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Physical activity level and associated factors among pregnant women: a population-based epidemiological study

Nível de atividade física e fatores associados entre gestantes: estudo epidemiológico de base populacional

Ingred Gimenes Cassimiro de Freitas1
Cássio de Almeida Lima2
Viviane Maia Santos3
Francisco Trindade Silva4
Josiane Santos Brant Rocha5
Orlene Veloso Dias6
Rosângela Ramos Veloso Silva7
Maria Fernanda Santos Figueiredo Brito8

1Faculdade de Saúde e Desenvolvimento Humano Santo Agostinho, Coordenação do Curso de Graduação em Enfermagem, Montes Claros – MG, Brasil. E-mail: igcassimiro@yahoo.com.br ORCID https://orcid.org/0000-0001-8325-0985
2Universidade Estadual de Montes Claros, Programa de Pós-Graduação em Ciências da Saúde, Montes Claros – MG, Brasil. E-mail: cassioenf2014@gmail.com ORCID https://orcid.org/0000-0002-4261-8226
3Centro Universitário FIPMoc, Coordenação do Curso de Graduação em Medicina. Montes Claros, MG, Brasil. E-mail: viviane.mestrado.2017@gmail.com ORCID https://orcid.org/0000-0002-2549-4612
4Universidade Estadual do Ceará, Programa de Pós-Graduação em Saúde Coletiva, Fortaleza - Ceará, Brasil. E-mail: ikotrindade@gmail.com ORCID https://orcid.org/0000-0003-2601-3515
5Universidade Estadual de Montes Claros, Programa de Pós-Graduação em Cuidado Primário em Saúde, Montes Claros – MG, Brasil. E-mail: josianenat@yahoo.com.br ORCID https://orcid.org/0000-0002-7317-3880
6Universidade Estadual de Montes Claros, Programa de Pós-Graduação em Cuidado Primário em Saúde, Montes Claros – MG, Brasil. E-mail: orlenedias@yahoo.com.br ORCID https://orcid.org/0000-0002-9017-7875
7Universidade Estadual de Montes Claros, Programa de Pós-Graduação em Cuidado Primário em Saúde, Montes Claros – MG, Brasil. E-mail: rosangela.veloso@unimontes.br ORCID https://orcid.org/0000-0003-3329-8133
8Universidade Estadual de Montes Claros, Programa de Pós-Graduação em Cuidado Primário em Saúde, Montes Claros – MG, Brasil. E-mail: maria.brito@unimontes.br ORCID https://orcid.org/0000-0001-5395-9491

Corresponding author
Cássio de Almeida Lima
Universidade Estadual de Montes Claros/Unimontes. Centro de Ciências Biológicas e da Saúde (CCBS/prédio 6). Avenida Dr. Ruy Braga, S/N, Vila Mauricéia, Montes Claros (MG), Brasil, CEP 39401-089. E-mail: cassioenf2014@gmail.com

Abstract
This research aimed to assess the level of physical activity and identify the associated factors in pregnant women assisted in Primary Health Care in the city of Montes Claros, Minas Gerais (Brazil). This was an epidemiological, cross-sectional, analytical study, carried out with 1,279 pregnant women. Socioeconomic, occupational, obstetric, behavioral, social, health, and emotional variables were assessed using a questionnaire. The Physical Activity Questionnaire for Pregnant Women was also applied. Descriptive statistical analysis and multinominal logistic regression with a hierarchical model were performed. The prevalence of physical inactivity in the physical activity and leisure time dimensions was verified. A mild level of physical activity was associated with the variables such as age from 21 to 30 years and up to 20 years old, income above two minimum wages, salaried work, and maternal-fetal attachment at a medium/high level. Income from one to two minimum wages and above two wages, paid work and self-employment, anxiety and stress symptoms, and medium/high maternal-fetal attachment were associated with the moderate/vigorous level. Multifactorial aspects must be considered in health promotion strategies directed to the practice of physical activity by pregnant women.
Keywords: Pregnant women, Exercise, Primary health care, Health surveys.

Resumo
Esta pesquisa teve como objetivo avaliar o nível de atividade física e identificar os fatores associados em gestantes assistidas na Atenção Primária à Saúde da cidade de Montes Claros – Minas Gerais (Brasil). Estudo epidemiológico, transversal, analítico, realizado com 1.279 gestantes. Utilizou-se questionário que contemplava variáveis socioeconômicas, ocupacionais, obstétricas, comportamentais, sociais, de saúde e emocionais. Também se aplicou o Questionário de Atividade Física para Gestantes. Realizou-se análise estatística descritiva e regressão logística multinominal com modelo hierarquizado. Verificou-se prevalência de inatividade física nas dimensões atividade física e lazer. O nível leve de atividade física foi associado aos fatores idade de 21 a 30 e até 20 anos, renda acima de dois salários mínimos, trabalho assalariado e apego materno-fetal nível médio/alto. Renda de um a dois salários mínimos e acima de dois salários, trabalho assalariado e por conta própria, sintomas de ansiedade e de estresse, apego materno-fetal médio/alto foram associados ao nível moderado/vigoroso. Aspectos multifatoriais devem ser considerados em estratégias de promoção da saúde direcionadas à prática de atividade física por gestantes.
Palavras-chave: Gestantes, Exercício físico, Atenção primária à saúde, Inquéritos epidemiológicos.

Introduction
Pregnancy is a period that involves maternal-fetal health care, such as the adoption of a healthy lifestyle. The practice of physical activity at this stage results in benefits for the pregnant woman and the fetus1,2. For the pregnant woman, physical activity ensures the improvement of circulation, respiratory quality, and sleep; strengthening of the endocrine and nervous system, as well as the muscles of the back and legs, helping in weight control and in the prevention or control of various diseases; it also improves quality of life and self-esteem2-5. In addition, it stimulates placental growth, provides better conditions for the baby\'s birth, and faster recovery during the postpartum period. For the fetus, the regular practice of physical activity results in benefits such as greater tolerance to vaginal labor, better neurodevelopment, and lower percentage of body fat2,3,6,7.
According to the Physical Activity Guide for the Brazilian Population8, this practice also contributes to the human development and well-being of the pregnant women, helping them to enjoy a full life with better quality; it promotes relaxation, fun and disposition. It reduces the risk of depression; helps in social inclusion, in the creation and strengthening of social bonds, links and solidarity; and reduces the risk of prematurity8.
However, for a long period, fears regarding the risks of complications for mother and fetus due to the practice of physical activity by pregnant women existed9,10. There is a consensus that light or moderate physical activity and regularly during pregnancy presents minimal risks and benefits most women, with improvement in the level of physical fitness of the pregnant woman, provided that she has no medical contraindication for this practice8-13. One must consider the need for continued research on the safety of physical activity for the fetus, since the possibility of reaching a consonance remains distant13.
International studies have shown the prevalence of insufficient physical activity during pregnancy. Research conducted with pregnant women from South Africa showed that 65.1% did not practice physical activity before pregnancy, and 69.6% never practiced physical activity in any of the trimesters14. In Germany, research conducted with pregnant women who had some type of restriction to physical activity found that 80% had less or no exercise during pregnancy15. In Singapore, there was a significant reduction in the pattern of physical activity and total energy expenditure from before to during pregnancy16. In Brazil, investigations have shown that the regular practice of physical activity by pregnant women is still low compared to non-pregnant women. Results of national studies show a high rate of insufficiently active pregnant women17,18.
There is a need to demystify the incompatibility of the practice of physical activity at this stage of the life cycle and stimulate its regular performance considering the reality in which the pregnant woman is inserted, so to contribute to the improvement of her health conditions, quality of life, minimize the discomforts of pregnancy, and benefit fetal health17,19-21.
Therefore, it is important to estimate the prevalence and identify factors related to levels of physical activity during pregnancy. However, investigations that address this issue are still incipient, especially in the northern region of Minas Gerais. Therefore, this research aimed to evaluate the level of physical activity and identify the associated factors in pregnant women assisted in Primary Health Care (PHC) in the city of Montes Claros – Minas Gerais (Brazil).

Methods
This is an observational, population-based, cross-sectional and analytical epidemiological study. This study is an excerpt from the matrix research entitled “Estudo ALGE – Avaliação das condições de saúde das gestantes de Montes Claros - MG: estudo longitudinal” (ALGE Study – Evaluation of the health conditions of pregnant women in Montes Claros – MG: longitudinal study). Recommendations of the “STROBE – Strengthening the reporting of observational studies in epidemiology” were followed22.
The population of this research consisted of pregnant women registered in the teams of the Family Health Strategy (FHS), in the urban area of the municipality of Montes Claros, in 2018. Sample size was established to estimate population parameters with a prevalence of 50% (to maximize the sample size and due to the project contemplating several events), 95% confidence interval (95% CI), and precision level of 2.0%. A correction was made for the finite population (N=1,661 pregnant women) and an increase of 20% was also established to compensate for possible non-responses and losses. The calculations showed the need for participation of at least 1,180 pregnant women.
The ALGE study aimed to analyze a series of outcome variables with several independent variables, and it was not possible to calculate a measure of association previously. The population was 1,661 women and the sample interviewed included 1,279 (higher than the minimum amount indicated in the sample calculation), so most of the population contingent was analyzed.
For sample selection, all the FHS centers of the municipality were considered, which totaled 15 in the period of this research and among which 125 family health teams were distributed. The number of pregnant women sampled in each center was proportional to their representativeness in relation to the total population of registered pregnant women. All those registered at the centers were invited to participate in the project.
As for the data collection process, initially contact was made with the managers of the PHC coordination of the municipality, to raise awareness and explain the purpose of the research. After their consent, the family health teams were also visited by the researchers for clarification on the study. The professionals of these teams responsible for prenatal care provided a list of pregnant women in their area of coverage containing their names, telephones and addresses. With these lists, a team of interviewers made initial telephone contact with the women, when there was an approach with the invitation and awareness about the study, so that data collection could be scheduled and carried out.
The collection took place between October 2018 and November 2019, in the health units of the FHS or in the homes of the participants, according to their availability. A multidisciplinary team of health professionals and undergraduate students was responsible for the interviews, which took place face-to-face, with an average duration of one hour per interview.
Pregnant women who were registered in a PHC family health team at any gestational age were included. Women who were pregnant with twins and those with cognitive impairment were excluded, according to information from the family member and/or the FHS team.
Prior to data collection, the interviewers were trained, and a pilot study with pregnant women was registered in a FHS unit (who were not included in the analysis of the study), to standardize the research procedures.
For data collection, a questionnaire was used that included socioeconomic (schooling, family income in minimum wages – R$998.00 at the time of the research, maternal age, marital status), occupational (maternal work), obstetric (number of children), behavioral (smoking and alcohol consumption), social (family and social support), health (pre-pregnancy nutritional status) and emotional (maternal-fetal attachment, anxiety, stress, self-esteem and body image) characteristics. The Physical Activity Questionnaire for Pregnant Women (QAFG) was adopted to assess physical activity levels in general categories -- household chores, caring for people, sports and exercise, occupation and leisure. Anthropometric data were obtained by copying the records of the Pregnant Women\'s Booklet (Chart 1).
To observe the pregnant woman\'s perception about the family function, an instrument named Family APGAR was applied, which signals the fulfillment of basic parameters defined by the acronym APGAR: A –Adaptation; P –Participation; G –Growth; A –Affection; R –Resolution. The questionnaire presents five questions with three possible answers each, and a score ranging from zero to two points - always (2), sometimes (1) and never (0)23-25. Thus, the sum of zero to ten points is given, which, the higher it is, the better the participant\'s satisfaction. We proceeded to the categorization in “functional family” (score of 7-10) and “dysfunctional family” (<6)25.
To measure the presence of social support, the Brazilian version of the Social Support Scale was used, consisting of 19 questions that comprise five dimensions: material, affective, emotional, positive social interaction, and information. For each item, the participant indicates how often she considers each type of support, using a Likert-type scale: never (1), rarely (2), sometimes (3), almost always (4) and always (5). The closer to 100 the final score is, the better the perceived social support26. The overall score of the scale was calculated by the total score of the 19 items and results above 66, which corresponds to the second tertile, were considered as high social support27.

Insert Chart 1

The QAFG is a questionnaire that evaluates the pregnant woman\'s energy expenditure in MET (metabolic equivalent), adapted for the Brazilian population in 2009, which is calculated based on the time spent on the 31 activities usually performed as household chores (05 activities), caring for other people (06), occupation (5 activities), sports and exercise (9 activities), locomotion (3 activities) and leisure (3 activities)34,35. The instrument was adapted and validated for use in pregnant women in Brazil by Silva35, in which it is available in its complete format.
The estimation of QAFG intensity from mild to vigorous activities results from the average MET/hour per week for the total activity. Each activity was classified by its intensity: physically inactive (<1.5 METs), mild (1.5-<3.0 METs), moderate (3.0-6.0 METs) or vigorous (>6.0 METs). These questions come from the work of Chasan-Taber et al.36,37, based on the compendium by Roberts et al.38 to represent physical activities, walking, and household chores, and on Ainsworth et al.39 to find the intensity of the other activities (for the general population) of the questionnaire. The number of minutes spent on each activity was multiplied by its intensity, in MET, and added to be presented in the form of weekly energy expenditure (MET-hrs/wk)35.
The specific values in MET indicated in all questions follow the pattern (question: MET: value), [3:2.5], [4:2.0], [5:3.0], [6:2.7], [7:4.0], [8:3.0] [9:4.0], [10:1.8], [11:1.0], [12:3.2], [13:2.5], [14:2.3], [15:3.0], [16:4.5], [17:2.5], [18:4.0], [19:1.5], [20:3.5], [21:5.0], [22:6.0], [23:7.0], [24:3.5], [25:6.0], [26:4.5], [27: See compendium38], [28: See compendium38], [29:1.8], [30:3.0], [ 31:2.0], [32:4.0], [33:3.3] 34,35.
The calculation was performed observing the following guidelines. For questions 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14, 17, 18, 19 the duration count corresponded to the duration categories 0 – 0.25 – 0.75 – 1.5 – 2.5 – 3.0, and the value found was multiplyed by 7 days a week. As for questions 11, 29, 30, 31, 32, 33, the duration times corresponded to 0 – 0.25 – 1.25 – 3.0 – 5.0 – 6.0 multiplying the values by 7 days a week; and for questions 15, 21, 16, 20, 21, 22, 23, 24, 25, 26, 27, 28 these questions correspond to duration in the time ranges 0 – 0.25 – 0.75 – 1.5 – 2.5 – 3.0 and these values are already in weekly form34,35.
The collected data were organized and analyzed using the IBM SPSS Statistics software version 22.0 for Windows ®. First, a double verification was carried out.
Descriptive analyses were performed using absolute and percentage frequency and central tendency measures. Then, bivariate analyses were performed between the outcome variable (level of physical activity during pregnancy) and each independent variable (sociodemographic factors, occupational factors, obstetric factors, behavioral factors, social aspects, health conditions and emotional conditions) using the chi-square test to verify the association between them. Variables with a descriptive level (p-value) of up to 20% were selected for multiple analysis. The hierarchical multinomial logistic regression model was used, following the scheme presented in Figure 1, consisting of blocks of variables at distal (education, family income, maternal age, marital status, maternal work and number of children), intermediate (smoking, alcohol consumption, family APGAR and social support) and proximal (pre-pregnancy nutritional status, maternal-fetal attachment, anxiety, stress, self-esteem and body image) levels.

Insert Figure 1

The block of sociodemographic, occupational and obstetric characteristics was the first to be included in the model, remaining as an adjustment factor for the intermediate and proximal levels. Subsequently, the variables of the intermediate level (behavioral factors and social aspects) were included, remaining as an adjustment factor for the variables of the proximal level. Finally, the variables of the proximal level (health and emotional conditions) were included. At all levels, only those variables that presented descriptive level p≤0.05 remained in the model, after adjustment for the variables of the previous levels. Adjusted odds ratios (OR) were estimated, with their respective 95% CI values.
The project of this investigation was approved by the Research Ethics Committee, through the Consubstantiated Opinion No. 2,483,623/2018. The participants gave their acquiescence via the Informed Consent Form and, in for minors, the Informed Consent Term was applied. There was also the formal agreement of the PHC Coordination of the Municipal Health Department, through the Institution\'s Term of Agreement for Participation in Research and Official Letter of the institution.

Results
A total of 1,279 pregnant women participated in the study, most of them (48.7%) between 21 and 30 years old. Regarding marital status, 76.9% reported having a partner. As for education, 64.9% had attended high school. It was observed that 44.9% of the sample received less than one minimum monthly wage. Most of the participants (56.4%) were housewives, “moonlighted” or did not exercise any professional occupation. As for obstetric factors, 49.2% of women had two or more children. Other characteristics are shown in Table 1.
Independent variables that presented p-value ≤0.20 in the bivariate analysis -- age (p=0.002), education (p<0.001), family income (p<0.001), maternal work (p<0.001), number of children (p=0.032), maternal-fetal attachment (p= 0.155), anxiety (p<0.001), stress (p=0.017) and self-esteem (p=0.133) – were included in the multiple model (Table 1).

Insert Table 1

Table 2 presents the classification of the levels of physical activity of pregnant women in general and in the dimensions: household chores, caring for people, occupation, sport and exercise, locomotion, and leisure. It was observed that 23.2% were classified as physically inactive in the general domain. In the domain household chores, 64.9% of the respondents presented a pattern classified as physically inactive. Regarding the category of physical activity related to care, 89.0% of those who perform this activity were classified as physically inactive. In the occupation domain, 36.5% of the pregnant women were considered physically inactive. In the sports and locomotion categories, 93.1% and 93.2% were physically inactive, respectively, while 41.4% were considered inactive in the leisure domain.

Insert Table 2

Considering the physically inactive level as a reference for the dependent variable, results of the multinomial logistic regression indicated statistical evidence of association of the mild level with the variables age from 21 to 30 years (OR=1.52; p=0.047) and up to 20 (OR=1.82; p=0.018), income above two salaries (OR=2.26; p=0.020), salaried work (OR=1.74; p=0.027) and maternal-fetal attachment at a medium/high level (OR=1.53; p=0.018). The variables income from one to two minimum wages (OR=2.53; p=0.006), above two wages (OR=3.51; p=0.002), salaried work (OR=4.59; p<0.001) and self-employed (OR=2.44; p=0.007), high level of anxiety (OR=2.20; p<0.001), presence of stress symptoms (OR=1.89; p=0.015) and medium/high maternal-fetal attachment (OR=1.52; p=0.034) were associated with moderate/vigorous level of physical activity (Table 3).

Insert Table 3

Discussion
This epidemiological survey provided an analysis of the performance of physical activity and associated factors among pregnant women assisted by the FHS teams. According to the findings, approximately half of the pregnant women practiced mild physical activity and one third moderate/vigorous in the general domain. In this same domain and in the others, a significant portion of the participants was considered physically inactive. The following statistical evidence of association was found: mild level of physical activity was associated with the factors age from 21 to 30 and up to 20 years, income above two minimum wages, paid work, and maternal-fetal attachment at a medium/high level. Income from one to two minimum wages and above two wages, employed and self-employed work, the presence of anxiety and stress symptoms, in addition to medium/high maternal-fetal attachment, were factors associated with moderate/vigorous level.
These results are relevant because they allow the recognition of factors that hinder the adoption of a more physically active lifestyle40. The practice of physical activity is related to positive outcomes for the health of the woman and child to be born, such as the lower risk for the development of gestational diabetes, hypertension, excessive gestational weight gain, preeclampsia, and depression symptoms. To date, there is no evidence of negative effects of moderate-intensity physical activity in healthy pregnant women41,42. It is widely argued that, in the absence of obstetric complications, the continuity or starting of safe physical activity should be encouraged. Considering that this behavior contributes to the prevention of negative events and health promotion, it is also beneficial to the health system41,43. The FHS is a strategic scenario for actions to promote body practices and physical activity41. Multiprofessional prenatal care is necessary, with the inclusion of physical education professionals in PHC, to guide the adoption of health-related behaviors40.
The results of this study indicated the low prevalence of physical activity among the participants. In basic health units in Fortaleza – Ceará/Brazil, a considerable portion (51.4%) of the participants also identified a level of mild energy expenditure35. Research in Rio Grande – RS also found that approximately one third (32.8%) of the sample investigated reported practicing some physical activity44. Research with pregnant women living in Vitória da Conquista – Bahia/Brazil classified 52% of the surveyed women as physically inactive17. Comparisons between such prevalences should be viewed with care, due to the population, cultural, and methodological differences in the various study scenarios.
The physical discomforts triggered by organic adjustments of pregnancy and the conceptions of society that worships the reduction of physical activity in this phase as care may explain the expressive prevalence of physical inactivity. The implementation and development of public policies focusing on the orientation and encouragement of such activity for this group should be considered to overcome these challenges represented by physical and cultural issues20.
When grouping a set of questions that seek to identify the daily time spent on energy in the various situations of daily life in the form of physical activity, it was found in the leisure category the greatest representation of energy expenditure with about one third of those surveyed in the moderate/vigorous classification of physical activity. This result differs from research with low-risk pregnant women assisted in the PHC of Fortaleza, which reported the highest energy expenditure in the category household chores, with 54.4% at the moderate/vigorous level35.
In the sport and exercise category, 93.1% of the interviewees were classified as physically inactive, results similar to those found in a study conducted with women between the 20th and 28th weeks of pregnancy, followed up in prenatal care of basic health units in the city of Manaus/AM45. The high prevalence of inactivity in this domain may mean that the pregnant woman does not practice systematized physical activity, with the recommended intensity, frequency and duration4.
The practice of light physical activity was significantly more frequent in pregnant women with younger age groups, a result similar to those found in Pelotas-RS46, Bristol-England47 and Beirut-Lebanon48. The possible explanation for the relationship between younger age and physical activity during pregnancy may be due to the fact that younger women are more concerned with body image and adopt a healthier lifestyle, thus recognizing the contribution of regular and oriented physical activity during pregnancy.
The practice of physical activity at the mild level and at the moderate/vigorous level showed statistical evidence of association with the factors: family income, maternal work, anxiety, and maternal-fetal attachment. It was observed that the highest income was associated with the practice of physical activity at the mild and moderate/vigorous levels. Divergent results were observed in an investigation conducted with a sample of 1,171 pregnant women from Singapore, in which those with higher family income were more likely to reduce physical activity16. But they were similar to those of research with pregnant women attended in the PHC of Vitória da Conquista/BA, in which income greater than two minimum wages served as a protective factor for a higher level of physical exercise17.
Low family income showed statistical evidence of association, with a three times higher probability of physical inactivity in a cross-sectional study conducted with a sample of 400 pregnant women in high-risk prenatal care in Massachusetts-USA19. An investigation carried out with the objective of evaluating the status of physical activity in pregnant women identified that the indices vary according to family income15. It was also found an association of physical activity with age and income in a study in the USA with a sample of 1,280 pregnant women49.
A study developed in the city of Cruz das Almas, Bahia/Brazil, with the participation of women of gestational age equal to or greater than 28 weeks found low income as one of the determinants of physical inactivity in pregnancy50. The explanation for the association between higher income and physical activity may be due to the knowledge of pregnant women about the appropriate exercises for this phase of life, as well as greater opportunities to perform it. The higher income also provides women with greater access to knowledge and understanding about the importance of physical activity for the health and well-being of pregnant women and their babies51.
Maternal paid work was associated with physical activity at the mild and moderate/vigorous levels, while self-employment was associated with moderate/vigorous levels. This result contrasts with those of a study developed with low-risk pregnant women assisted in the PHC of Botucatu/SP, which observed that working outside the home reduced the chance of reaching the recommended level of activity18. In a prospective study in Recife/PE, with obese and overweight pregnant women, when evaluating the work/occupational activity variable, and a 0.63 mean MET increase was observed for those who worked in relation to those who did not work52.
The positive effect of maternal work on the practice of physical activity during pregnancy is probably due to the fact that women who perform any professional activity outside the home can value their health more and recognize the importance of physical exercise for the health of the baby, as well as to maintain and improve their physical and emotional condition during pregnancy and postpartum recovery. Added to this is the fact that occupational activity provides greater body movement and, consequently, generates greater energy expenditure52.
The presence of anxiety and stress symptoms was associated with moderate/vigorous physical activity. The high level of anxiety was also borderline related to the practice of light physical activities. These results differ from those assumed a priori and differ from those recorded in São Luís/Maranhão53. A possible hypothesis is that pregnant women with such symptoms have sought to exercise more, after professional recommendations, as a form of mental health care. One should consider the cross-sectional nature of the current investigation, which does not allow defining a temporal and causality statement for the recorded result. Thus, longitudinal design and intervention investigations may better elucidate this finding.
One must also consider the relationship between the practice of regular physical activity and the presence of anxiety and stress symptoms. This is because pregnancy is considered a period in the life of women of greater vulnerability regarding mental health. An active lifestyle characterized by higher levels of physical activity can contribute to the psychic health of pregnant women, reducing anxiety and stress. Psychological well-being is desirable for maternal and fetal health, and may have positive implications throughout child development and later, in adulthood42,54,55.
Greater maternal-fetal attachment was also a factor that was associated with physical activity at the mild and moderate/vigorous levels. This finding suggests that physical activity is a self-care behavior, which can provide a general feeling of health and physical well-being. It is a sensation that benefits the adaptation to pregnancy, the successful transition to motherhood and, consequently, the affective bond with the fetus54. Attachment includes behaviors and feelings of care, protection and integration with the fetus, expressed through affection, emotions, perceptions, concerns and expectations56. Although this construct is a predictor of the pregnant woman\'s behavior, there are gaps in evidence about its influence on the practice of physical activity.
This work has some limitations. One of them was the self-report, which may have been affected by social desirability and memory bias. The results obtained are valid only for the population of pregnant women assisted in the FHS units of Montes Claros, so extrapolations to other populations are not possible. It is suggested the development of further research on the subject, with longitudinal design, to explain cause and effect relationships for the associations detected.
Despite these limitations, it is worth noting the positive aspects of this survey. To measure physical activity and variables related to subjective constructs, instruments validated in Brazil were applied. The multinomial logistic regression analysis, with a hierarchical approach to the factors investigated, gave greater robustness and consistency to this investigation. The sample investigated was significant and representative of the population, strengthening the results and associations recorded. The findings obtained contribute to add epidemiological evidence on the importance of assessing physical activity and its determinants in pregnant women.

Individual contributions
IGC Freitas, CA Lima and VM Santos contributed to the conception and development of the study, data interpretation and elaboration of the article. FT Silva contributed to the analysis and interpretation of the data and critical review of the article. JSB Rocha, OV Dias, RRV Silva and MFSF Brito contributed to the study orientation, study conception and design, data analysis and critical review of the article. All authors reviewed and approved the final version of the article.

Acknowledgments
To the pregnant women participating in the ALGE Study. To the team of interviewers who worked in the collection and in the research database. To the Coordination of Primary Health Care of the Municipal Health Department of Montes Claros – MG. To the National Council for Scientific and Technological Development (CNPq), the Research Support Foundation of the State of Minas Gerais (FAPEMIG) and the State University of Montes Claros (Unimontes) for Scientific Initiation scholarships awarded to the academics involved in the project.


References
1. Surita FG, Nascimento SL, Silva JLP. Exercício físico e gestação. Rev Bras Ginecol Obstet 2014; 36(12):531-534.

2. Giacopini SM, Oliveira DV, Araújo APS. Benefícios e recomendações da prática de exercícios físicos na gestação. Revista BioSalus 2016; 1(1):1-19.

3. Montenegro LP. Musculação: abordagem para a prescrição e recomendação para gestantes. Revista Brasileira de Prescrição e Fisiologia do Exercício 2014;8(2):494-498.

4. Nascimento SLD, Godoy AC, Surita FG, Pinto e Silva JL. Recomendações para a prática de exercício físico na gravidez: uma revisão crítica da literatura. Rev Bras Ginecol Obstet 2014; 36(9):423-431.

5. Thangaratinam S, Rogozinska E, Jolly K, Glinkowski S, Roseboom T, Tomlinson JW, Kunz R, Mol BW, Coomarasamy A, Khan KS. Effects of interventions in pregnancy on maternal weight and obstetric outcomes: meta-analysis of randomised evidence. BMJ 2012; 16;344:e2088.

6. Fonseca CC, Rocha LA. Gestação e atividade física: manutenção do programa de exercícios durante a gravidez. R Bra Ci e Mov 2012; 20(1):111-121.

7. Leal DPS, Rodríguez LM. La condición materna y el ejercicio en la gestación favorecen el bienestar del hijo y el parto. Av Enferm 2010; 26(2):51-58.

8. Brasil. Ministério da Saúde. Secretaria de Atenção Primária à Saúde. Departamento de Promoção da Saúde. Guia de Atividade Física para a População Brasileira. Brasília (DF): Ministério da Saúde, 2021. 54 p.

9. Opala-Berdzik A, Bacik B, Markiewicz A, Cieślińska-Świder J, Swider D, Sobota G, Błaszczyk JW. Comparison of static postural stability in exercising and non-exercising women during the perinatal period. Med Sci Monit 2014; 20:1865-1870.

10. Lima FR, Oliveira N. Gravidez e exercícios. Rev Bras Reumatol 2005; 45(3):188-190.

11. Pigatto C, Santos CM, Santos WM, Neme WS, Portela LOC, Moraes EN, Gallarreta FMP. Efeito do exercício físico sobre os parâmetros hemodinâmicos fetais. Rev Bras Ginecol Obstet 2014; 36(5):216-221.

12. Connely M, Brown H, Van Der Pligt P, Teychenne M. Modifiable barriers to leisure-time physical activity during pregnancy: a qualitative study investigating first time mother’sviews and experiences. BMC Pregnancy Childbirth 2015; 15(100):1-7.

13. Melo ASO, Silva JL, Tavares JS, Barros VO, Leite DF, Amorim MM. Effect of a physical exercise program during pregnancy on uteroplacental and fetal blood flow and fetal growth: a randomized controlled trial. Obstet Gynecol 2012; 120(2 pt 1):302-310.

14. Okafor UB, Goon DT. Physical activity level during pregnancy in south Africa: a facility-based cross-sectional study. Int J Environ Res Public Health 2020; 17(21):7928.

15. Schmidt T, Heilmann T, Savelsberg L, Maass N, Weisser B, Eckmann-Scholz C. Physical exercise during pregnancy - how active are pregnant women in germany and how well informed? Geburtshilfe Frauenheilkd 2017; 77(5):508-515.

16. Padmapriya N, Shen L, Soh SE, Shen Z, Kwek K, Godfrey KM, Gluckman PD, Chong YS, Saw SM, Müller-Riemenschneider F. Physical activity and sedentary behavior patterns before and during pregnancy in a multi-ethnic sample of Asian women in Singapore. Matern Child Health J 2015; 19(11):2523-2535.

17. Souza VA, Mussi RFF, Queiróz BM. Nível de atividade física de gestantes atendidas em unidades básicas de saúde de um município do nordeste brasileiro. Cad Saude Colet 2019; 27(2):131-137.

18. Carvalhaes MABL, Martiniano ACA, Malta MB, Takito MY, Benício MHDA. Physical activity in pregnant women receiving care in primary health care units. Rev Saúde Pública 2013;47(5):1-10.

19. Nobles CJ, Marcus BH, Stanek EJ, Braun B, Whitcomb BW, Manson JE, Markenson G, Chasan-Taber L. The health behaviors of ethnically diverse women at increased risk of gestational diabetes: the behaviors affecting baby and you (B.A.B.Y.) study. Matern Child Health J 2018; 22(5):735-744.

20. Romero SCS, Kurashima CH, Romero A, Takito MY. A influência dos profissionais de saúde sobre a prática de atividade física no lazer em gestantes. Pensar a Prática 2015; 18(3):584-599.

21. Harrod CS, Chasan-Taber L, Reynolds RM, Fingerlin TE, Glueck DH, Brinton JT, Dabelea D. Physical activity in pregnancy and neonatal body composition: the Healthy Start study. Obstet Gynecol 2014; 124(201):257-264.

22. Elm EV, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, STROBE Initiative. Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ 2007; 335:806.

23. Smilkstein G. The family APGAR: a proposal for a family function test and its use by physicians. J Fam Pract 1978; 6(6):1231-9.

24. Smilkstein G, Ashworth C, Montano D. Validity and reliability of the Family APGAR as a test of family function. J Fam Practic 1982; 15(2): 303-11.

25. Duarte YAO. Família: rede de suporte ou fator estressor: a ótica de idosos e cuidadores familiares [tese]. São Paulo (SP): Escola de Enfermagem, Universidade de São Paulo; 2001.

26. Griep RH, Chor D, Faerstein E, Werneck GL, Lopes CS. Validade de constructo de escala de apoio social do Medical Outcomes Study adaptada para o português no Estudo Pró-Saúde. Cad Saúde Pública 2005; 21(3):703-714.

27. Rocha PC, Britto e Alves MTSS, Chagas DC, Silva AAM, Batista RFL, Silva RA. Prevalência e fatores associados ao uso de drogas ilícitas em gestantes da coorte BRISA. Cad Saúde Pública 2016;32(1):e00192714.

28. Feijó MCC. Validação brasileira da “Maternal-Fetal Attachment Scale”. Arq Bras Psicol 1999; 51(4):52-62.

29. Fioravanti-Bastos ACM, Cheniaux E, Landeira-Fernandez J. Development and validation of a short-form version of the Brazilian State-trait Anxiety Inventory. Psicol Reflex Crit 2011; 24(3):485-494.

30. Luft CD, Sanches SO, Mazo GZ, Andrade A. Versão brasileira da Escala de Estresse Percebido: tradução e validação para idosos. Rev Saúde Pública 2007; 41(4):606-615.

31. Cavalcante MCV, Lamy Filho F, França AKTDC, Lamy ZC. Relação mãe-filho e fatores associados: análise hierarquizada de base populacional em uma capital do Brasil – Estudo BRISA. Cienc Saúde Coletiva 2017; 22(5):1683-1693.

32. Dini GM, Quaresma MR, Ferreira LM. Adaptação cultural e validação da versão brasileira da Escala de Auto-estima de Rosenberg. Rev Soc Bras Cir Plást 2004; 19(1):41-52.

33. Scagliusi FB, Polacow VO, Cordás TA, Coelho D, Alvarenga M, Philippi ST, Lancha Júnior AH. Psychometric testing and applications of the Body Attitudes Questionnaire translated into portuguese. Percept Mot Skills 2005; 101(1):25-41.

34. Silva FT, Costa FS. Transcultural adaptation of the pregnancy physical activity questionnaire-PPAQ to Portuguese: a tool for evaluation of physical activity in Brazilian pregnant. FIEP Bull 2009; 79.

35. Silva FT. Avaliação do nível de atividade física durante a gestação [dissertação]. Fortaleza: Universidade Estadual do Ceará; 2007. Disponível em: http://www.uece.br/ppsac/wp-content/uploads/sites/37/2011/03/FRANCISCO_TRINDADE_SILVA.pdf

36. Chasan-Taber L, Schmidt MD, Pekow P, Sternfeld B, Manson J, Markenson G. Correlates of physical activity in pregnancy among Latina women. Matern Child Health J 2007; 11(4):353-363.

37. Chasan-Taber L, Schmidt MD, Roberts DE, Hosmer D, Markenson G, Freedson PS. Development and validation of a Pregnancy Physical Activity Questionnaire. Med Sci Sports Exerc 2004;36(10):1750-1760.

38. Roberts DE, Fragala M, Pober D, Chasan-Taber L, Freedson P. Energy cost of physical activities during pregnancy. Medicine & Science in Sports & Exercise 2002; 34(5):S124.

39. Ainsworth BE, Haskell WL, Whitt MC, Irwin ML, Swartz AM, Strath SJ, O´Brien WL, Basset Jr DR, Schmitz KH, Emplaincourt PO, Jacobs Jr DR, Leon AS. Compendium of physical activities: an update of activity codes and MET intensities. Med Sci Sports Exerc 2000; 32(Suppl9):S498-516.

40. Surita FG, Paulino DSM, Pinho-Pompeu M. Health-related behaviors in pregnancy: a key to achieve better outcomes. Rev Bras Ginecol Obstet 2020; 42(3):121-123.

41. Silva VR, Boing FA. Prevalence of physical activity and associated factors among pregnant women: a cross-sectional population-based study in southern Brazil. Rev Bras Saúde Mater Infant 2021; 21(3):925-934.

42. Rodriguez-Ayllon M, Acosta-Manzano P, Coll-Risco I, Romero-Gallardo L, Cosic MB, Estevez-Lopez F, Aparicio VA. Associations of physical activity, sedentary time, and physical fitness with mental health during pregnancy: The GESTAFIT project. J Sport Health Sci 2021;10:379-386.

43. Tsakiridis I, Bakaloudi DR, Oikonomidou AC, Dagklis T, Chourdakis M. Exercise during pregnancy: a comparative review of guidelines. J Perinat Med 2020;48(6):519-525.

44. Dumith SC, Domingues MR, Mendoza-Sassi RA, Cesar JA. Physical activity during pregnancy and its association with maternal and child health indicators. Rev Saúde Pública 2012; 46(2):327-333.

45. Pereira MSS. Atividade física na gestação: aplicabilidade de um questionário específico para gestantes (PPAQ) e sua associação com Diabete Melito Gestacional (DMG), sobrepeso/obesidade [tese]. Botucatu: Universidade Estadual Paulista Júlio de Mesquita Filho, Faculdade de Medicina de Botucatu; 2013.

46. Cool CVN. Prática de atividade física na gestação: barreiras, tendências e efeitos sobre os sintomas depressivos no período pós-parto [tese]. Pelotas: Universidade Federal de Pelotas; 2017.

47. Liu J, Blair SN, Teng Y, Ness AR, Lawlor DA, Riddoch C. Physical activity during pregnancy in a prospective cohort of British women: results from the Avon longitudinal study of parents and children. Eur J Epidemiol 2011; 26(3):237-247.

48. Mourady D, Richa S, Karam R, Papazian T, Hajj Moussa F, El Osta N, Kesrouani A, Azouri J, Jabbour H, Hajj A, Rabbaa Khabbaz L. Associations between quality of life, physical activity, worry, depression and insomnia: a cross-sectional designed study in healthy pregnant women. PloS One 2017; 12(5):e0178181.

49. Everson KR, Wen F. Prevalence and correlates of objectively measured physical activity and sedentary behavior among US pregnant women. Preventive Medicine 2011;53(1):39-43.

50. Conceição WB. Nível de atividade física em gestantes e fatores influenciantes [monografia]. Governador Mangabeira: Faculdade Maria Milza; 2016.

51. Ribeiro CSP. Conhecimento, atitude e prática de exercícios físicos na gravidez [tese]. Campinas: Universidade Estadual de Campinas; 2011.

52. Santos TM. Padrão de atividade física e saúde na gravidez e pós-parto: implementação de um programa de atividade física na gravidez [dissertação]. Rio Maior: Instituto Politécnico de Santarém; 2015.

53. Takahasi EHM, Alves MTSSB, Alves GS, Silva AAM, Batista RFL, Simões VMF, Del-Bem CM, Barbieri MA. Mental health and physical inactivity during pregnancy: a cross-sectional study nested in the BRISA cohort study. Cad. Saúde Pública 2013; 29(8):1583-1594.

54. Ertmann RK, Bang CW, Kriegbaum M, Væver MS, Kragstrup J, Siersma V, Wilson P, Lutterodt MC, Smith-Nielsen J. What factors are most important for the development of the maternal-fetal relationship? A prospective study among pregnant women in Danish general practice. BMC Psychol 2021;9(2):1-9.

55. Kołomanska-Bogucka D, Micek A, Mazur-Bialy AI. The COVID-19 pandemic and levels of physical activity in the last trimester, life satisfaction and perceived stress in late pregnancy and in the early puerperium. Int J Environ Res Public Health 2022, 19: 3066.

56. Rosa KM, Scholl CC, Ferreira LA, Trettim JP, Cunha GK, Rubin BB, Matos MB. Maternal-fetal attachment and perceived parental bonds of pregnant women. Early Human Development 2021; 154:105310.