We noticed that data saturation was earned and three extracted themes relevant to the difficulties encountered about physical activity during pregnancy, which based on PEN-3 cultural model. They were: (1) facilities factors, (2) barriers factors (3), and structural factors, which are shown in Table 2.
Barriers factors are specified into three categories: individual factors, social and socioeconomic factors that have been identified as barriers factors to lack of physical activity in pregnant women, which are shown in Table 3 that are involved:
Socio-cultural factors. Subjective norms make to diminish opportunities for doing physical activity behavior. Pregnant women infrequently reported that exercise during pregnancy and were scarcely seen by the investigators that they were exercising with other people, but found that their husbands' attend in pregnancy classes encouraged them to do physical activity. Of the 30 participants in interview, 28 said they would like to participate in exercise classes with other pregnant women. Of the 30 participants, 21 mentioned a lack of exercise facilities for pregnant women, such as a lack of fitness classes. Within follow-up periods, six pregnant women on trial did not agree with this subject that the presence of other men in their pregnant women's exercise classes.
My husband and I practically talk about physical activity during pregnancy every day as I like to do exercise, but my husband does not permit me to do that, he thinks it is dangerous for our baby!
(Mahdis, the late twenties)
Participants were asked whom they consulted about physical activity during pregnancy, and most pregnant women reporting that they try to consult their doctor for regular exercise during pregnancy. Some of them are reportedly banned from exercising with other women and their families because they thought exercise was dangerous during pregnancy (Elina, the early thirties). Many participants stated that the lack of a social culture indicates that these pregnant women often did not support each other.
It is hard to explain, but I think that in this country, the culture of pregnant women's sports is still absent, and many families are not allowed to exercise because they have misinformation about it.
When asked during frequent visits, some participants confirmed this idea. One of these pregnant women strongly disagreed with this idea. This is the main effect of encouraging them to be active during pregnancy. Among the 12 women who explained that pregnant women were encouraged to exercise, eight did not. A small number of participants said that if they had a kind spouse who could encourage them to attend or take classes, they would probably do physical activity. The opposite sex roles also confined pregnant women’s chances of being active to have social accountability during pregnancy. Several participants had not confirmed on behalf of their extended family, whereas few did.
Socioeconomic factors. Socioeconomic factors do not allow participants to take part freely in exercise classes during pregnancy. Within interviews of these women, they reported a variety of socioeconomic restrictions. First, several women said that there is no proper place to do exercise. Several participants noted that homes are small and not suitable for physical activity. Some women said that being active at home and doing activities such as washing, cleaning is enough as an exercise in their pregnancy. Throughout follow up sessions, participants reported that it was not likely to do physical activity in their homes because they lived in small apartment houses. Pregnant women as well as stated that they do not have the necessary facilities for exercise at home. For example, one of the pregnant women described:
I prefer to select a sports class that is not expensive that I could have a private trainer. If physical activity classes were held for pregnant women in health centers or were given free cards to participate in exercise classes, they would use more...
One participant described the physical inactivity during her pregnancy:
"The city is very crowded, and everywhere in the city is built houses, and there is not even the right place to walk for pregnant women, especially with this polluted air … no… in this daytime is no way! It is a place, not for walking!"
One pregnant woman commented: "I do not have to pay for my diet, but if I want to attend pregnancy classes, I have to pay." Because of this, I think it is better than having a gym for health. Isn’t expensive, so I think, the diet has more effectiveness than physical activity."
(Kati, the late twenties)
During the participant sessions, 18 women spoke of their spouse's economic situation and claimed that they were not allowed to attend exercise classes because of their financial problems, and they did not get awareness about free sports classes for participating. This means that health care providers must provide all information about the existence of these classes to pregnant women, as well as social networks, and media must inform them that pregnancy exercise classes for women who have financial problems are free.
Most women, who do not have enough money or time to attend classes, try to be active. Several of these participants described a diversity of main strategies, including having mobility, dancing, walking, and jobs that need activity at home. However, some women did encounter structural problems (Husband's opposition or family, affordable classes) that enabled them to attend classes or doing mobility. It seems outdoor is not a suitable place and facilities for pregnant women. For one of the participants, walking was comfortable form of physical activity because of financial constraints. She described, "walking to the shopping center and reported: Instead of sitting in the car for a long time, I prefer only to walk."
Individual factors. Many women were upset that they did not have any knowledge of conducting exercise classes for pregnant women in hospitals or health centers. This lack of awareness of women can be due to the neglect of healthcare personnel who do not inform women at the time of their visit or may have weaknesses in educational or social media. A few women said that if we participate in affordable classes, there is no competent and ethical education. Furthermore, opportunities for pregnant women is limited in developing countries
Mother's health, not the primary motivation for doing exercise during pregnancy and this is not the right motivation for them to participate in the exercise.
One woman summarized this and said, "I'd rather eat less than exercise and get tired, but if it doesn't work, it's too hard and bad because of my body condition and it's not good at all."
However, few pregnant women said that during pregnancy, if they feel the risk of having pregnancy-induced diabetes due to a history of familial or high blood pressure, which seriously danger their fetal deaths, they try to participate in exercise classes. One woman described:
"My baby's health is more important than myself, but I am apprehensive about diabetes and hypertension due to my obesity in pregnancy, and I prefer to exercise for my health. Things just happen…"
One woman commented, “Previously, women had a lot of activity and therefore were easier to give birth or had any problems, but with the advancement of technology, nobody cares about this issue.” She kept on and asserted that the old opinion and belief confined the culture.
(Fateme, the late Thirties)
Many women believed that if they could control their weight through healthy nutrition, they would no longer need to exercise. One pregnant woman commented:
"I always had my health rights before pregnancy, and I was very active in physical activity, but now due to my baby not being injured, I prefer to take a diet and do not let the illness come to me to have a more comfortable delivery."
The belief in pregnant women that having healthy eating is more comfortable and more effective than doing physical activity during pregnancy is a reflection of health professional's role in increasing women's awareness and cultural poverty in this community.
One woman explained:
"In my idea that everything is depended on the nutritional health. If pregnant women regard and take care of their diet, I am sure that they do not get overweight and obesity and no longer need to exercise."
Another woman described that "Maintaining a healthy diet avoids exercise during pregnancy and reduce the risk of harm to the baby."
Almost most of the women who participated in the interview agreed with this opinion that the diet of healthy food would reduce the need for physical activity in pregnancy. Just seven pregnant women recognized being fitness as the first motivation to do exercise in pregnancy.
One woman explained:
"Whenever I go to my doctor's or healthcare provider's visit, she never advises me to" exercise for my health.
Therefore, most women thought of physical activity as fitness and did not know what benefits to exercise during pregnancy. For instance, a participant reported attending in a free counseling class: "Nutrition Advisor recommended me that I could lose more than 10 pounds if I remained on a severely diet."
(Rosha, the late twenties)
While being activity in pregnancy was introduced as one of the weight loss methods, many pregnant women believed that having healthy nutrition is a likely alternative to have physical activity in this period.
During the interviews and meetings held with pregnant women, several factors were extracted as facilitating factors that we will refer to them. These facilitators were removed from the follow-up interview while answering questions such as “What factors in your pregnancy can help you to do exercise?” Some responses have been extracted among women's speeches on other issues.
Nurture factors. Nurture factors & support are the factors to do physical activity during pregnancy. In physical activity classes, it seemed that pregnant women know other women, and connecting was the most critical problem of the social system. One of the women who attended the exercise classes described her reasons: “When I came to the health center for pregnancy care, I saw that other pregnant women talked about exercise classes and became curious and took the address from them. […laughs] This does not seem convenient … At first! [Silence]”
(Junos, the late twenties)
Awareness of free class was suggested as an essential motivator for presence in the sports class. Some women said that being a free class for participating is very important in this social-economic situation. As Sima went on to summarize, “Stolen water is sweet” [Laughs]. She explained: "Since I got pregnant, I lost my job, and my husband's income is not high; therefore, it is motivational for me to participate in these classes.”
(Maryam, the late twenties, no children)
Electronic communication via a group consists of pregnant women in the same physical activity class that make stronger this social motivation. Electronic communication is formed of mass media application that was generally used by the pregnant women group, and its traditional was used in a similar method of services of text messages to motivate pregnant women to do physical activity in pregnancy and entered into the group with the exchange messages in a usual forum. One of the pregnant participants described a Telegram group:
I am encouraged by my friends, because umm ... My friends in my group are invited to do physical activity during pregnancy, and when I get bored, I go to social media and talk with my friends. I get excited. The group [...] encourages you to feel as satisfied as to do physical activity with them.
(Raziye, the late thirties)
It seems that there is a direct and secure link between virtual networks and the motivation of pregnant women to attend and encourage them to exercise classes.
When health was not offered as the primary motivation for exercise during pregnancy, pregnant women tended to go to gym classes because of their new relationship with other pregnant women. Women talked about experiencing reduced back pain during pregnancy, reduced ankle and knee ache, and more Joy and peace and increased cardio output. One of the pregnant women commented: “Before my pregnancy I had depression and when I became pregnant unintentionally, my wife and family were very worried about the deterioration of my condition […] Until one of my friends advised me to take part in pregnancy exercises classes, after a few sessions, I am feeling very well In terms of mentally and physically, and I do not use other depressions pills–! [Laughs]. ”
Environmental factor. “I provided the device for myself at home, and I do not like to get out of the house due to air pollution, and I try to exercise at home so that we do not face any problems because of the pregnancy situation. –However, I do not like to do that for a long time.”
(Sogand, the late thirties)
Some participants said dancing and stretching movement is a good alternative rather than physical activity in pregnancy; there is no need to spend time or money outdoors. They did describe dancing does not require space or individual facilities or pay cash, and they saw kind of dancing as fun. One woman commented: “I think dancing and aerobic instead of exercising is much better. I do not like to do slow movements.”
Organizational Factors. Some pregnant women mentioned that working out of home regards as physical activity in response to whether they are exercising or not. For example, one of the pregnant women reported using while working. She described:
I work in a hospital as a nurse. My work requires much energy, and I am always moving, and it is a kind of physical activity, especially during pregnancy. I do not like to do more activities after leaving work because I'm afraid it will be dangerous for my baby.
(Rahil, the late twenties)
Employed women with sedentary and non-mobile jobs said they would like to be active and have the opportunity to exercise. For example, Zahra, explained how to try to make the time of her chief to have opportunities for walking all over her daytime: “for instance, if I have no time to do physical activity at my desk I am trying to walk around in my workplace […] my office is so far of my work and walk to there every day. Like… about ten minutes.”
Nazanin, who worked at an office, described, “Due to pregnancy, someone does not let me work at home, but I always try to be active.”
(Nazanin, the late twenties)
Another woman described, “Exercising at a gym class near her workplace, which costs $10 per week. Another woman described close to my workplace, due to my pregnancy situation and economic problems, I found the gym class that is also affordable for me.” Therefore, the cost of pregnancy classes is a significant barrier to pregnancy. The result of these item are shown in Table 4. The relationship between themes and subthemes about physical activity in pregnant women is shown in Fig. 1
(Raziye, the late thirties)