Pregnancy Physical Activity Questionnaire reliable tool for assessing Physical Activity in pregnant women: Study
Physical activity (PA) is associated with significant positive impacts on both physical and mental health in non-pregnant populations. Several health organisations have strongly suggested that PA is directly correlated to a lower risk of heart disease, diabetes type 2, metabolic syndrome, anxiety, and some types of cancer. Considering the physical changes that occur during pregnancy, the maternal lifestyle can be a modifying factor for both maternal and foetal health. For example, pregnant women are at risk of pregnancy complications such as gestational diabetes and preeclampsia, which are related to maternal obesity and inactivity.
Traditionally, pregnancy constitutes a barrier to PA due to certain factors, beliefs, and lifestyle restraints. Moreover, pregnancy related symptoms, including vomiting, abdominal discomfort, and easy fatigue, along with safety concerns as well as limited scientific in formation and social support, have steered pregnant women away from being active. However, over the last few decades, scientific societies have issued guidelines recommending that pregnant women without complications should engage in PA. For example, the American College of Obstetricians and Gynecologists (ACOG) recommends at least 150 min of moderate-intensity PA per week. Despite these recommendations, only a small percentage of pregnant women actually meet them. Few studies, with limited numbers of cases, have examined PA levels during pregnancy in some parts of the world. These studies used questionnaires with a small number of participants and compared the data with the data collected using smartwatches to estimate actual PA levels.
The pregnancy physical activity questionnaire (PPAQ) is specially designed for pregnant women, which considers several hinderances that women face during pregnancy. Several advantages, such as low cost, easy implementation, self-administration, and ease of accessing a high volume of individuals, make the questionnaire a suitable means to evaluate and promote PA in a large population. The PPAQ has been translated into several languages and adopted by various cultures, including the recently introduced Greek version. This study aimed to record the degree of PA in pregnant Greek women during the three trimesters of pregnancy and examine possible associations with gestational age (GA), maternal age, education, and population of the residential area. Authors tested the Greek version of the PPAQ and examined the reliability of answers using a smartwatch in several cases.
This prospective study comprised two stages. The first stage was the completion of the PPAQ Greek version twice, with a one-week interval between the two rounds, to assess internal consistency and repro ductivity. The validity was evaluated by comparing the PPAQ results with data from smartwatches that recorded step counts and metabolic equivalent tasks (METs). The second stage included pregnant women from various regions of Greece that completed the PPAQ once during their pregnancy. The level of PA during pregnancy and consistency with the international PA recommendations was evaluated with the use of METs.
A total of 1058 pregnant women filled the PPAQ Greek version, while eighteen women randomly participated in the reliability and validity analyses of the PPAQ. Results from the PPAQ completed one week apart showed strong agreement (Intraclass Correlation Coefficient [ICC]: 0.82–0.96). A comparison between the PPAQ results and smartwatch data revealed no significant differences in PA levels (correlation coefficient: 0.542; p = 0.022). The median total PA for all the participants was 142.1 MET-hours/week (interquartile range: 106.04 MET-hours/week).
PA levels increased with advancing gestation in sports/exercise (1st vs. 2nd trimester, p = 0.048; 2nd vs. 3rd trimester, p < 0.001), occupational activities (1st vs. 3rd trimester, p < 0.001; 2nd vs. 3rd trimester, p = 0.024), and transportation activities (1st vs. 3rd trimester, p < 0.001; 2nd vs. 3rd trimester, p < 0.001).
Moderate-to-vigorous intensity activities also increased with gestational age (p = 0.023, 95 % confidence interval [CI]: 0.1–1.4; p = 0.045, 95 % CI: 0–0.08, respectively).
Women were more active in household/ caregiving activities across all trimesters (p = 0.017; 95 % CI: 0.09–0.95).
Women with higher educational levels were more likely to engage in sports/exercise (p = 0.039, 95 % CI: − 3.3 to − 0.08) and had higher overall PA levels (p = 0.029, 95 % CI: 0.37–6.3). However, only 14.8 % of the participants met the international PA recommendations for pregnancy.
The results of this study demonstrate that the total PA during pregnancy increases with advancing gestation. Women become more physically active as pregnancy progresses, mainly in terms of household and sports/exercise activities. A possible explanation is that women are familiar with this new condition and might feel confident about the well-being of their pregnancy. In addition, fear of a potential miscarriage and several symptoms that are present in early pregnancy (fatigue, nausea, and vomiting) also play a significant role in preventing pregnant women from engaging in activities. Regarding the mode of conception, pregnant women who conceived through ART had a significantly lower total level of PA, with similar findings for all subcategories, except for vigorous-intensity and sedentary activities. Women who conceived spontaneously performed significantly fewer sedentary activities than those in the ART group. Most couples using ART are older and have experienced from long-term infertility. Authors postulated that these women are overcautious in protecting their pregnancy, which was achieved through additional effort; thus, it is difficult for them to adopt an active lifestyle.
Another interesting point is the association between maternal educational level, residential area population, and PA. Although the total amount of PA between the two groups was similar, pregnant women with higher educational levels performed significantly more sports/exercise activities. This may be because well-educated people are usually better informed and open to following new habits and recommendations. As far as residential areas are concerned, broad and easy access to multiple exercise or sports activities for citizens in areas with large populations could explain our significant results. Moreover, the regression analysis showed that women of advanced maternal age compared to younger ones, are more physically active in most of the PA intensities, mainly referring to moderate and vigorous activities. This finding is of great significance because it highlights the fact that younger women participate in less energy “demanding” activities, while the total level of PA does not differ. Pregnant women at a greater GA conduct more household/caregiving activities. Furthermore, women with a university degree were more likely to meet the recommendations for moderate-intensity exercise during pregnancy.
The Greek version of the PPAQ is a reliable and valid tool for assessing the PA levels in pregnant women. Moreover, the results of this study demonstrate that pregnant women in the 3rd trimester, those with a higher educational level, and those living in cities with large populations were more active in sports and exercise. On the other hand, those who conceived of using ART were less physically active. This highlights the need for clinicians to promote PA during pregnancy in Greece so that exercise is part of the daily routine of pregnant women.
Source: I. Mitrogiannis et al.; European Journal of Obstetrics & Gynecology and Reproductive Biology 307 (2025) 29–33
