, Appropriate, Transparency and Soundness (RATS) review guidelines to ensure rigour and quality [21, 22].

This study adopted a deductive logic approach [20] and was grounded in the Theory of Planned Behaviour (TPB) [16]. Since this research was aimed at eliciting personal experiences and perceptions regarding the concepts of physical activity in its broader sense, an interpretative phenomenological analysis approach was adopted [20]. Within the construct of PBC, the current study did not explicitly address the areas of self-efficacy or controllability. Instead, this was measured indirectly based on beliefs regarding the perceived ease or difficulty in participating in and performing a behaviour (e.g. I don’t have the money to attend the gym) [16, 18, 19, 23]. This belief based method of measuring PBC may have the advantage of providing underlying cognitive insights that would otherwise be missed if measured directly [19]. The rationale, as described by Ajzen [16], is that the more resources and opportunities available, and the less or more manageable the barriers, the increased confidence to participate in the behaviour, and the higher the degree of perceived behavioural control exhibited [19]. Furthermore, perceived control over the performance of a behaviour also involves various intrinsic and extrinsic factors that may serve to help or hinder the behaviour. Although it may be argued that self-efficacy is measured through intrinsic factors, and controllability through external factors, these concepts may reflect both beliefs and were therefore not treated as mutually exclusive in the current study [19]. Since self-efficacy and controllability are also found to be closely related, both these constructs can be seen as influencers of an individual’s perceived ability to control their behaviour [19].

Semi-structured interviews were conducted between March – December 2014. All interviews were conducted in English, which is the language common to most inhabitants of Soweto. Each interview was conducted at the DPHRU by the researcher (EW), who did not have a clinical role in the participants’ visits to DPHRU. Open-ended questions, with probes, were developed using the TPB theoretical framework, and informed by previous studies [24‐27]. They were designed to facilitate breadth and depth of conversation and provide information-rich discussion [20]. Although the concept of perceived behavioural control was not explicitly asked in the interview guide, questions related to factors that obstruct or facilitate participation in physical activity were used to elicit the participants’ perception about their control over the achievement of the behaviour [24]. The guide was reviewed for qualitative properties by an expert in the field of public health, and pilot tested prior to data collection. Each interview, which lasted between 45 and 80 min, was audio-recorded and notes on non-verbal actions were taken by the researcher.

Demographic and pregnancy medical history information was collected on all participants using an interview-administered questionnaire. Furthermore, physical activity levels were measured using the Global Physical Activity Questionnaire (GPAQ), a valid and reliable tool that measures physical activity in various domains, including work, travel and recreation [28].

Recorded data were transcribed verbatim and reviewed by the researcher for accuracy. A formal thematic analysis process was undertaken, including familiarisation, construction of an initial framework within the TPB, indexing and sorting, reviewing, data summary, constructing categories and identifying links and patterns [20]. A data analysis software tool (ATLAS.ti 5.0) was used to organise the codes and themes into a structure for analysis. Major themes are represented according to frequency, and thematic saturation was reached by the ninth interview. To ensure reliability of the coding framework the initial thematic coding was completed and left, and then done again one month later. In addition, a sample of three transcripts were peer-reviewed to agree on the coding framework.

Although some women warned against the potential adverse effects of alcohol, drugs, stress and heavy work during pregnancy, the majority of participants were aware of the importance of adopting healthy behaviours during pregnancy including a healthy diet, exercise, and sufficient rest.

“A good diet. Exercise, but not excessive exercise. Good rest is also very important.” (BMI 30 kg/m ² ; Active)

All the women who participated in the interviews believed that physical activity was in some way beneficial. For most of the women, walking appeared to be the preferred form of physical activity. The most popular perceived benefits reported by participants included the belief that physical activity would help to prepare the body for labour, reduce labour time, and that the baby would also be prepared:

“It helps relax the muscles so that when you give birth, the muscles are not tight, they’re used to expanding, yes, that movement and even the baby is used to the movement and he won’t be surprised…it prepares the body and the baby also.” (BMI 24.6 kg/m ² ; Active)

One woman explained:

“I think for my own health…Apart from the birth, I think for myself, my own health, my heart, and I also feel the skin, I don’t know, when I’m walking, I feel like my skin is breathing more. So I think it keeps it healthier, you know? The more it sweats and, I think it’s good….It helps you relax as well. When you [walk], it is kind of therapeutic for me, I don’t know.” (BMI 30 kg/m ² ; Active)

For many of the women, physical activity was defined as an activity of daily living, such as occupational and household tasks, and few described it as recreational. Throughout the interviews, many women presented the idea that being busy was synonymous with being active:

“I f you have a job, that job keeps you busy, you are always busy so the baby is busy too, but if you are always sleeping the baby will be sleeping too.” (BMI 32 kg/m ² ; Active)

Another woman commented:

“Physical activity, I think, is just keeping active…when you’re home walking around and not sitting too still. I have a baby so she keeps me very busy. If you have a child you don’t have a problem with physical activity because you’re always running after them.” (BMI 30 kg/m ² ; Active)

While participants reported on the benefits of physical activity, several women were also conscious of ‘overdoing’ it during pregnancy. Certain occupational, household and recreational tasks were described as too vigorous and were therefore perceived as unsafe. Many women revealed a general uncertainty, without always knowing why these activities were deemed unsafe. The perception as to whether a certain activity was safe or not, often originated from advice from family and friends, or listening to their own bodies:

“I can talk about me…we used to go and fetch water at the tap, we must use the bucket and …when I pick it up, I can feel something inside me that is telling me that this thing is heavy just leave it, you know.” (BMI 30.6 kg/m ² ; Active)

One woman commented:

“I don’t know about swimming…you know you’re working on all muscles of your body, so I don’t know what impact that would have. Things like bending over, squatting… I always feel because it’s very difficult… I think maybe it’s hurting the baby.” (BMI 30 kg/m ² ; Active)

The women in the current study discussed various barriers, or obstacles, to participating in physical activity, which may influence the perceived control that women have over their physical activity behaviour, therefore reducing the time spent being physically active. The most frequently reported intrinsic barriers included tiredness, morning sickness, interrupted sleep and discomfort due to the size of the stomach. Participants appeared to display a reduced self-efficacy, and described the increasing difficulty in performing physical activity due to the pregnancy-associated physical changes. This was combined with a limited perceived control over their activity levels, where the unborn baby was described as determining the amount of physical activity done:

“You know, this person is heavy, that you’re carrying….you get very tired. And being tired makes you sit down more, and you’re not very… you can’t do much.” (BMI 26.8 kg/m ² ; Active)

Another participant commented:

“You’re tired quicker when you're pregnant. I can tell when I can’t take anymore, so I just stop when I feel like that’s enough. Pregnancy is quite interesting, because you have those bouts of activity, you know, being extremely active and you do not know where it comes from and then the next minute you’re, like, I don’t want to do anything. I’m tired. So, it’s quite interesting in that sense. It differs from woman to woman. It depends on how heavy your belly is.” (BMI 30 kg/m ² ; Active)

On the other hand, one woman described her belief that these barriers are within her control, and was determined not to allow the pregnancy to affect her behaviour:

“They just say that this pregnancy it’s too tiring…so if you let the pregnancy control you, you won’t do anything in life truly. It does not mean that the baby just took over your body or your everything, you must exercise, you must eat well and do everything just the way that you are, you are not sick you are just pregnant.” (BMI 32 kg/m ² ; Active)

Commonly reported extrinsic barriers included limited time or money available for physical activity. Prioritising their resources to meet their family’s needs appeared to diminish the participants’ perception of control towards being active:

“I don’t have the time [to go to the gym]. When I’m coming to work I’m tired seriously. When you are off you are supposed to do the things at home so there is not time to go to gym.” (BMI 37.4 kg/m ² ; Active)

Another woman commented:

“Some [people] do not have the money to buy healthy food. Yes it [gym] is expensive, and that money you can use for the child…to buy medication for that child or milk.” (BMI 32.2 kg/m ² ; Inactive)

Another extrinsic barrier noted by many women was the lack of information provided by healthcare professionals about physical activity during pregnancy. Many women reported receiving little information at the antenatal clinics, and information that was provided was often vague or non-specific. Some women mentioned that, within the healthcare system, education regarding communicable diseases was prioritised over providing information on the benefits of physical activity. Added to this, many women reported bad experiences at their antenatal clinics that prevented them from asking any physical activity-related questions:

“They [the nurses] are just teaching HIV and AIDS and that’s it. There’s no time to ask questions or anything, you know…” (BMI 24.6 kg/m ² ; Active)

Another woman agreed:

“No to be honest those people [the nurses] are mean and they’re not helpful. I don’t know, maybe they don’t like pregnant women, we are making their lives difficult somehow. They don’t seem to care that much so I wouldn’t trust someone who doesn’t care about you at all. No I’m very intimidated by them so I do not ask questions, I rather ask friends and family.” (BMI 29.4 kg/m ² ; Inactive)

In fact, one women articulated the importance of being provided with correct information to improve her perceived behavioural control, noting that with advice and education she would be more likely to be active:

“I don’t know, I’m just too lazy to do them [exercise], I don’t know. Or maybe I don’t know the importance of doing them.” (BMI 29.4 kg/m ² ; Inactive)

Many women also discussed extrinsic and environmental influences that would assist them in becoming more active. They were particularly supportive of having community-based group exercise classes aimed at pregnant women. A supportive and safe environment appeared to be a motivator to become active, and may therefore improve their perceived behaviour control in this area. Many of the women felt that not only would these community facilities improve their physical activity behaviour, but that it would provide an opportunity to expand their social support network:

“Having antenatal classes in my neighbourhood, that would be awesome actually. Because they focus more on pregnant woman so I’ll feel much safer. I know I can do anything that they tell me to do there; because I know it’s not going to harm the baby. That would be great…I just want my baby to be safe.” (BMI 29.4 kg/m ² ; Inactive)

And another agreed:

“Pregnant ladies coming together, doing such [exercises], it would help a lot. If I had a group like that next to me, I would have been doing it…because that’s where you get to know also the other experiences and what other ladies go through.” (BMI 26.8 kg/m ² ; Active)

Healthcare providers were reported by some of the women as potential social influencers of their physical activity behaviours. However, since they provided very little education, healthcare workers were unlikely to provide any social pressure when it comes to participating in physical activity:

“If they [the gynaecologist] also gave us information on that, that would help – the exercise positions, show you that when you’re pregnant you can do this, or in late pregnancy, you can’t do this. They don’t tell you…they never even mentioned to me to do exercise.” (BMI 30 kg/m ² ; Active)

Due to this lack of information, many women turned to family, friends or the media for advice regarding pregnancy. However, in most cases, this advice encouraged women to reduce their activity levels during pregnancy, as a time to “take it easy”. Furthermore, this advice to reduce activity levels was coupled with the fact that many women did not have family or friends that participated in, or talked about the importance of, physical activity:

“Just because you’re pregnant it doesn’t mean you’re sick, you’re not sick at all…go ahead and do what you normally would do, your daily routines as usual, keep them going until you can …You know, it’s so easy to be spoiled. My family …they used to just spoil me, but no, don’t do this, don’t go down, don’t pick it up, don’t do this, you know? So you get spoiled easily, and it’s easy for you to go, ah, I don’t feel like doing this, and get so lazy…” (BMI 26.8 kg/m ² ; Active)

One woman described her friend’s reactions to being active:

“Most of my friends are not physically active. If I even mention walking, they’re like, "Why would you …? “Only dogs walk” you know? I’m like, "No, it’s good for you!" They always want to drive, so yes. That’s the experience that I’ve always had. I don’t know if it’s a South African thing, but most people just want to get into a car. My husband is, every time I say, let’s go on a walk he says no. He doesn’t feel a need. Whereas for me it is…kind of…a need.” (BMI 30 kg/m ² ; Active)

Many of the participants mentioned cultural beliefs and practices during pregnancy that are passed down through the generations. Often the women noted that these beliefs and practices are followed without knowing the reasoning behind them. One woman described the beliefs passed on from her family:

“We have a lot of indigenous knowledge on pregnancy and, you know, as African people, you’re taught that at a very young age. "Do this, don’t …" You know, some of them are silly, but…! Like, don’t stand by the door, you know? Okay, some are just common knowledge, it’s like common sense. Don’t stand for too long. Maybe that’s why they say don’t stand at the door, but they have their own reasons, like superstitious reasons. You know, sometimes I remember things my mom used to tell me not to do this, from like a long time ago, but she never told me why! But I do it, every time. Even physical activity, some people will say, you don’t sleep enough. Why are you walking? You know? Things like that. You should just let your husband drive you, things like that. "Why are you so busy? You have to rest." You know? "You're pregnant.” (BMI 30 kg/m ² ; Active)

There appeared to be conflicting ideas regarding activity during pregnancy. Whilst most women reported that their families were encouraging them to rest and take it easy, many women also reported on being warned of the dangers of too much rest. Many women alluded to the concept of being lazy during pregnancy, and believed this excessive rest was associated with adverse delivery outcomes:

“There’s this myth that if you sleep a lot during the day the baby gets lazy, and when it’s nearer to giving birth, the baby won’t know when it’s time…you might get issues with the baby still sitting and the baby doesn’t want to come.” (BMI 26.8 kg/m ² ; Active)

This study reached saturation after 13 interviews, and therefore utilized a small, homogenous sample of urbanised black South African women, and may not be representative of other races, cultures or communities. Therefore, the findings from this study should be applied with caution to other contexts and sub-cultures. However, very little research has been done in black African women, and our study adds to the theory-based research upon which intervention protocols for pregnant women can be based.

Furthermore, the interviews were conducted in English, and although all women could speak English, there may have been a small percentage that could not have been able to fully express themselves. Despite these limitations, the current study provided rich data that reflects unique cultural beliefs and environmental context.