Assessing Dietary and Physical Activity Patterns during Pregnancy among Antenatal Mothers in Sri Lanka: A Cross-Sectional Study at a Selected Medical Officer of Health Clinic

: This study assessed 240 antenatal mothers in Sri Lanka’s Kebithigollawa Medical Officer of Health Clinic. Demographics varied, revealing distinct marital statuses, ethnicities, income levels, and employment statuses. Pregnancy stages, parity, pre-pregnancy BMI, and gestational age exhibited diverse profiles. Hemoglobin levels ranged, reflecting nutritional status, while BMI indicated varied weight categories. Dietary patterns demonstrated associations with maternal health indicators; fruits, vegetables, meat, fish, unsweetened dairy products, prepared food, and rice/noodles positively correlated with hemoglobin levels, BMI, and gestational weight gain. Conversely, some dietary choices displayed weaker correlations. These findings emphasize the need for tailored interventions to enhance antenatal mothers’ dietary and physical activity behaviors, benefiting maternal and child health.


Introduction
There are several social, psychological, behavioral, and biological changes that occur during pregnancy [1].The health behaviors that a woman adopts while pregnant carry lifelong consequences for her own well-being and the long-term health of her child [2].Encouraging a balanced diet and regular physical activity throughout pregnancy can facilitate optimal weight gain [3], thereby reducing the likelihood of unfavorable consequences, such as obesity, excessive gestational weight gain, gestational diabetes, pre-eclampsia, and heightened susceptibility to type 2 diabetes; moreover, it can help mitigate the probability of offspring developing childhood overweight, obesity, and the eventual onset of type 2 diabetes in adulthood [4,5].Although maintaining a healthy lifestyle during pregnancy is crucial, many women fail to meet the recommended dietary and physical activity guidelines, and while numerous interventions have been created to address this issue, the outcomes of trials frequently demonstrate insignificant, limited, or transient effects [3,6].Moreover, in the Anuradhapura district, a study conducted by [7], reported an annual average of approximately 15,000 births between 2010 and 2015.During this timeframe, several notable trends emerged, including an increase in the prevalence of low-birth-weight infants, a rise in home deliveries, and a decline in stillbirth rates.Additionally, there was a decrease in teenage pregnancy rates, whereas the rates of lower-segment cesarean sections and antenatal morbidity increased.Maternal body mass index rates decreased, and maternal mortality rates exhibited fluctuation.The use of family planning methods also displayed fluctuations, marked by an increased utilization of oral contraceptive pills, intrauterine devices, and implants, accompanied by reduced unmet needs.It is important to highlight that there has been minimal research conducted on antenatal healthcare during and after this period.Therefore, this study aimed to assess the diet, physical activity, and associated factors during pregnancy among antenatal mothers at the Kebithigollawa Medical Officer of Health Clinic in Sri Lanka.

Methods
A descriptive cross-sectional design was employed to assess the relationship between pregnancy and factors encompassing diet, lifestyle, and physical activity.Ethical approval(KIU/ERC/23/053) was secured from the Ethics Review Committee of KIU, and permission was granted by the 'Kebithigollawa' Medical Officer of Health Clinic in Sri Lanka.In the study, only volunteer participants were involved, and they were given the freedom to withdraw from the study at any time, without being required to provide a reason.Pregnant mothers who were registered at 'Kebithigollawa' Medical Officer of Health Clinic in Sri Lanka were included, while pregnant mothers with medical or obstetric contraindications for exercise during pregnancy, multiple pregnancies, and complicated pregnancies and those subject to special diets or dietary restrictions were excluded.Furthermore, a pretest was conducted by enrolling 10 pregnant mothers registered at 'Kebithigollawa' Medical Officer of Health Clinic in Sri Lanka, who were subsequently excluded from the sample, and the prepared questionnaire was adjusted according to the feedback received.The sample size of 224 was calculated using the following established formula devised by [8,9]: where n = sample size; Z = Z statistic for a level of confidence; P = expected prevalence or proportion (in proportion of one; if 20%, P = 0.2); d = precision (in proportion of one; if 5%, d = 0.05).
An interviewer-administered questionnaire, conducted through the pencil/paper method [10], was used to cover socio-demographics, pregnancy details, dietary habits, and physical activity (measured using the International Physical Activity Questionnaire) [11].A data analysis was performed using SPSS version 25.0, and ethical considerations were rigorously adhered to throughout the research process.

Results
The demographic characteristics of the antenatal mothers at the 'Kebithigollawa' Medical Officer of Health Clinic, Anuradhapura district, Sri Lanka, are displayed in Table 1, revealing a diverse range of profiles.Among 224 participants, the majority, constituting 68.75% (n = 154) of the mothers, fell within the age range of 25 to 34 years.Other age ranges were prevalent, each accounting for 15.63% (n = 35) of the total.When considering marital status, most of the antenatal women were married, comprising 87.95% (n = 197), while others had to manage their healthcare without the support of a spouse.The education status results indicated that only 2.23% (n = 5) could be considered illiterate, making the rest more easily amenable to maternal self-care education.The antenatal women represented three major ethnicities of Sri Lanka, namely, Sinhala, Tamil, and Muslims, with the majority belonging to Sinhala ethnicity, accounting for 74.11% (n = 166).When considering the economic status of the antenatal women, 41.52% (n = 93) were unemployed during their maternal period, and approximately 67.86% (n = 152) were earning less than 50,000 LKR, indicating their low-income status.The pregnancy-related data are presented in Table 2.They reveal that, out of the total sample size of 224, 21% (n = 47) of the antenatal mothers attended the clinic during their first trimester, while the majority, comprising 43% (n = 97), were in their second trimester.Additionally, 36% (n = 80) of the antenatal mothers were in their third trimester.When considering the duration of pregnancy before birth based on historical data and neonatal examinations, the majority, 81% (n = 182), exceeded three months.Furthermore, 45.5% (n = 102) of the antenatal mothers had no previous viable pregnancies, classifying them as nulliparous, while 25.4% (n = 57) had one previous viable pregnancy, indicating primiparity.In addition, 15.2% (n = 34) of the antenatal mothers had two previous viable pregnancies, making them multiparous with two pregnancies, and 13.8% (n = 31) had more than three previous viable pregnancies, categorizing them as multiparous with three or more pregnancies.Regarding pre-pregnancy BMI, 48% (n = 107) had a BMI below 25.0 kg/m 2 , signifying normalcy, while 32% (n = 71) had a BMI between 25.0 and 29.9 kg/m 2 , indicative of overweight.Furthermore, 20% (n = 46) had a pre-pregnancy BMI greater than 30.0 kg/m 2 , classifying them as obese.Regarding hemoglobin levels, 3% (n = 6) had levels less than 8 g/dL, indicating anemia, while 20% (n = 44) fell between 8 and 9.9 g/dL, signifying mild anemia.Additionally, 35% (n = 79) had levels between 10 and 10.9 g/dL, considered within the normal range for non-pregnant women, albeit slightly lower during pregnancy, and 42% (n = 95) had levels greater than 11 g/dL, signifying a normal and healthy hemoglobin level during pregnancy.In terms of current BMI, 12% (n = 27) were below 18.5 kg/m 2 , indicating underweight, while 31% (n = 70) fell between 18.5 and 24.9 kg/m 2 , within the normal weight range.Moreover, 39% (n = 87) had a current BMI between 25 and 29.9 kg/m 2 , classifying them as overweight, and 18% (n = 40) had a current BMI greater than 30 kg/m 2 , categorizing them as obese.Diverse dietary patterns were observed in the study, as mentioned in Table 3, with the most common consumption pattern for unsweetened milk products noted in 37% of the respondents, who reported no consumption, while 63% consumed 1-5 portions per day.Sweetened beverages were consumed by 71% of the participants, with intake ranging from 1 to 5 portions per day.The majority of participants, constituting 87%, consumed 1-5 portions of whole grain bread daily.Likewise, 81% of participants consumed 1-5 portions of white bread daily.When assessing weekly consumption, meat and fish intake was 1-5 portions per week (84%), while ready-made meals (93%) and fried potatoes (94%) were consumed in the range of 1-7 portions per week.Potatoes were also consumed by 94% of the participants, with intake falling within 1-5 portions per week, and rice/noodles found popularity at 1-7 portions per week (86%).These findings offer a comprehensive insight into the dietary and health profiles of the antenatal mothers in the study, laying the foundation for further analysis of their nutritional requirements and potential interventions.In the assessment of physical activity engagement among pregnant women during a trimester, as detailed in Table 3, a substantial duration was allocated to diverse activities, with the findings revealing a notable percentage of expectant mothers participating in these activities.Regarding food preparation, it is noteworthy that 33% of the participants allocated 1 to almost 2 h daily to this activity, suggesting that a minimum of 76% of the pregnant women were actively engaged in cooking and related tasks for a minimum of half an hour.Significant involvement in caregiving tasks while sitting was indicated by a substantial percentage (57%) of the antenatal women, with 77% also participating in these activities while standing, dedicating half to nearly three hours per day to tasks such as dressing, bathing, and feeding children.Active participation in childcare activities, including playing with children while either sitting or standing, was reported by 77% of the antenatal women, with 75% engaging in such activities while walking or running, for durations spanning from under half an hour to three hours.Work-related activities revealed that, in work or class settings, 67% of the participants spent less than half an hour to two hours per day sitting at work or in class.In the context of watching TV or videos, a substantial majority, accounting for 96% of the participants, spent less than half an hour to three hours per day watching TV or videos, with no one dedicating more than 3 h.Concurrently, activities encompassing arranging beds, doing laundry, ironing, and tidying up occupied the time of 93% of the respondents for durations ranging from under half an hour to three hours per day.Concerning heavier cleaning activities encompassing tasks like vacuuming, mopping, sweeping, and washing windows, 83% of the participants reported their engagement, with daily durations spanning from less than half an hour to two hours.Shopping activities, which included purchasing groceries, clothing, and various items, were undertaken by 89% of the study's participants, with daily time allocations ranging from less than half an hour to two hours.Daily activities involving walking, standing, and carrying objects were common among participants, with 85% engaging in slow walking for durations ranging from under half an hour to two hours per day, 79% spending less than half an hour to three hours per day on standing or slow walking while carrying items, and another 79% allocating similar durations to standing or slow walking at work without carrying anything.The research demonstrated that the majority of the expectant mothers engaged in walking quickly to various destinations, allocating between half an hour to three hours per day, while a minority of 32% did not participate in such activities.Additionally, among those who were employed, 87% spent between half an hour to three hours per day walking quickly while carrying items, and 82% dedicated a similar time frame to quick walking at work when not carrying anything.The study indicated that the majority of participants (64%) did not engage in any form of exercise, with only one-quarter (25%) reporting participation in exercise for half to one hour per day; similarly, while 75% of the participants did not jog, 13% were involved in jogging exercises for a duration of half to one hour.These findings offer a comprehensive overview of the physical activities undertaken by antenatal women during the specified trimester, highlighting the varying levels of involvement in different tasks.
The investigation into the effects of dietary habits during pregnancy uncovered noteworthy correlations, supported by specific values, shedding light on their impact on various health indicators.Notably, a positive and statistically significant correlation was found between the consumption of fruits and vegetables (r = 0.55), meat (r = 0.54), fish (r = 0.64), unsweetened dairy products (r = 0.57), and prepared food (r = 0.57) with hemoglobin levels, indicating the crucial role of these dietary components in maintaining healthy hemoglobin levels.Likewise, these dietary choices exhibited positive and significant correlations with BMI, with meat (r = 0.707), fish (r = 0.679), prepared food (r = 0.795), unsweetened dairy products (r = 0.517), and rice/noodles (r = 0.599) demonstrating their influence on maternal weight status during pregnancy.Furthermore, the consumption of sweet drinks (r = 0.194), fried potatoes (r = 0.44), and certain types of bread (r = 0.274) displayed weaker positive correlations with both hemoglobin levels and BMI, suggesting a less pronounced but still relevant impact.Additionally, positive and significant correlations were observed between the intake of fruits and vegetables (r = 0.66), meat (r = 0.76), fish (r = 0.538), prepared food (r = 0.69), rice/noodles (r = 0.56), and unsweetened dairy products (r = 0.66) with gestational weight gain, emphasizing the substantial role of these dietary components in shaping maternal weight during pregnancy.Conversely, fried potatoes (r = 0.30), sweet drinks (r = 0.194), and certain types of bread (r = 0.34) displayed weaker positive correlations with gestational weight gain, providing a comprehensive understanding of the complex relationship between dietary choices and maternal health indicators during pregnancy, which can inform targeted nutritional interventions.
The investigation into the impact of physical activity during pregnancy unveiled intriguing correlations between specific activities and maternal health indicators.In relation to BMI, the data showed varying correlations, with activities such as watching TV or a video (r = 0.41), light cleaning (r = 0.31), and exercises (r = 0.27) demonstrating positive associations, suggesting that engagement in these activities tended to be associated with higher BMI levels during pregnancy.Conversely, activities like heavier cleaning (vacuuming, mopping, sweeping, and washing windows) exhibited a negative correlation (r = −0.31),indicating a potential link between such tasks and lower BMI levels.Moreover, the correlation between physical activities and gestational weight gain revealed distinct patterns, with watching TV or a video (r = 0.78), light cleaning (r = 0.45), and exercises (r = 0.39) displaying positive associations, indicating that participation in these activities may contribute to greater weight gain during pregnancy.In contrast, heavier cleaning displayed a negative correlation (r = −0.22),suggesting a potential role in limiting gestational weight gain.These findings underscore the intricate relationship between specific physical activities and maternal health indicators, providing valuable insights for tailored recommendations and interventions during pregnancy.

Conclusions
During this investigation involving antenatal mothers in Sri Lanka, a diverse array of demographic profiles and pregnancy experiences within this cohort was revealed.Significant correlations emerged between specific dietary components, physical activities, and critical maternal health indicators, highlighting the intricate interplay of lifestyle factors during pregnancy.These findings underscore the imperative need for tailored interventions and educational initiatives to enhance dietary and physical activity behaviors among antenatal mothers, potentially mitigating adverse health outcomes and contributing to the long-term well-being of both mothers and their offspring.

Table 1 .
Socio-demographic characteristics of study participants.

Table 2 .
Maternal health profile of study participants.

Table 3 .
The details of dietary patterns and physical activities of antenatal mothers.