Evidence has shown that ANEx enhances the physical and psychological well-being of pregnant women. Appropriately prescribed ANEx is safe and beneficial in improving maternal health. Despite this, exercises during pregnancy are poorly practiced in many part of the world. It is imperative that pregnant women understand the components, benefits, contraindications, and precautions to effectively practice ANEx supported by good attitude.
In this study, pre-pregnancy exercise, higher level of education, prior advice about ANEx, institutional employment, and most importantly knowledge about ANEx are found to be strong predictors for the practice of ANEx. Furthermore, Christian orthodox, unemployment and parity have been identified as predictors for not engaging in ANEx. The women in this study were shown to be not adequately knowledgable concerning the practice of ANEx their overall mean score was just below 50% and their attitude towards ANEx was favorable; however, very few actually practiced ANEx adequately. The study sample consisted of young women with the majority of them in the reproductive age group, about two-thirds of women had school level or no formal education, and mean parity was about two. These characteristics are comparable to those found in the samples described in the regional studies by Hjorth et al. , Gebregziabher et al.  and Hailemariam et al. , who evaluated predictors of physical activity during pregnancy and a study by Mbada et al.  which reported on knowledge and attitude about ANEx among Nigerian pregnant women. About 38% (n = 133) of respondents in this study had been advised about ANEx. This is much lower than the studies in Brazil (68.1%) and India (66%). Further, the knowledge level of the pregnant women in this study was lower than studies Brazil and India [28, 32]. The differences in awareness and knowledge might be due to the majority of participants in this study had lower education, lack of education and counseling about ANEx resulting in a paucity of information, cultural belief, lack of family support, and myths in Ethiopia. However, the reported knowledge level of pregnant women in this study was higher than the other African country Zambia (19%) . This could be due to the factors that lower educational status of women, beliefs that exercise does not suit their cultural and strong impact of the same predictors in this study.
Most of the pregnant women in this study reported being aware of walking, aerobics, and back exercises, and relaxation exercise. However, pelvic exercise (kegel), cycling, swimming, and breathing exercise were mostly not known as a component of ANEx. On the contrary, the APA ranked ANExs in order as Kegel, swimming, walking, cycling, aerobics, and dance . Further, lack of swimming pools, lack of swimming skills, non-affordability or non-availability of bicycles may have contributed to low awareness. Surprisingly, most of the women in this study were not aware of the much important pelvic floor exercise (Kegel exercise). In regards to knowledge about the benefits of ANEx, most women in this study believed antenatal exercise enhances post-natal recovery, improves stamina, and prevent weight gain. Except for the later benefit, these findings were contrasted with the other studies [33, 34].
A finding in the present study which was much expected like elsewhere  was knowledge, attitude, and practice of ANEx was significantly higher among pregnant women with a higher level of education and paid employment. Besides, the women in this study also believed that back pain and vaginal bleeding during pregnancy are contraindications for ANEx. Except for vaginal bleeding, in the absence of underlying complications, back pain during pregnancy is at best a relative contraindication and should not rule not pregnant women from engagement in exercise according to ACOG recommendations . Nonetheless, the findings of this study revealed that the knowledge about ANEx was influenced by education level, pre-pregnancy exercise habits, and previous advice about ANEx.
About 55% of pregnant women in this study demonstrated a positive attitude towards exercise during pregnancy. Therefore, a large group of respondents seems to have a negative attitude towards ANEx in pregnancy. This finding is below par with the recent studies that have reported a positive prototype shift in attitudes toward exercise among pregnant women globally over the past two decades [9–11, 31]. This study found that attitude towards exercise in pregnancy was mostly influenced by concerns about fetal safety, cultural constraints, lack of family support, and insufficient information about ANEx. This finding is thoroughly contrasting to the findings elsewhere, the most reported reasons for not exercising were tiredness, uncomfortable, lack of time, and lack of motivation [28, 31, 35]. This unique reporting could be due to feeling of inadequacy, need for support, long working days, prioritizing family routines, and women in Africa rather feel that pregnancy is mostly a barrier to engage in exercise. And most of the participants in this study during the interview reported that pregnancy is a barrier for physical activity. Hence, pregnancy is perceived as a barrier that prevents this population from exercising despite being aware of the possible benefits of ANEx. A qualitative design study in this population is needed to further illuminate the views of non-exercising Ethiopian pregnant women.
This study found that about 30% of the pregnant women practiced exercise during pregnancy, nonetheless, only 11.7% among the overall sample and 37.9% among those who practiced exercise had adequate practice in accordance with the minimum recommended guidelines for this group [1, 17]. This is almost similar to the findings of two regional studies reporting about level of physical activity during pregnancy [20, 30]. However, this is much lower than the practice of exercise reported in Nigeria (84.7%), Canada (29%), and Brazil (29%) in a similar population [28, 31, 36]. This difference might be due to the knowledge level, awareness level, educational level, socio-economic differences, and more importantly the limitation in the utility of care including lack of health care counseling concerning ante-natal exercises. Also, the cut off for adequacy (ACOG recommendation; ≥ 3 days/week, ≥ 20 min/day) of practice set in this study is similar to the Canadian and Brazilian studies. The most frequent reported barriers to practice exercise in this study were risk to fetus, lack of time, and inadequate information or training, which is consistent with the barriers reported by pregnant mothers in Australia, Canada, and Brazil [28, 36, 37].
Further, the most reported exercise practiced by the respondents in this study was walking, breathing, and relaxation exercises. Hence, improved guidelines and counseling concerning ANEx that includes exercises that they would like to perform and exercises that are most important (pelvic floor exercise) could have a better impact on maternal wellbeing in this population.
Limitations and strengths
To the best of our knowledge, few studies elsewhere and none regionally in the literature have evaluated the knowledge, attitude, and practice of antenatal exercises and the explanations why this population does not exercise, which possibly could have limited the comparing or contrasting the findings of this study. Further, the operational definition for adequate knowledge involves the perception of right and wrong which depends on the individual’s level of access to different means of communication and life experience. Nevertheless, this interpretation was based on the recommendation of the ACOG and the population included was homogenous which could have minimized any interpretation bias. Despite these limitations, this study included a power calculated sample and we believe that the findings of this study may collaborate towards enhancing prenatal care guidance and counseling concerning antenatal exercises among healthcare professionals and policymakers in Ethiopian women's health.