medRxiv preprint doi: https://doi.org/10.1101/2023.07.25.23292807; this version posted July 28, 2023.

The copyright holder for this preprint

(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

A CROSS-SECTIONAL SURVEY OF AUSTRALIAN WOMEN’S PERSPECTIVES

AND EXPERIENCES OF EXERCISE DURING PREGNANCY, INCLUDING
WOMEN THAT EXPERIENCE MENTAL ILLNESS

Noor S. Jarbou (PhD)ᵃ, Kimarnie Baskerville (MD)b, Mariam Gabra (MD)b, Tess Mawson
(MClinEP)ᵃ, Kelly A. Newell (PhD)ᵃ* and Jessica Nealon (PhD)ᵃ ,ᵇ*

Affiliations:
ᵃ Molecular Horizons and School of Medical, Indigenous and Health Sciences, Faculty of Science,
Medicine and Health, University of Wollongong, Wollongong, New South Wales 2522 Australia
b
Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales 2522
Australia
*joint corresponding authors: Kelly A. Newell knewell@uow.edu.au; Jessica Nealon
jnealon@uow.edu.au

Abstract
Purpose: The aim of this study was to develop an understanding of Australian women’s perspectives and
experiences around exercise during pregnancy, including women that experience mental illnesses such as
depression.
Method: An anonymous online survey of women, administered via Qualtrics Australia, was open for 4 weeks
between November - December 2021. The survey consisted of a 45-item questionnaire collecting data on
demographics (including pregnancy status), attitudes/beliefs regarding conducting exercise during pregnancy,
knowledge of exercise in pregnancy guidelines, exercise in pregnancy experience and mental health
experiences of responders during pregnancy. Analysis of responses were restricted to those who have
experienced a pregnancy. Descriptive statistics and frequency tables were calculated for all questions.
Pearson’s Chi-Squared tests were used to determine the differences in response by mental health status
(p < 0.05).
Results: There were 695 eligible responses. Most responders believe that regular exercise during pregnancy is
safe for mother and baby (94%), would help prevent a decline in a pregnant person’s mood (88%) and help to
improve a pregnant person's mood (92%). The majority of responders (71%) were not aware of the WHO and
Australian Government Department of Health recommendations for conducting exercise during pregnancy.
68% of responders conducted exercise during all or part of their most recent pregnancy. However, there was a
significant association between a reported diagnosis of a mental illness during their lifetime and participation
in structured exercise during pregnancy (p=0.009), with fewer individuals with a mental illness exercising
during pregnancy compared to those without (61 vs 71%). Despite the majority of respondents participating in
exercise during pregnancy, more than half of responders report conducting less exercise than that recommended
by current guidelines. Fifty-seven percent of responders recall being advised to exercise during their most
recent pregnancy, mostly by their GP (54%), midwife (46%) and obstetrician (38%). Walking was the most
advised exercise type (80%) followed by swimming (46%). However, 69% of responders report receiving no
or little advice from their healthcare provider about the safety and benefits of exercise during their most recent
pregnancy, but 45% of responders felt satisfied about the advice they did receive.
Conclusion: This study has shown that Australian women believe that exercise during pregnancy is safe and
has benefits for mental health. However, many women report receiving little advice about this from their
healthcare provider. Furthermore, women report not being aware of or meeting the WHO/National guidelines
regarding exercise in pregnancy. Women do report primarily conducting low intensity exercise during
pregnancy (walking, swimming, yoga). Importantly, fewer respondents with a diagnosed mental illness report
exercising during pregnancy. Considering the potential benefits of exercise for mental illness, employing
strategies to increase engagement with exercise during pregnancy is important. Further research to determine
strategies to increase exercise in pregnant women, particularly those with a mental illness, are needed.
NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.

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medRxiv preprint doi: https://doi.org/10.1101/2023.07.25.23292807; this version posted July 28, 2023. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

Introduction

Exercise during pregnancy has been shown to have numerous benefits for women including

decreased risk of developing gestational diabetes (Abirami and Judie, 2014; de Barros et al., 2010;

Koivusalo et al., 2015), hypertension and preeclampsia (Kasawara et al., 2012; Martin and Brunner

Huber, 2010; Spracklen et al., 2016), reduced risk of excessive gestational weight gain (Bennett et

al., 2018; Hinman et al., 2015; Hopkins and Cutfield, 2011), improved cardiovascular function

(Witvrouwen et al., 2020), and prevention of or improvement in lower back and pelvic pain during

pregnancy (Davenport et al., 2019b). Emerging evidence also suggests exercise in pregnancy is

beneficial for mental health. In our recent systematic review we showed that structured exercise

(including resistance training, walking, and aquatic exercise) during pregnancy in those with no

diagnosed mental illness, reduced anxiety and depressive scores when measured during and after

pregnancy (Jarbou and Newell, 2022). In the limited studies that have examined exercise in

pregnancy in depression, the exercise interventions have been restricted to yoga, with the evidence

regarding its ability to reduce anxiety and depressive-like symptoms inconclusive (Jarbou and

Newell, 2022).

The World Health Organisation (WHO), Exercise and Sports Science Australia (ESSA) and the

American College of Obstetrics and Gynaecology (ACOG) recommend that pregnant women,

without contraindications(e.g. preeclampsia, premature labour, incompetent cervix), participate in at

least 150 mins of moderate intensity exercise or 75 mins of vigorous intensity exercise per week (or

an equivalent combination thereof), or exercise at least five days per week (e.g., completing 30-min

of exercise for 5 days a week to perform 150 mins) (Bull et al., 2020). Women should avoid contact

sports, sit-ups, risk of falls or supine exercises, but are encouraged to participate in Pilates or yoga,

walking, stationary cycling, and aquatic based activities (Exercise and Sports Science Australia

2018, p. 25). These recommendations are also reflected in the Australian Department of Health

guidelines for physical activity during pregnancy (Australian Goverment Department of Health,

2021).

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medRxiv preprint doi: https://doi.org/10.1101/2023.07.25.23292807; this version posted July 28, 2023. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

Despite the potential benefits of exercise and the guidelines recommending exercise during

pregnancy, pregnant women are not meeting the recommended guidelines for exercise worldwide

(Gaston and Vamos, 2013; Gjestland et al., 2013; Hesketh and Evenson, 2016; Mottola et al., 2018).

Recently, the Australian Institute of Health and Welfare (AIHW) reported that only 30% of pregnant

women met the physical activity recommendations of WHO and the Australian Department of Health

(Australian Institute of Health and Welfare, 2019). On the other hand, the same AIHW report found

that around 66% of women who were not pregnant met the WHO and Australian Department of

Health guidelines (Australian Institute of Health and Welfare, 2019). A study based in Rockhampton

Australia reported that 92% of study participants were not meeting the guidelines for exercise in

pregnancy, but the study was limited by the small sample size (n = 142) and its regional location

(Hayman et al., 2016), emphasising the need for further research on the Australian population.

Collectively, this raises the question of why pregnant women are not meeting these guidelines. In the

past, there have been concerns regarding the possible consequences of exercise in pregnancy on the

foetus (Artal et al., 2003), however the current guidelines reflect that the many benefits outweigh

any potential risks. Exercise has been shown to not be associated with a greater risk of miscarriage,

perinatal mortality or birthing a child small for gestational age (Davenport et al., 2019a). A recently

published Australian review on physical activity in pregnancy and the postpartum period reported no

evidence of adverse outcomes of any form of exercise, including resistance training, during

pregnancy (Brown et al., 2022). They further reported that physical activities during pregnancy

should depend on individual preferences and pre-pregnancy routine activities (Brown et al., 2022).

Furthermore, the review revealed a potential association between sedentary behaviour during

pregnancy and poorer maternal and foetal circulatory health outcomes (e.g. venous pooling) (Brown

et al., 2022). It is not clear if pregnant women are aware of the benefits of exercise and the guidelines

regarding exercise in pregnancy, or whether they receive advice to exercise during their pregnancy.

Insufficient advice from healthcare practitioners has been reported to contribute to the low rates of

engagement in satisfactory exercise during pregnancy in USA, among Hispanic, African American,

and White participants (Evenson et al., 2009), with the majority (60%) of American obstetricians

indicating they were unaware of the recommended guidelines for exercising during pregnancy

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medRxiv preprint doi: https://doi.org/10.1101/2023.07.25.23292807; this version posted July 28, 2023. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

(McGee et al., 2018). A survey conducted in regional Australia (through 11 medical practices within

the Rockhampton region of Central Queensland), reported that only 1.5% of respondents could recall

a health practitioner providing them with exercise guidelines during pregnancy (Hayman et al.,

2016). In 2015, Watson et al., reported in a South African convenience sample that despite the

majority of medical practitioners believing that exercise in pregnancy was beneficial, the majority

were not aware of the recommended guidelines and their advice did not always align with the current

guidelines (Watson et al., 2015).

The aim of the current survey was to develop an understanding of Australian women’s perspectives

and experiences around exercise during pregnancy, including women that experience depression or

other mental illness. Specifically, this study aimed to obtain Australian women’s perspectives and

experiences regarding:

1) Whether Australian women are aware of the national and international guidelines regarding

exercise in pregnancy

2) Whether women, including those with depression or mental illness, were meeting these guidelines

in pregnancy and what types of exercise women were performing

3) What advice women received about exercise during pregnancy, and

4) Women's perception about the safety of exercise in pregnancy and the potential benefits of exercise

in pregnancy for the prevention and management of depressive symptoms.

Methodology

This survey study was approved by the University of Wollongong Human Research Ethics

Committee (HREC) in compliance with the National Statement on Ethical Conduct in Human

Research (2021/335).

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medRxiv preprint doi: https://doi.org/10.1101/2023.07.25.23292807; this version posted July 28, 2023. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

Study design

An anonymous online survey, administered via Qualtrics Australia, was used to collect data for this

study. The survey aimed to develop an understanding of Australian women’s perspectives and

experiences around exercise during pregnancy, including women that experience depression. It

assessed women’s perspectives about: 1) safety of exercise during pregnancy, 2) preferable exercise

type during pregnancy, 3) whether exercise in pregnancy is beneficial for depression/mood, 4)

sources of medical advice about exercise in pregnancy and 5) whether women are meeting the WHO

and the Australian Department of Health guidelines regarding exercise in pregnancy. The study

population was defined as any person over the age of 18 who had previously been or were currently

pregnant and was currently living in Australia. A subset of questions from the survey were directed

at those participants who have never been pregnant. These questions and responses were excluded

from the current project as they do not answer the aims of this study. Demographic details were

collected followed by questions on the respondent’s knowledge and beliefs around the benefits and

risks of exercise in pregnancy as well as their physical activity habits during pregnancy. The survey

consisted of the following components:

1. Demographics

2. Pregnancy status (recent pregnancy, method of delivery, number of pregnancies, etc.)

3. Health status (including trusted medical information source, advice they received)

4. Attitudes/beliefs (regarding conducting exercise during pregnancy)

5. Physical activity habits during pregnancy

The final survey for those who have carried a pregnancy consisted of 45 questions. Response formats

were varied to serve each question’s aim and type, to include fixed category format, free text

responses and Likert scales. Skip logic resulted in having some questions not being displayed to all

participants. Survey questions can be found in the supplementary materials.

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medRxiv preprint doi: https://doi.org/10.1101/2023.07.25.23292807; this version posted July 28, 2023. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

Validity of Questionnaire

The face validity of the survey was assessed by inviting 10 women of varying ages (≥18), including

pregnant and non-pregnant women, to read aloud the questionnaire with a member of the research

team. Participants then indicated their understanding and provided feedback to a member of the

research team. Comments and suggestions were incorporated into the survey revision, to ensure that

every question was clear and the format for answering was suitable.

Pilot survey

The survey was piloted on the researchers’ personal social media networks for three days to improve

reliability and validity for a wider audience. 47 participants responded to the pilot survey; analysis

of this data resulted in several changes being made to the survey tool (e.g. inclusion of additional

response options for some questions, correcting the survey logic).

Recruitment

The survey was launched in November 2021 and remained open for four weeks. Invitation to

participate in the survey was shared on various Facebook groups that were identified by the

researchers to be of relevance to the target audience. Facebook groups were identified using key

search terms such as “mums”, “bubs”, “baby”, “mothers”, “pregnant” and were restricted to

Australian pages. The survey was also advertised on Twitter and Instagram.

Data analysis

Data was analysed using IBM SPSS Statistics for Windows, Version 28.0. (IBM Corp., Armonk,

NY, USA). Frequencies and descriptive statistics of respondent characteristics were calculated and

presented in tables. Pearson’s Chi-Square analyses were performed to assess the association between

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medRxiv preprint doi: https://doi.org/10.1101/2023.07.25.23292807; this version posted July 28, 2023. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

variables according to prior mental health diagnosis, and pairwise z-tests adjusted to Bonferroni

correction to assess the differences between columns’ proportions. Significance was reported when

p<0.05.

Results
Demography

Demographic details are provided in Table 1. There was a total of 695 eligible responses. The

majority (51%) of the participants were 26-35 years of age. Thirty-seven percent of respondents had

been diagnosed with a mental illness during their life-time. Those that had been diagnosed with a

mental illness during their lifetime had significantly more respondents in the 18-25 age category and

fewer in the 46 and over category (p<0.001), fewer respondents with university level education

(p<0.001) and lower household income (p<0.001). There was no difference in recency of pregnancy

between those that had and had not been diagnosed with a mental illness during their lifetime, with

61% of all respondents being pregnant within the previous two years. One hundred and fifty-seven

respondents (24%) reported experiencing mental illness during pregnancy; and 12% reported

experiencing depression during pregnancy (Supp. Table S1).

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Table 1: Demographic details of the responders
Variables n (%) Diagnosed with a mental illness
during their lifetime
Total Yes No Chi-square p-value
responses value
Age 687 253 (36.8) 434 (63.2)
18-25 54 (7.9) 31(12.3)* 23(5.3)*
26-35 349 (50.8) 140(55.3) 209 (48.2)
23.773 <0.001
36-45 205 (29.8) 67 (26.5) 138(31.8)
46 and over 79 (11.5) 15(5.9)* 64(14.7)*

State of residence 683 252 (36.9) 431 (63.1)

NSW 458 (671) 175 (69.4) 283 (65.7)
ACT 40 (5.9) 17 (6.7) 23 (5.3)
NT 3 (0.4) 0 (0) 3 (0.7)
QLD 69 (10.1) 14 (5.6) 55 (12.8) 13.291 0.065
SA 15 (2.2) 4 (1.6) 11 (2.6)
TAS 8 (1.2) 4 (1.6) 4 (0.9)
VIC 61 (8.9) 25 (9.9) 36 (8.4)
WA 29 (4.2) 13 (5.2) 16 (3.7)

Length of time since most recent pregnancy 670 243 (36.3) 427 (63.7)
Currently pregnant 173 (25.8) 59 (23.3) 114 (26.7)
< 6 months 102 (15.2) 44 (18.1) 58 (13.6)
6-12 months 65 (9.7) 23 (9.5) 42 (9.8) 3.103 0.541
12-24 months 66 (9.9) 26 (10.7) 40 (9.4)
> 2 years 264 (39.4) 91 (37.4) 173 (40.5)

8
Experienced mental illness during pregnancy 654 241 (36.9) 413 (63.1)
No 497(76) 117(48.5)* 380(92)*
157.582 <0.001
Yes 157(24) 124(51.5)* 33(8)*

Ethnicity 683 253 (37) 430 (63)

Non-Caucasian 109 (16) 35(13.8) 74(17.2)
1.353 0.245
Caucasian 574 (84) 218(86.2) 356(82.8)

Marital status 688 254 (36.9) 434 (63.1)

Married 464 (67.4) 141(55.5)* 323(74.4)*
Cohabiting / Defacto 154 (22.4) 74(29.1)* 80(18.4)*
Partner but live separately 18 (2.6) 11(4.3)* 7(1.6)*
Divorced 21 (3.1) 8(3.1)* 13(3)* 32.196 <0.001
Single 26 (3.8) 16(6.3)* 10(2.3)*
Other 1 (0.1) 1(0.4) 0(0.0)
Prefer not to say 4 (0.6) 3(1.2) 1(0.2)

Education level 687 254 (37) 433 (63)

Less than high school 22 (3.2) 9(3.5) 13(3)
HSC or year 12 equivalent 56 (8.2) 31(12.2)* 25(5.8)*
Certificates I-V (TAFE) 97 (14.1) 49 (19.3)* 48 (11.1)*
Diploma 81 (11.8) 31(12.2) 50(11.5) 24.468 <0.001
(Diploma and above) # 256 (37.3) 120(47.2)* 136(31.4)*
Undergraduate degree 226 (32.9) 63(24.8)* 163(37.6)*
Postgraduate degree 205 (29.8) 71(28) 134(30.9)

9
 Employment Status⁽ᵃ⁾
Student 45 (6.5) 23 (9.1) 22 (5.1)
Unemployed 66 (9.5) 33 (13.1)* 33 (7.6)*
Maternity leave 140 (20.1) 58 (23) 82 (18.9)
Casual job 51 (7.3) 22 (8.7) 29 (6.7) 35.155 <0.001
Full-time job 253 (36.4) 65 (25.8)* 188 (43.3)*
Part-time job 168 (24.2) 67 (26.6) 101 (23.3)
Retired 12 (1.7) 3 (1.2) 9 (2.1)

Household Income 685 252 (36.8) 433 (63.2)

< $18,200 6 (0.9) 3(1.2) 3(0.7)
$18,201 - $37,000 26 (3.8) 16(6.3)* 10(2.3)*
$37,001 - $80,000 76 (11.1) 44(17.5)* 32(7.4)*
31.374 <0.001
> $80,001 493 (72) 162(64.3)* 331(76.4)*
Prefer not to say 50 (7.3) 11(4.4)* 39(9)*
Not applicable 34 (5) 16(6.3) 18(4.2)

ACT: Australian Capital Territory, NSW: New South Wales, NT: North Territory, QLD: Queensland, SA: South Australia, TAS: Tasmania, VIC: Victoria,
WA: Western Australia, ⁽ᵃ⁾: Multiple responses Chi-square analysis, #: collapsed category comprised of diploma, undergraduate degree and postgraduate
degree, and was not run in a separate analysis, * signifies the pairwise comparisons. Responses are presented as n (%) No question was compulsory to answer,
therefore the total number of responders for each question may vary.

10
Awareness of WHO and Australian guidelines

Descriptive analysis showed that 425 (71%) of the responders were not aware of the WHO and Australian Government Department of Health guidelines

regarding exercise during pregnancy, and this findings was not influenced by mental health diagnosis (Table 2). Moreover, education level did not influence

the number of the participants who were aware of the WHO and Australian Department of Health guidelines.

Table 2: Awareness of WHO and Australian Health guidelines

Variables n Diagnosed with a mental illness during
(%) their lifetime
Total responses Yes No Chi-square p-value
value
Awareness of the WHO guidelines⁽ʳ⁾ 596 222 (37.2) 374 (62.8)
Yes 171 (28) 60 (27) 111 (29.7) 0.479 0.489
No 425 (71.3) 162 (73) 263 (70.3)

Awareness of the WHO guidelines ⁽ʳ⁾

Total responses Yes No
Education level 595 171 (28.7) 424 (71.3)
≤Diploma 209 (35.1) 48 (28.1) 161 (38)
5.284 0.071
Undergrad 198 (33.3) 64 (37.4) 134 (31.6)
Postgrad 188 (31.6) 59 (34.5) 129 (30.4)
WHO: World Health Organization, ⁽ʳ⁾: WHO Guidelines recommend that individuals (including pregnant people) engage in 150 minutes of moderate intensity
or 75 minutes of vigorous intensity exercise per week, or a combination of both. Responses are presented as n (%). No question was compulsory to answer,
therefore the total number of responders for each question may vary.

11
medRxiv preprint doi: https://doi.org/10.1101/2023.07.25.23292807; this version posted July 28, 2023. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

Perspectives on safety and benefits of exercise during pregnancy

Descriptive analysis showed the majority of responders (94%) agree that exercise during

pregnancy is safe for both mother and baby (Table 3), with 88-96% agreeing it is safe during

each of the three trimesters (Supp. Table S1). There was a significant association between a

mental illness diagnosis and the belief that exercise is safe for the mother and baby (X2 =

12.442, p = 0.014). Pairwise comparisons revealed that those with a mental illness diagnosis

were less likely to strongly agree, and more likely to be neutral with this statement. Eighty-

eight percent of responders agree that regular exercise would help to prevent a decline in a

pregnant person’s mood and 92% agree that regular exercise would help to improve a pregnant

person’s mood (Table 3). The majority of responders (73%) believed that pregnant women

should preform 150 mins or less of moderate intensity exercise/week for general health and

most responders believed that pregnant women should perform 60 mins or less of vigorous

intensity exercise/week for general health (Table 3). These perspectives were not influenced

by a mental health diagnosis (Table 3, p > 0.05).

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Table 3: Participants’ beliefs and perspectives toward exercise during pregnancy
Variables n (%) Diagnosed with a mental illness
during their lifetime
Total responses Yes No Chi-square p-value
value
Conducting exercise is safe for the mother
631 233 (36.9) 398 (63.1)
and her baby
Strongly agree 393 (62.3) 130 (55.8)* 263 (66.1)*
Agree 200 (31.7) 82 (35.2) 118 (29.6)
Neutral 31 (4.9) 19 (8.2)* 12 (3)*
12.442 0.014
Disagree 6 (1) 2 (0.9) 4 (1)
Strongly 1 (0.2) 0 (0) 1 (0.3)
disagree

Regular exercise would help to prevent a

621 233 (37.5) 388 (62.5)
decline in a pregnant person's mood
Strongly agree 324 (52.2) 121 (51.9) 203 (52.3)
Agree 220 (35.4) 78 (33.5) 142 (36.6)
Neutral 65 (10.5) 27 (11.6) 38 (9.8)
3.141 0.535
Disagree 10 (1.6) 6 (2.6) 4 (1)
Strongly 2 (0.3) 1 (0.4) 1 (0.3)
disagree

Regular exercise would help to improve a

622 233 (37.5) 389 (62.5)
pregnant person's mood
Strongly agree 332 (53.4) 121 (51.9) 211 (54.2)
Agree 238 (38.3) 90 (38.6) 148 (38) 1.483 0.830
Neutral 46 (7.4) 20 (8.6) 26 (6.7)

13
 Disagree 5 (0.8) 2 (0.9) 3 (0.8)
Strongly 1 (0.2) 0 (0) 1 (0.3)
disagree

Perception of how often a pregnant

women should perform moderate 558 203 (36.4) 355 (63.6)
intensity exercise for general health
None 4(0.7) 1(0.5) 3(0.8)
< 30 min/week 11(2) 5(2.5) 6(1.7)
30-60 min/week 56(10) 22(10.8) 34(9.6)
60-90 min/week 95(17) 41(20.2) 54(15.2)
90-120 121(21.7) 38(18.7) 83(23.4)
min/week 8.313 0.306
120-150 121(21.7) 46(22.7) 75(21.1)
min/week
(≤150 408(73.1) 153(75.4) 255(71.8)
min/week)#
>150 min/week 108(19.4) 31(15.3) 77(21.7)
Not sure 42(7.5) 19(9.4) 23(6.5)

Perception of how often a pregnant

women should perform vigorous intensity 557 203 (36.4) 354 (63.6)
exercise for general health
None 138 (24.8) 49(24.1) 89(25.1)
< 30 min/week 71(12.7) 27(13.3) 44(12.4)
30-60 min/week 97(17.4) 28(13.8) 69(19.5)
5.991 0.541
60-90 min/week 57(10.2) 21(10.3) 36(10.2)
90-120 33(5.9) 14(6.9) 19(5.4)
min/week
14
 120-150 25(4.5) 7(3.4) 18(5.1)
min/week
>150 min/week 12(2.2) 4(2) 8(2.3)
(>60 min/week) 127(22.8) 46(22.7) 81(22.9)
#

Not sure 124(22.3) 53(26.1) 71(20.1)

#
: an accumulated data from collapsed categories and was not run in a separate analysis, * signifies the pairwise comparisons. Responses are
presented as n (%). No question was compulsory to answer, therefore the total number of responders for each question may vary.

15
medRxiv preprint doi: https://doi.org/10.1101/2023.07.25.23292807; this version posted July 28, 2023. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

Type and source of medical advice/information received about exercise during

pregnancy

Data related to advice participants received about exercising during pregnancy is provided in

Table 4. Descriptive analysis showed that 71% of respondents considered GPs to be the most

widely considered as a trusted source of medical advice including during pregnancy. Fifty-

seven percent of responders recall being advised to exercise during their most recent

pregnancy, mostly by their GP (54%), midwife (46%) and obstetrician (38%). Walking was

the most advised exercise type (80%) followed by swimming (46%). Overall, 69% of

responders report receiving no or little advice from their healthcare provider about the safety

and benefits of exercise during their most recent pregnancy, but 45% of responders felt satisfied

about the advice they did receive.

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Table 4: Type and source of provided medical advice/information about exercise during pregnancy:
Variables n Diagnosed with a mental illness
(%) during their lifetime
Total Chi-square p-value
Yes No
responses value
Trusted medical resource⁽ᵃ⁾
GP 491 (70.6) 189 (75.3) 302 (70.1)
Midwife 364 (52.4) 137 (54.6) 227 (52.7)
Obstetrician/Gynaecologist 326 (46.9) 115 (45.8) 211 (49)
Friends/ family 123 (17.7) 45 (17.9) 78 (18.1)
Psychiatrist/psychologist 63 (9.1) 51 (20.3)* 12 (2.8)* 70.446 <0.001
Online media 48 (6.9) 14 (5.6) 34 (7.9)
Cultural medicine 19 (2.7) 8 (3.2) 11 (2.6)
Physiotherapist/ EP/Chiro 14 (2) 4 (1.6) 10 (2.3)
Scientific/medical
sources/govt. websites 11 (1.6) 6 (2.4) 5 (1.2)
Other 19 (2.7) 2 (0.8)* 17 (3.9)*

Were responders advised to exercise during

681 250 (36.7) 431 (63.3)
their most recent pregnancy
Yes 386 (56.7) 141 (56.4) 245 (56.8)
No 185(27.2) 69(27.6) 116(26.9) 0.039 0.981
Unsure 110(16.2) 40(16) 70(16.2)

Source of that advice⁽ᵃ⁾

GP 201 (53.5) 83 (61) 118 (49.2)
Midwife 174 (46.3) 67 (49.3) 107 (44.6) 8.628 0.196
Obstetrician 141 (37.5) 49 (36) 92 (38.3)
17
 Family/Friend 59 (15.7) 25 (18.4) 34 (14.2)
Personal trainer/Gym 47 (12.5) 15 (11) 32 (13.3)
instructor
Other 48 (12.8) 14 (10.3) 34 (14.2)

Type of exercise that was advised during

pregnancy⁽ᵃ⁾
Walking 301 (80.1) 112 (82.4) 189 (78.8)
Swimming 174 (46.3) 66 (48.5) 108 (45)
Yoga 103 (27.4) 44 (32.4) 59 (24.6)
Weight Lifting/Resistance 84 (22.3) 27 (19.9) 57 (23.8)
No specific 59 (15.7) 20 (14.7) 39 (16.3) 10.64 0.301
Running 40 (10.6) 10 (7.4) 30 (12.5)
Cycling 26 (6.9) 7 (5.1) 19 (7.9)
Other 62 (16.5) 17 (12.5) 45 (18.8)
Cannot remember 5 (1.3) 2 (1.5) 3 (1.3)

Amount of advice received by healthcare 665 243 (36.5) 422 (63.5)

provider(s) about exercise safety and benefits
during pregnancy
None at all 170(25.6) 56(23) 114(27)
A little 288(43.3) 113(46.5) 175(41.5)
A moderate amount 134(20.2) 44(18.1) 90(21.3)
3.513 0.621
A lot 23(3.5) 10(4.1) 13(3.1)
A great deal 19(2.9) 7(2.9) 12(2.8)
Unsure 31(4.7) 13(5.3) 18(4.3)

18
 Level of satisfaction with advice received from
their healthcare provider regarding the safety 663 243 (36.7) 420 (63.3)
& benefits of exercise during pregnancy
Very satisfied 97(14.6) 34(14) 63(15)
Satisfied 202(30.5) 60(24.7) 142(33.8)
Neutral 281(42.4) 118(48.6) 163(38.8) 7.785 0.100
Dissatisfied 62(9.4) 23(9.5) 39(9.3)
Very dissatisfied 21(3.2) 8(3.3) 13(3.1)
⁽ᵃ⁾: Multiple responses Chi-square analysis. Responses are presented as n (%). No question was compulsory to answer, therefore the total number of responders
for each question may vary.

19
medRxiv preprint doi: https://doi.org/10.1101/2023.07.25.23292807; this version posted July 28, 2023. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

Exercise during pregnancy

Participant responses regarding the amount of and type of exercise conducted during pregnancy

are shown in Table 5. Descriptive analysis showed that 412 (68%) out of 610 responders

conducted exercise during all or part of their most recent pregnancy. There was a significant

association between a reported diagnosis of a mental illness during their lifetime and

participation in structured exercising during pregnancy (X2=6.862, p=0.009), with fewer

individuals with a mental illness exercising during pregnancy compared to those without (Table

5). Similarly, there was a significant association between a reported diagnosis of a mental

illness during their lifetime and participation in structured exercising prior to pregnancy

(X2=10.225, p=0.001), with fewer individuals with a mental illness participating in exercise

prior to pregnancy. Of those respondents that reported participating in structured exercise

during all/part of their most recent pregnancy, 51% reported exercising 3-4 times per week and

23% less than 3 times/week; 79% reported conducting less than or equal to 150mins of

moderate intensity exercise/week and 78% reported conducting 60mins and less of vigorous

intensity exercise/week. There was no significant association between mental illness diagnosis

during their lifetime and the frequency nor total time spent in conducting exercise during

pregnancy (p > 0.05). The most common types of exercise conducted during pregnancy were

walking (87%), swimming (38%) and yoga (36%) (Table 5). However there was a significant

association between mental illness diagnosis and type of exercise conducted during pregnancy

with fewer respondents with a mental illness performing higher intensity exercises such as

swimming, running, cyclising HIIT and more yoga (Table 5).

20
Table 5: Exercise experience during the most recent pregnancy
Variables n Diagnosed with a mental illness during their
(%) lifetime

Total Yes No Chi-square p-value

responses value
Participating structured exercise during all/part of 610 229 (37.5) 381 (62.5)
pregnancy
Yes 412 (67.5) 140(61.1)* 272(71.4)*
6.862 0.009
No 198 (32.5) 89(38.9)* 109(28.6)*

Practiced exercise prior to falling pregnant, or 567 216 (38.1) 351 (61.9)
during previous pregnancies
Yes 472 (83.2) 166(76.9)* 306(87.2)*
10.225 0.001
No 95 (16.8) 50(23.1)* 45(12.8)*

Pregnancy trimester and participation in exercise

1st trimester 398 132 (33.2) 266 (66.8)
Yes 350 (87.9) 108 (81.8)* 242 (91*)
No 42 (10.6) 20 (15.2)* 22 (8.3)* 7.838 0.020
Unsure 6 (1.5) 4 (3) 2 (0.8)
2nd 393 131 (33.3) 262 (66.7)
trimester
Yes 367(93.4) 118 (90.1) 249 (95)
No 18(4.6) 8(6.1) 10(3.8) 4.293 0.117
Unsure 8(2) 5(3.8) 3(1.1)
3rd trimester 381 128 (33.6) 253 (66.4)
Yes 300(78.7) 102(79.7) 198(78.3) 0.798 0.671

21
 No 55(14.4) 16(12.5) 39(15.4)
Unsure 26(6.8) 10(7.8) 16(6.3)

Frequency of exercise during most recent 401 136 (33.9) 265 (66.1)
pregnancy
<3 times a week 94(23.4) 36(26.5) 58(21.9)
3-4 times a week 203(50.6) 68(50) 135(50.9) 1.281 0.530
≥5 times a week 104(25.9) 32(23.5) 72(27.2)

Total time spent conducting moderate physical 401 136 (33.9) 265 (66.1)
activity/week

None 11(2.7) 6(4.4) 5(1.9)

<30 min/week 19(4.7) 10(7.4) 9(3.4)
30-60 min/week 49(12.2) 16(11.8) 33(12.5) 9.566 0.215
60-90 min/week 83(20.7) 33(24.3) 50(18.9)
90-120 min/week 89(22.2) 29(21.3) 60(22.6)
120-150 min/week 64(16) 20(14.7) 44(16.6)
(≤150min) # 315(78.6) 114(83.8) 201(75.8)
>150 min/week 77(19.2) 19(14) 58(21.9)
Unsure 9(2.2) 3(2.2) 6(2.3)

Total time spent conducting vigorous physical 402 136 (33.8) 266 (66.2)
activity/week
None 150(37.3) 56 (37.3) 94 (62.7)
<30 min/week 64(15.9) 21(15.4) 43(16.2) 3.745 0.809
30-60 min/week 87(21.6) 27(19.9) 60(22.6)

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 60-90 min/week 41(10.2) 16(11.8) 25(9.4)
90-120 min/week 24 (6) 6(4.4) 18(6.8)
120-150 min/week 13 (3.2) 4 (2.9) 9 (3.4)
>150 min/week 12 (3) 4 (2.9) 8 (3)
(≥60 min) # 90 (22.4) 30 (22.1) 60 (22.6)
Unsure 11 (2.7) 2 (1.5) 9 (3.4)

Type of exercise conducted during pregnancy⁽ᵃ⁾

Aerobic 381 (94.5) 127 (93.4) 254 (95.1)
resistance 171 (42.4) 53 (39) 118 (44.2)
6.095 0.192
Both 174 (43.2) 56 (41.2) 118 (44.2)
Yoga/Pilates 170 (42.2) 67 (49.3) 103 (38.6)

Walking 350 (86.8) 121 (89) 229 (86.7)

Swimming 153 (38) 38 (27.9)* 115 (43.6)*
Yoga 143 (35.5) 59 (43.4)* 84 (31.8)* 28.935 0.001
Running/Jugging 117 (29) 33 (24.3)* 84 (31.8)*
HITT/Cross fit 75 (18.6) 22 (16.2)* 53 (20.1)*
Cycling 65 (16.1) 14 (10.3)* 51 (19.3)*
Pilates 37 (9.2) 11 (8.1) 26 (9.8)
Team support 17 (4.2) 5 (3.7) 12 (4.5)
Aerobics/Dance 31 (7.7) 16 (11.8) 15 (5.7)
Martial arts combat 4 (1) 1 (0.7) 3 (1.1)

Reason for stopping exercise during pregnancy⁽ᵃ⁾

Feeling fatigue 119 (61.7) 54 (62.8) 65 (60.7) 10.231 0.176
23
 Morning sickness 105 (54.4) 54 (62.8) 51 (47.7)
Not enough time 76 (39.4) 36 (41.9) 40 (37.4)
Concerns about the baby safety 26 (13.5) 9 (10.5) 17 (15.9)
Concerns about self-safety 17 (8.8) 5 (5.8) 12 (11.2)
Medical advice 14 (7.3) 9 (10.5) 5 (4.7)
Other 57 (29.5) 26 (30.2) 31 (29)
⁽ᵃ⁾: Multiple responses Chi-square analysis, #: an accumulated data from collapsed categories and was not run in a separate analysis, *: signifies the
pairwise comparisons. Responses are presented as n (%). No question was compulsory to answer, therefore the total number of responders for each
question may vary

24
medRxiv preprint doi: https://doi.org/10.1101/2023.07.25.23292807; this version posted July 28, 2023. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

Participants who experienced mental illness during pregnancy (including

antenatal depression)

Twenty four percent of survey responders reported experiencing a mental illness during their

most recent pregnancy (Table 1), including 12% depression, 21% anxiety, and 1% other,

with some respondents experiencing more than one mental illness (Supp. Table S1). Fifty-

three percent of the responders who experienced mental illness during their most recent

pregnancy were advised to conduct exercise, similar to those that did not experience a mental

illness (Supp. Table S3). Interestingly, out of the 157 responders who experienced mental

illness during their pregnancy, 72% report receiving little-to-no advice about the safety and

benefits of conducting exercise during pregnancy (Supp. Table S3). Seventy one percent of

the responders who had not experienced mental illness during their most recent pregnancy

reported that they conducted exercise during their most recent pregnancy (Supp. Table S3).

This was significantly different in those that experienced mental illness during pregnancy,

with 57% conducting exercise during their most recent pregnancy (X2= 8.306, p=0.004)

(Supp. Table S3), specifically this significant difference was during the first and third

pregnancy trimester (Supp. Table S3). Only 164 (29%) of the 570 responders were aware of

the WHO and the Australian Department of Health guidelines regarding exercise during

pregnancy; and there was no significant association between this awareness and an

experience of mental illness during pregnancy (Supp. Table S3).

There was a significant association between a reported experience of a mental illness during

pregnancy and conducted exercise type during pregnancy (X2=21.326, p=0.019) (Supp.

Table S3). Although walking was the most common conducted exercise during pregnancy in

those with and without a mental illness during pregnancy, fewer respondents with a mental

illness during pregnancy reported swimming, running/jugging and cycling during their

pregnancies, while more women with a mental illness during pregnancy reported practicing

yoga during their pregnancies (Supp. Table S3). There was also a significant association

25
medRxiv preprint doi: https://doi.org/10.1101/2023.07.25.23292807; this version posted July 28, 2023. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

between experiencing mental health illness during pregnancy and the belief that exercise is

safe for the mother and baby (X2 = 16.191, p = 0.003), with fewer responders experiencing

mental health illness during pregnancy who strongly agree that exercise is safe for the mother

and baby (Supp. Table S3).

Discussion

Evidence suggests that exercise during pregnancy can have a positive influence on maternal

physical and mental health, as well as newborn health outcomes. Accordingly, the WHO and

National guidelines recommend women exercise during pregnancy. Our study showed that

most women surveyed were not aware of the WHO/National guidelines regarding exercise

in pregnancy. Despite this, the vast majority believed that regular exercise during pregnancy

is safe for mother and baby and that it would help prevent a decline in and improve a pregnant

person's mood. Most of the responders also reported conducting exercise during all or part

of their most recent pregnancy; however, there were significantly fewer individuals with a

mental illness that reported exercising during pregnancy. Despite the majority participating

in exercise during pregnancy, more than half of responders report conducting less exercise

than that recommended by WHO. While just over half of the responders recall being advised

to exercise during their most recent pregnancy, the majority report receiving no or little

advice from their healthcare provider about the safety and benefits of exercise during their

most recent pregnancy.

Knowledge and beliefs about exercise in pregnancy

The current survey showed that the majority of responders were not aware of the WHO and

Australian Health guidelines, in regard to conducting exercise during pregnancy. To our

knowledge the current study is the first to assess the awareness of Australian women about

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medRxiv preprint doi: https://doi.org/10.1101/2023.07.25.23292807; this version posted July 28, 2023. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

the WHO and Australian Health guidelines, in regard to exercise during pregnancy.

Notwithstanding, despite the lack of knowledge of the existing international/national

guidelines towards exercise during pregnancy, the majority believe that exercise during

pregnancy is safe and beneficial for a person’s mood, specifically. In line with these findings,

a previous study, conducted in Victoria Australia reported that the majority believed that

regular low intensity exercise was safe during pregnancy; while the majority also believed

moderate intensity exercise use was safe, only a small percentage believed high intensity

exercise was safe during pregnancy (Duncombe et al., 2009). Similarly, our findings showed

that many responders believe women should be performing no or limited vigorous activity

per week.

The current finding, regarding the belief of safe and beneficial of exercise during pregnancy,

was consistent with several international surveys that were spread among their general

population. For example, in a USA study, it was reported that among the 500 participants

there were 76% who believe that exercise during pregnancy is safe and 86% believe it is

beneficial (Babbar and Chauhan, 2015). Similarly, in a study from Saudi Arabia, out of the

472 participants 67% believed that exercise during pregnancy is safe (Al-Youbi and Elsaid,

2020). However in Ethiopia, only 52% of the 403 participants believed that exercise is safe

during pregnancy (Janakiraman et al., 2021). A theoretic explanation for this drop in the

percentage from USA to Saudi to Ethiopia, might be as a result of the different cultures, as

it was previously reported in both Saudi Arabian and Ethiopian reports that the majority of

pregnant women believe that physical exercise would cause a miscarriage, early delivery and

low birth weight, also it might be harmful to their health during pregnancy (Addis et al.,

2022; Gari et al., 2022; Hjorth et al., 2012; Musaiger et al., 2012); however this belief has

recently started to change (Addis et al., 2022; Gari et al., 2022).

An overwhelming majority of responders report receiving no or little advice from their

healthcare provider about the safety or benefits of exercise during their most recent

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medRxiv preprint doi: https://doi.org/10.1101/2023.07.25.23292807; this version posted July 28, 2023. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

pregnancy, and this did not differ between those that have and have not been diagnosed with

a mental illness. Our finding was consistent with a Chinese survey, that reported only 8% of

pregnant women have received advice from a medical practitioner about the safety and

benefits of physical activity during pregnancy (Zhang et al., 2014). Furthermore, only 33%

of Ethiopian pregnant women were advised to conduct exercise during their pregnancy,

according to a recent survey (Janakiraman et al., 2021). This does raise a question about

whether health care providers have enough knowledge and awareness of the safety and

benefits of exercise during pregnancy. To our knowledge, there are no Australian studies that

have assessed medical practitioners’ knowledge towards the WHO guidelines regarding

exercise during pregnancy, however there are several international assessments. In Michigan,

USA, 60% of practicing healthcare providers and 86% of physicians and certified nurse

midwives were not familiar with the guidelines (Bauer et al., 2010). Among health care

providers in South Africa, 83% were unaware of the WHO guidelines (Watson et al., 2015),

while in Pakistan 72% of the medical practitioners were unaware of the WHO guidelines

towards exercise during pregnancy (Batool et al., 2021). Collectively, this suggests greater

international effort is needed to educate health care providers so they can provide appropriate

guidance to their patients.

Exercise conducted during pregnancy

The majority of women surveyed in the current study report they did conduct exercise during

their most recent pregnancy. Of those that exercised, many did not meet the WHO guidelines.

This current finding was consistent with the Australian Institute of Health and Welfare report

in 2019 that stated: “two-thirds of pregnant women were active for fewer than 150 minutes

per week” (Australian Institute of Health and Welfare, 2019). Also, Zhang et al., have

reported that only 11% of the pregnant women have managed to meet with the WHO

guidelines (Zhang et al., 2014). This finding is also consistent with reports from other

countries including Ethiopia (Janakiraman et al., 2021), Saudi Arabia (Al-Youbi and Elsaid,

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medRxiv preprint doi: https://doi.org/10.1101/2023.07.25.23292807; this version posted July 28, 2023. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

2020), USA (specifically Virginia state) (Babbar and Chauhan, 2015) and China (Zhang et

al., 2014), with reports in these studies of 11-23% of women meeting the WHO guidelines

in pregnancy. We found that significantly fewer women diagnosed with a mental illness,

including those with antenatal depression, report performing exercise in pregnancy. This is

consistent with an Australian pregnancy cohort study (Watson et al., 2018) that reported an

increase in depressive and anxiety symptoms was associated with a steeper decline in

exercise frequency during the perinatal period, across pregnancy trimesters and postpartum

period (up to 12 months after delivery) (Watson et al., 2018). Interestingly, Watson et al.,

reported that women with depression and taking antidepressant medication conducted

significantly less exercise compared to the control group, during the first trimester (Watson

et al., 2018). According to a growing body of literature, exercise has been shown to bring

positive effects to mood states such as anxiety, stress, and depression (in non-pregnant

populations) (Cooney et al., 2013; El-Kade and Al-Jiffri, 2016; López-Torres Hidalgo et al.,

2019), with emerging evidence suggesting this also extends to the pregnant population

(Jarbou and Newell, 2022).

Understanding the barriers to conducting exercise during pregnancy will assist in developing

strategies to support women to meet the WHO guidelines. In this study, the main barriers to

exercise in pregnancy reported by Australian women were fatigue, morning sickness, and

lack of time; and there were no significant differences in the barriers reported between those

with and without a diagnosed mental illness in their lifetime. Interestingly, barriers appear to

have changed over time, as according to a Victorian survey in 2009, in Australia, the

concerns of pregnancy safety was one of the major barriers to conduct exercise during

pregnancy, followed by feeling tired (Duncombe et al., 2009). Internationally, some of the

main barriers to conduct exercise during pregnancy were similar, for example, in Saudi-

Arabia 84% of women reported feeling tired was the main barrier to conducting exercise

during pregnancy, followed by a lack of knowledge of the importance of maternal exercise,

29
medRxiv preprint doi: https://doi.org/10.1101/2023.07.25.23292807; this version posted July 28, 2023. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

and a lack of time and transportation difficulties (Al-Youbi and Elsaid, 2020). However,

barriers to conduct exercise during pregnancy were different in both the Ethiopian and

Chinese studies, where the main barrier was a concern for the foetus safety (78% and 67%

of the participants, respectively), followed by a lack of knowledge of the WHO guidelines

regarding exercise during pregnancy (Guelfi et al., 2015; Janakiraman et al., 2021; Zhang et

al., 2014). This highlights some important varieties about the beliefs and attitudes towards

exercise during pregnancy among different cultures. This was previously reported by Guelfi

et al., that compared Chinese to Australian pregnant women’s beliefs about exercise during

pregnancy (Guelfi et al., 2015). Their study reported that Australian pregnant women

conducted significantly more vigorous and moderate-intensity physical activity compared to

the Chinese women, while Chinese women reported more walking activity than the

Australian women (Guelfi et al., 2015). However, there was no significant difference

between groups when the Metabolic equivalent minutes (MET-minute) per week were

calculated for all activities combined (Guelfi et al., 2015). Differences between cultures,

beliefs and attitudes need to be fully explored in future studies to assist in the design of

exercise interventions to maximise exercise adherence and lifelong activity behaviour.

The most common types of exercise that the responders report conducting during their most

recent pregnancy were walking, swimming, then yoga, which was similar to what they report

being generally advised to conduct during their most recent pregnancy. This was consistent

with the Virginia, USA study (Babbar and Chauhan, 2015), as almost 62% conducted

walking, 20% swimming and 15% were practicing yoga during pregnancy (Babbar and

Chauhan, 2015). Walking was the most conducted exercise during pregnancy in China,

Ethiopia and Saudi Arabia (98%, 91% and 66%, respectively (Al-Youbi and Elsaid, 2020;

Janakiraman et al., 2021; Zhang et al., 2014). These exercises would be considered as low

intensity exercises. It is possible that the focus on low intensity exercise is derived from a

lack of knowledge about the types of exercise and safety of different exercises in pregnancy.

30
medRxiv preprint doi: https://doi.org/10.1101/2023.07.25.23292807; this version posted July 28, 2023. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

As discussed by Watson et al, 2015, clinicians may see pregnancy as a high-risk state which

leads to low intensity exercise such as walking, yoga and swimming being the most highly

recommended (Watson et al., 2015).

Study strengths and limitations

Despite the fact that similar studies have been conducted in other countries (Al-Youbi and

Elsaid, 2020; Janakiraman et al., 2021; Zhang et al., 2014), this study is the first of its kind

assessing Australian women's beliefs and attitudes towards exercise during pregnancy, as

well as their levels of satisfaction with the advice provided regarding exercise during

pregnancy. Such research is essential to determine the next step in implementing effective

protocols to raise awareness of WHO guidelines for exercise during pregnancy, and how

essential, beneficial and safe is exercise during pregnancy. However, there were several

limitations of this study which need to be considered.

1) Online surveys of this nature are limited to responders that have internet access and likely

who were interested in the topic (Andrade, 2020) and due to the unrestricted selection of

participants, voluntary online surveys have limited generalizability to the target population

(Singh and Sagar, 2021).

2) This survey was only distributed in English, limiting responses to those that understand

English. It is estimated that approximately 2% of the Australian population do not speak

English (Australia Community Profile, 2021); it may be that these communities have

different perceptions and experiences regarding exercise during pregnancy.

3) Australia is considered a multi-cultural society (Australian Human Rights Commission,

2022), however, the majority of responders were Caucasian (84%, Table 1). This limits the

perceptions of different cultural or ethnic groups. As based on previously discussed evidence,

experience, believes and barriers regarding exercise during pregnancy could be different

between different cultures.

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medRxiv preprint doi: https://doi.org/10.1101/2023.07.25.23292807; this version posted July 28, 2023. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

4) This survey required responders to recall exercise amount and advice received from

several years prior, with 40% of responders required to recall from more than two years prior,

subjecting responses to recall bias. Prospectively tracking exercise conducted during

pregnancy would provide a more accurate indication.

5) The majority of the participants that responded were from NSW, and in the 26-45 age

range (Table 1), biasing responses towards this demographic. While the available evidence

shows that surveys conducted in different regions/states in Australia report similar findings

to the present study (Hayman et al., 2016; Newham et al., 2016), it is expected that the under

25 and 45+ demographic may have differing views and experiences.

Conclusion

This study has shown that Australian women believe that exercise during pregnancy is safe

and has benefits for mental health. However, many women report receiving little advice

about this from their healthcare provider. Furthermore, women report not being aware of or

meeting the WHO/National guidelines regarding exercise in pregnancy. Women do report

primarily conducting low intensity exercise during pregnancy (walking, swimming, yoga).

Importantly, fewer respondents with a diagnosed mental illness report exercising during

pregnancy. Considering the potential benefits of exercise for mental illness, employing

strategies to increase this group of women’s engagement with exercise during pregnancy is

important. The main barriers to exercise include fatigue and time. Further research to

determine strategies to increase exercise in pregnant women, particularly those with a mental

illness, are needed.

32
Supplementary Material

Table S1: What medical conditions did you experienced during your most recent pregnancy?
Variables n (%)
Experiencing pregnancy complications⁽ᵃ⁾ Total Diagnosed with a Chi- p-value
responders mental illness during square
their lifetime value
Yes No
Diabetes 58 (8.9) 21 (8.7) 37 (9.1)
Preeclampsia 28 (4.3) 13 (5.4) 15 (3.7)
High blood pressure 53 (8.1) 24 (10) 29 (7.1)
Thyroid 57 (8.7) 22 (9.1) 35 (8.6)
Depression 80 (12.2) 66 14 (3.4)*
(27.4)* 294.097 <0.001
Anxiety 138 (21.1) 115 23 (5.6)*
(47.7)*
Other mental health 8 (1.2) 6 (2.5) 2 (0.5)
Other complications 81 (12.4) 31 (12.9) 50 (12.3)
Had no complications 330 (50.4) 81 249 (61)*
(33.6)*
⁽ᵃ⁾: Multiple responses Chi-square analysis. Responses are presented as n (%). No question was compulsory to answer, therefore the total
number of responders for each question may vary.

33
 Table S2: Perspectives about safety of conducting exercise during each pregnancy trimesters
Variables n (%)
Which pregnancy trimester do you believe Total Diagnosed with a mental
conducting exercise is safe for the mother and/or responders illness during their
baby? lifetime
Yes No Chi-square p-
value value
1st trimester 621 229 (36.9) 392 (63.1)
Yes 560 (90.2) 199 (86.9) 361 (92.1)
Unsure 41 (6.6) 22 (9.6) 19 (4.8) 5.477 0.065
No 20 (3.2) 8 (3.5) 12 (3.1)
2nd trimester 620 230 (37.1) 390 (62.9)
Yes 597(96.3) 219 (95.2) 378 (96.9)
Unsure 22(3.5) 10 (4.3) 12 (3.1) 2.398 0.302
No 1(0.2) 1 (0.2) 0 (0)
3rd trimester 617 224 (36.3) 393 (63.7)
Yes 548 (88.8) 197 (87.9) 351 (89.3)
Unsure 51 (8.3) 18 (8) 33 (8.4) 1.512 0.469
No 18 (2.9) 9 (4) 9 (2.3)
None 56 22 (39.3) 34 (60.7)
Yes 4 (7.1) 2 (9.1) 2 (5.9)
Unsure 10 (17.9) 6 (27.3) 4 (11.8)
2.615 0.270
No 42 (75) 14 (63.6) 28 (82.4)
Responses are presented as n (%). No question was compulsory to answer, therefore the total number of responders for each question may vary.

34
Table S3: Exercise experience and advice received about exercise during the most recent pregnancy, in those that did and did not experience mental illness
during pregnancy
Variables n (%) Experiencing mental health
illness during pregnancy
Total responders Yes No Chi- p-
square value
During your most recent pregnancy, how much information did
you receive from your healthcare provider(s) about 639 152 (23.8) 487 (76.2)
safe/appropriate exercise to conduct during pregnancy and the
benefits of exercise
None at all 159 (24.9) 40 (26.3) 119 (24.4)
A little 279 (43.7) 69 (45.4) 210 (43.1)
A moderate amount 131 (20.5) 27 (17.8) 104 (21.4)
1.450 0.919
A lot 20 (3.1) 5 (3.3) 15 (3.1)
A great deal 19 (3) 5 (3.3) 14 (2.9)
Unsure/can’t remember 31 (4.9) 6 (3.9) 25 (5.1)

Did you, or are you currently participating in structured exercise

582 141 (24.2) 441 (75.8)
during all/ or part of your most recent pregnancy?
Yes 392 (67.4) 81 (57.4)* 311 (70.5)*
8.306 0.004
No 190 (32.6) 60 (42.6)* 130 (29.5)*

Did you exercise prior to falling pregnant, or during previous

543 128 (23.6) 415 (74.4)
pregnancies?
Yes 454 (83.6) 101 (78.9) 353 (85.1)
2.703 0.100
No 89 (16.4) 27 (21.1) 62 (14.9)

35
How often do you or did you exercise during your most recent
383 79 (20.6) 304 (79.4)
pregnancy?
<3 times a week 90 (23.5) 22 (27.8) 68 (22.4)
3-4 times a week 198 (51.7) 40 (50.6) 158 (52) 1.256 0.534
5+ times a week 95 (24.8) 17 (21.5) 78 (25.7)

Which pregnancy trimester you were conducting exercise?

1st trimester 381 77 (20.2) 304 (79.8)
Yes 336 (88.2) 60 (77.9)* 276 (90.8)*
No 40 (10.5) 15 (19.5)* 25 (8.2)* 9.783 0.008
Unsure 5 (1.3) 2 (2.6) 3 (1)

2nd trimester 377 77 (20.4) 300 (79.6)

Yes 353 (93.6) 68 (88.3)* 285 (95)*
No 17 (4.5) 6 (7.8) 11 (3.7) 4.773 0.092
Unsure 7 (1.9) 3 (3.9) 4 (1.3)

3rd trimester 366 74 (20.2) 292 (79.8)

Yes 287 (78.4) 50 (67.6)* 237 (81.2)*
No 54 (14.8) 15 (20.3) 39 (13.4) 7.165 0.028
Unsure 25 (6.8) 9 (12.2)* 16 (5.5)*

Time spent conducting moderate intensity exercise 383 78 (20.4) 305 (79.6)
<150min moderate exercise 301 (78.6) 64 (82.1) 237 (77.7)
>150min moderate exercise 74 (19.3) 12 (15.4) 62 (20.3) 1.041 0.594
Not sure 8 (2.1) 2 (2.6) 6 (2)

Time spent conducting vigorous intensity exercise 384 78 (20.3) 306 (79.7)
<60 min 290 (75.5) 67 (85.9)* 223 (72.9)* 6.648 0.036

36
 >60 min 84 (21.9) 11 (14.1) 73 (23.9)
Not sure 10 (2.6) 0 (0) 10 (3.3)

Conducted exercise type⁽ᵃ⁾

Walking 334 (83) 70 (88.6) 264 (87.1)
Swimming 149 (37) 26 (32.9)* 123 (40.6)*
Yoga 137 (34) 38 (48.1)* 99 (32.7)*
Running/Jugging 110 (27.3) 14 (17.7)* 96 (31.7)*
HITT Cross Fit 72 (17.9) 15 (19) 57 (18.8)
21.326 0.019
Cycling 60 (14.9) 8 (10.1)* 52 (17.2)*
Pilates 37 (9.2) 10 (12.7) 27 (8.9)
Aerobics/Dance 31 (7.7) 9 (11.4) 22 (7.3)
Team Sport 17 (4.2) 1 (1.3) 16 (5.3)
Martial Arts Combat 4 (1) 1 (1.3) 3 (1)

Conducted exercise setting⁽ᵃ⁾

Individually 297 (74.6) 75 (84.3) 222 (80.4)
in group 209 (52.5) 44 (49.4) 165 (59.8) 6.538 0.088
both 213 (53.5) 45 (50.6) 168 (60.9)

Are you aware that the current World Health Organisation and
Australian Health guidelines recommend that pregnant women 570 140 (24.6) 430 (75.4)
should aim to meet these exercise targets? ⁽ʳ⁾
Yes 164 (28.8) 41 (29.3) 123 (28.6)
0.024 0.877
No 406 (71.2) 99 (70.7) 307 (71.4)

Were you advised to exercise during your most recent 655 157 (24) 498 (76)
pregnancy?
Yes 372 (56.8) 83 (52.9) 289 (58) 1.799 0.407

37
 No 178 (27.2) 49 (31.2) 129 (25.9)
Unsure/can’t remember 105 (16) 25 (15.9) 80 (16.1)

During your most recent pregnancy, how satisfied were you with
the advice you received from your healthcare provider regarding 637 151 (23.7) 486 (76.3)
the safety and benefits of exercise when pregnant?
Very satisfied 91 (14.3) 14 (9.3) 77 (15.8)
Satisfied 195 (30.6) 44 (29.1) 151 (31.1)
Neither satisfied or dissatisfied 272 (42.7) 70 (46.4) 202 (41.6) 5.967 0.202
Dissatisfied 58 (9.1) 18 (11.9) 40 (8.2)
Very dissatisfied 21 (3.3) 5 (3.3) 16 (3.3)

If I was diagnosed with depression during pregnancy, I would

perform exercise during pregnancy if advised by my GP,
593 145 (24.5) 448 (75.5)
psychiatrist/psychologist, midwife or obstetrician that it might
improve any depressive symptoms.
Strongly agree 314 (53) 71 (49) 243 (54.2)
Agree 198 (33.4) 48 (33.1) 150 (33.5)
Neutral 67 (11.3) 22 (15.2) 45 (10) 3.297 0.509
Disagree 10 (1.7) 3 (0.5) 7 (1.6)
Strongly disagree 4 (0.7) 1 (0.7) 3 (0.7)

I believe that exercise during pregnancy, is safe for mother and 603 146 (24.2) 457 (75.8)
baby
Strongly agree 375 (62.2) 77 (52.7)* 298 (65.2)*
Agree 193 (32) 52 (35.6) 141 (30.9)
Neither agree or disagree 28 (4.6) 14 (9.6)* 14 (3.1)* 16.191 0.003
Disagree 6 (1) 3 (2.1) 3 (0.7)
Strongly disagree 1 (0.2) 0 (0) 1 (0.2)

38
⁽ᵃ⁾: Multiple responses Chi-square analysis, ⁽ʳ⁾= The Australian Physical Activity Guidelines recommend that individuals (including pregnant people) engage
in 150 minutes of moderate intensity or 75 minutes of vigorous intensity exercise per week, or a combination of both. No question was compulsory to answer,
therefore the total number of responders for each question may vary Responses are presented as n (%). No question was compulsory to answer, therefore the
total number of responders for each question may vary.

39
medRxiv preprint doi: https://doi.org/10.1101/2023.07.25.23292807; this version posted July 28, 2023. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

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