Exploring Factors Influencing Physical Inactivity During the First Trimester of Pregnancy: A Convergent Mixed‐Methods Study

ABSTRACT

Aim

This study aims to investigate physical inactivity levels in early pregnancy and explore the associated factors among Chinese pregnant women.

Design

A convergent mixed‐methods study was employed, comprising a cross‐sectional survey (n = 802) and in‐depth semi‐structured interviews (n = 18).

Methods

First trimester pregnant women were recruited through convenience sampling method between August 2022 and March 2023. Sociodemographic, obstetric, social support, and lifestyle characteristics were obtained using a structured questionnaire. Physical inactivity levels were assessed using the International Physical Activity Questionnaire. Quantitative data were analysed using logistic regression, while qualitative data underwent thematic analysis. The results were integrated through a side‐by‐side comparison approach.

Results

The prevalence of physical inactivity in early pregnancy was 51.2%, with walking being the predominant activity. Logistic regression analysis indicated that women under the age of 25 were more likely to engage in physical activity during early pregnancy than those aged 25–29 (adjusted odds ratio [aOR] = 2.213, 95% confidence interval [CI]: 1.063–4.605) and 30–34 years (aOR = 2.320, 95% CI: 1.107–4.866). Compared to women with a high school education or lower, those with a college degree (aOR = 2.158, 95% CI: 1.153–4.039) or a postgraduate education or higher (aOR = 2.116, 95% CI: 1.058–4.231) were more likely to be physically inactive during early pregnancy. Factors associated with higher inactivity included not engaging in regular exercise before pregnancy (aOR = 0.671, 95% CI: 0.500–0.900), experiencing vaginal bleeding in early pregnancy (aOR = 1.504, 95% CI: 1.097–2.063), and reporting poor sleep quality in early pregnancy (aOR = 1.529, 95% CI: 1.133–2.063). Thematic analysis identified four key themes: individual, interpersonal, social, and environmental factors. The main barriers included time constraints, pregnancy‐related discomfort, fears and anxieties, lack of confidence, limited resources and conflicting advice. Key facilitators were spousal support and policies that encouraged or enabled exercise during pregnancy.

Patient or Public Contribution

Pregnant women participated in surveys and interviews, while Dr. Hu, Nurse Director Zhu, and Shen were involved in participant recruitment.

1. Background

Physical activity, by definition, is any skeletal muscle body movement that gives rise to energy expenditure, which is measured using metabolic equivalents (Sharif et al. 2018). According to different intensities, physical activity is divided into three categories: light‐intensity, moderate‐intensity and vigorous‐intensity activity. The World Health Organization (Bull et al. 2020) and the American College of Obstetricians and Gynaecologists (ACOG Committee Opinion 2020) all recommend that pregnant women should engage in at least 150 min of moderate‐intensity physical activity per week to achieve clinically meaningful reductions in pregnancy complications.

Previous studies have indicated that physical inactivity (< 150 min/week of moderate‐intensity physical activity) is a widespread problem among pregnant women. Research conducted by Santos et al. (2022) shows that only 21.4% of pregnant women met the recommendations for physical activity, and their activity levels tended to decline as pregnancy progressed. This trend differs from that observed among pregnant women in China. A longitudinal cohort study demonstrated that physical activity participation increases from early to mid‐to‐late pregnancy (Lü et al. 2021). Another study also reported an increase in moderate‐to‐vigorous physical activity among Chinese pregnant women from early to late pregnancy (Liu et al. 2024). The prevalence of physical inactivity remains high during pregnancy, especially in the first trimester (Zhou, Lin, et al. 2022). Similarly, Syed Nor et al. (2022) found that 38.3% of pregnant women do not engage in sufficient physical activity during early pregnancy in Malaysia. Based on the results mentioned above, more attention should be paid to physical inactivity among pregnant women in early pregnancy.

It is worth noting that although Santos et al. (2022, 2024) did not find an association between physical activity levels and neonatal outcomes or maternal anxiety, this does not negate the potential benefits of prenatal physical activity. In fact, a substantial body of evidence suggests the positive effects of physical activity during early pregnancy on the mother and fetus. For example, Ehrlich et al. (2021) found that engaging in at least 38 min per day of moderate‐intensity physical activity in the first trimester reduces the risk of abnormal screening results and gestational diabetes mellitus. A cohort study indicated that moderate‐to‐vigorous intensity physical activity during the first trimester may help prevent hypertensive disorders of pregnancy (Lu et al. 2023). Zhang et al. (2024) reported that exercise during early pregnancy can reduce the risk of preterm birth for women without pregnancy complications. Additionally, Lv et al. (2024) demonstrated that high levels of physical activity at various intensities, as well as meeting exercise guidelines during early pregnancy, were associated with a lower incidence of premature rupture of membranes. A randomised controlled trial also showed that combining exercise with cognitive behavioural therapy in early pregnancy effectively alleviates maternal anxiety and improves quality of life (Mei et al. 2024). Furthermore, Song et al. (2024) found that engaging in at least 7.5 MET‐hours per week of moderate‐intensity physical activity during early pregnancy promotes maternal mental health and significantly reduces adverse pregnancy outcomes.

Given the high prevalence of physical inactivity during the first trimester and the importance of early physical activity participation in reducing pregnancy complications, it is essential to focus on the physical activity levels and associated influencing factors in early pregnancy. This will provide scientific evidence to support the development of targeted intervention programmes and promotion strategies for physical activity in the first trimester. A cross‐sectional study elucidated that reproductive history, education level, and body mass index have certain effects on the level of physical inactivity during the first trimester (Syed Nor et al. 2022). Another study in Serbia alluded to potential connections among economic status, pre‐pregnancy exercise, and leisure‐time physical activity level during early pregnancy (Todorovic et al. 2020). Liu et al. (2024) reported that pre‐pregnancy smoking habits and depressive symptoms in early pregnancy were associated with insufficient physical activity in the first trimester of pregnancy. Current evidence primarily relies on single observational quantitative designs, with a lack of mixed‐method approaches that integrate both qualitative and quantitative data. This limitation constrains a comprehensive and in‐depth understanding of the factors influencing physical inactivity among Chinese pregnant women in early pregnancy.

To address this gap, we aimed to collect and integrate quantitative and qualitative data using semi‐structured interviews and questionnaires with a convergent design to gain greater perspective than using a single research method alone. Therefore, the objective of the present study was to assess physical inactivity status during the first trimester among pregnant women in Shanghai, China, and to explore the associated factors using a mixed‐methods approach.

2. Methods

2.1. Study Design

We conducted a convergent mixed‐methods study, integrating a cross‐sectional survey and in‐depth individual interviews to better align with our research objectives. Simultaneously collecting and analysing both quantitative and qualitative data facilitates the correlation and comparison of these data types, thereby enhancing the reliability, interpretability, and accuracy of the findings. This approach mitigates limitations in using a single method and provides a holistic understanding of the factors influencing physical inactivity during the first trimester of pregnancy. Quantitative data provides broad, generalisable insights, while qualitative data delivers deep, nuanced understanding. The entire study adheres to the GRAMMS guidelines for mixed methods research. The cross‐sectional quantitative component follows the STROBE checklist for observational studies and the qualitative component complies with the COREQ reporting standards. The detailed data collection and analysis process is shown in Figure 1.

FIGURE 1.

Flow chart of data collection and analysis in the convergent mixed‐methods study.

2.2. Participants

In the quantitative study, we employed a cross‐sectional design. This study was conducted at a tertiary first‐class obstetrics and gynaecology hospital in Shanghai, China. This hospital integrates medical treatment, teaching, and scientific research, with approximately 12,000 births annually. These conditions provide sufficient potential participants for this study. From August 2022 to March 2023, two research nurses enrolled 860 women during their first prenatal visit. The inclusion criteria were as follows: (1) older than age 18 years and (2) less than 14 weeks' gestation. We excluded women with serious comorbidity (e.g., cardiovascular disease, severe anaemia, placenta previa), poor mental health status, or physical disabilities. Participants were recruited using a convenience sampling method, the sample size was calculated using the formula (Charan and Biswas 2013) $\left(Z_{\frac{\alpha }{2}}^2\times p\times \left(1-p\right)\right)/d^2$, based on a 95% confidence level and a 5% margin of error. Considering that 38.3% of Chinese pregnant women were reported to engage in physical activity during early pregnancy (Syed Nor et al. 2022), and adjusting for a 20% attrition rate, the minimum required sample size was estimated to be 455 participants. Ultimately, 58 incomplete response questionnaires were excluded, a total of 802 pregnant women complete the survey, with a response rate of 93.3%. We conducted an improved post hoc power analysis using a Bayesian approach based on the final sample size (n = 802), which demonstrated that the statistical power exceeded 90% for detecting both the maximum effect size (OR = 2.320) and the minimum effect size (OR = 0.671) at a 95% confidence level (Quach et al. 2022).

In the qualitative study, considering the principle of maximum variation, we employed purposive sampling to select interviewees. We chose pregnant women of different ages, educational levels, pre‐pregnancy body mass index, current working status, nausea and vomiting of pregnancy in early pregnancy, vaginal bleeding in early pregnancy, and physical activity levels in early pregnancy for the interviews. The sample size was subject to ‘data saturation’. After the topic was saturated, three to four interviewees were added to ensure that no information was omitted. Finally, 18 pregnant women completed the interviews.

2.3. Ethical Considerations

This study was approved by the Ethics Committee of Obstetrics and Gynaecology Hospital of Fudan University (approval number 202123). Before conducting the cross‐sectional survey or the semi‐structured interviews, all participants were provided with a written informed consent form and were informed that they could withdraw from the study at any time for any reason.

2.4. Data Collection

2.4.1. Quantitative Data

A structured questionnaire was developed through consultations with experts in the field and extensive discussions within the research team. Additionally, a pilot test involving 10 participants was conducted to ensure feasibility of the study. The results indicated that the questionnaire was clear and comprehensible, with an average completion time of 20–30 min. Data collection was carried out by uniformly trained investigators who verified questionnaire responses at survey sites to ensure data quality. The survey queried sociodemographic information (maternal age, ethnicity, education level, current employment status, personal monthly income), obstetric characteristics (history of spontaneous abortion, parity, singleton pregnancy, use of assisted reproductive technology, nausea and vomiting of pregnancy in early pregnancy, vaginal bleeding in early pregnancy), social support (support from family, friends and medical workers), and lifestyle characteristics (pre‐pregnancy body mass index, regular exercise before pregnancy, smoking exposure, alcohol consumption, sleep quality in early pregnancy, and anxiety or depressive symptoms in early pregnancy). Sociodemographic and obstetric characteristics were cross‐checked with medical records in the hospital electronic information system. Social support included three questions addressing whether participants had support from their family, friends and medical workers; these questions were sourced from the Social Support Rating Scale and adapted for our investigation (Xiao 1994). Pre‐pregnancy body mass index was calculated as pre‐pregnancy body weight divided by height squared and categorised as underweight (< 18.5 kg/m²), normal weight (18.5–23.9 kg/m²), overweight (24.0–27.9 kg/m²) and obese (≥ 28.0 kg/m²), according to the Chinese classification (Zhou 2002). Regular exercise before pregnancy was defined as consciously engaging in walking, yoga, or running at least 30 min per week in the period of preconception. Smoking exposure was defined as smoking or passive smoking 3 months before pregnancy. Alcohol consumption was defined as drinking any alcoholic beverages 3 months before pregnancy. Sleep quality in early pregnancy was measured using the Pittsburgh Sleep Quality Index, which determines poor sleep quality using a cutoff of 5 points (Buysse et al. 1989). Anxiety symptoms in early pregnancy were assessed using the Self‐Rating Anxiety Scale; a raw score of 50 as the cutoff for clinical significance is recommended (Dunstan and Scott 2019). Depressive symptoms in early pregnancy were measured using the Edinburgh Postnatal Depression Scale with a cutoff of 10, which has been validated for detecting depression in pregnancy as well as in the postpartum period (Cox et al. 1987). Additionally, physical activity level in early pregnancy was assessed using the International Physical Activity Questionnaire‐short form, and total energy expenditure was evaluated by summing the different metabolic equivalent scores (Fan et al. 2014).

2.4.2. Qualitative Data

Qualitative data collection was carried out using a predesigned semi‐structured interview outline (File S1), mainly to explore the barriers and facilitators of physical activity in early pregnancy. This outline was developed according to the literature on physical activity and was validated by clinical experts and piloted in two women before the formal interviews. For respondents who provided their written informed consent, an individual face‐to‐face interview was conducted by the first and second authors in a private room of the research hospital. All interviews began with broad issues, such as experiences, views, and attitudes regarding physical activity during early pregnancy; this was followed by further probing questions. Each interview was conducted in Mandarin and lasted between 20 and 40 min. Interviews were audio‐recorded and transcribed, and field notes were taken to record non‐verbal cues.

2.5. Data Analysis

2.5.1. Quantitative Data

IBM SPSS 25.0 (IBM Corp., Armonk, NY, USA) was used for quantitative data analysis. Categorical variables are described using frequency (percentage); continuous variables with a normal distribution are described as mean ± standard deviation and as median (interquartile range) for those with a nonnormal distribution. Binary logistic regression was used to analyse the influencing factors of physical inactivity in early pregnancy, and odds ratios and 95% confidence intervals were calculated. The dependent variable in this study, physical activity, was defined as < 600 metabolic equivalent min/week of the total energy expenditure. The independent variables were included using backward elimination to remove variables with p > 0.2. Furthermore, variables that were clinically relevant or that were found to be significant in previous studies were also included in the logistic regression model; these included current employment status, personal monthly income, history of spontaneous abortion, parity, and nausea and vomiting of pregnancy. A two‐sided p‐value < 0.05 was regarded as indicating statistical significance.

2.5.2. Qualitative Data

Thematic analysis (Kiger and Varpio 2020), consisting of six steps outlined by Braun and Clarke (2006), was used to analyse data from the interviews and to identify major themes and subthemes; this analysis was carried out by two independent reviewers. First, reviewers actively and repeatedly read the transcripts of audio‐recorded files, immersing themselves to become thoroughly familiar with the entire dataset. Second, statements that were relevant and significant to the research topic were identified, and initial codes were generated accordingly. Then, the coded and collated data extracts were examined to identify underlying themes of broader significance. Subsequently, appropriate definitions were generated for each theme. Finally, the most vivid extracted examples were selected for inclusion in the final academic report. Any discrepancies between the two reviewers were resolved through discussion until consensus was reached regarding the codes, subthemes and themes.

3. Results

3.1. Quantitative Results

3.1.1. Participant Characteristics

Table 1 describes the sociodemographic, obstetric, social support and lifestyle characteristics of all survey respondents during the first trimester of pregnancy. Among the 802 participants, the average age was 30.1 ± 3.5 years, 92.9% had a college degree or above, and 79.9% reported a personal monthly income exceeding 10,000 RMB. The majority of women (98.9%) had singleton pregnancies, 81.8% were primipara, 5.5% used assisted reproductive technology, 29.8% had vaginal bleeding in early pregnancy, and 84.9% experienced nausea and vomiting of pregnancy in the first trimester. Before pregnancy, overweight and obese women accounted for 15.7%, whereas 15.1% of women were underweight; less than half of women (45%) engaged in regular exercise, 15.2% reported smoking exposure, and 10.8% drank alcohol. Poor sleep quality (39.2%) was also a common phenomenon in early pregnancy. Psychological stress, such as anxiety symptoms (45.6%) or depressive symptoms (23.4%), was reported by some pregnant women during the first trimester.

TABLE 1.

Basic characteristics of the study population (n = 802).

Variables	Frequency
Age (years), n (%)
< 25	39 (4.9%)
25–29	327 (40.8%)
30–34	347 (43.3%)
≥ 35	89 (11.1%)
Ethnicity, n (%)
Han	788 (98.3%)
Minorities	14 (1.7%)
Education level, n (%)
High school or below	57 (7.1%)
College	536 (66.8%)
Postgraduate or above	209 (26.1%)
Current employment status, n (%)
Does not work	158 (19.7%)
On duty	644 (80.3%)
Personal monthly income, n (%)
< 10,000 RMB	161 (20.1%)
≥ 10,000 RMB	641 (79.9%)
History of spontaneous abortions, n (%)	110 (13.7%)
Parity, n (%)
Primiparous	656 (81.8%)
Multiparous	146 (18.2%)
Singleton pregnancy, n (%)	793 (98.9%)
Assisted reproduction, n (%)	44 (5.5%)
Nausea and vomiting of pregnancy in early pregnancy, n (%)	681 (84.9%)
Vaginal bleeding in early pregnancy, n (%)	239 (29.8%)
Family support, n (%)	767 (95.6%)
Friends support, n (%)	407 (50.7%)
Medical workers support, n (%)	198 (24.7%)
Pre‐pregnancy body mass index, n (%)
Underweight	121 (15.1%)
Normal weight	555 (69.2%)
Overweight	106 (13.2%)
Obese	20 (2.5%)
Regular exercise before pregnancy, n (%)	361 (45.0%)
Smoking exposure, n (%)	122 (15.2%)
Alcohol drinking, n (%)	87 (10.8%)
Poor sleep quality in early pregnancy, n (%)	314 (39.2%)
Anxiety symptoms in early pregnancy, n (%)	366 (45.6%)
Depressive symptoms in early pregnancy, n (%)	188 (23.4%)

3.1.2. Physical Activity Status in Early Pregnancy

Table 2 presents the level and intensity of physical activity in early pregnancy. The median energy expenditure of total activity was 594 metabolic equivalent min/week. Walking, a light‐intensity activity, was the main form of physical activity during early pregnancy, accounting for 91.3% of the total metabolic equivalents. The prevalence of physical inactivity in the first trimester was 51.2%, and only 2.1% of participants reached the international physical activity guideline of at least 150 min of moderate‐intensity physical activity per week. Moreover, 95.7% of participants who reported sufficient physical activity in early pregnancy did not meet the international physical activity guidelines (Table 3).

TABLE 2.

Physical activity status in early pregnancy among participants (n = 802).

Physical activity	N (%)	Median (IQR)	MET ratio (%)
Energy consumption (MET‐min/week)
Total activity	802 (100.0%)	594 (277, 693)	100.0%
Light‐intensity activity (walking)	778 (97.0%)	594 (297, 693)	91.3%
Moderate or vigorous intensity activity	72 (9.0%)	240 (144, 690)	8.1%
Reported no physical activity	23 (2.9%)	—	—
Physical inactivity
No	391 (48.8%)	—	—
Yes	411 (51.2%)	—	—
Meeting the guideline
No	785 (97.9%)	—	—
Yes	17 (2.1%)	—	—

Abbreviations: IQR, interquartile range; MET, metabolic equivalent; MET ratio, the contribution of the metabolic equivalent of each intensity of activity to the metabolic equivalent of total physical activity.

TABLE 3.

Prevalence of women meeting the international physical activity guidelines according to physical activity status (n = 802).

Categories	Physical activity status < 600 MET min/week (n = 411)	Physical activity status ≥ 600 MET min/week (n = 391)
Do not meet the guideline, n (%)	411 (100.0%)	374 (95.7%)
Meet the guideline, n (%)	0 (0.0%)	17 (4.3%)

Abbreviation: MET, metabolic equivalent.

3.1.3. Influencing Factors of Physical Inactivity in Early Pregnancy

In multivariable logistic regression analysis (Table 4), maternal age, education level, regular exercise before pregnancy, vaginal bleeding, and poor sleep quality in early pregnancy were significantly associated with physical inactivity in the first trimester (Table 4). Women younger than 25 years old were more likely to engage in physical activity in early pregnancy than those aged 25–29 (adjusted odds ratio 2.213, 95% confidence interval 1.063–4.605) and 30–34 years (adjusted odds ratio 2.320, 95% confidence interval 1.107–4.866). Compared with women who had a high school education or below, those who graduated from college (adjusted odds ratio 2.158, 95% confidence interval 1.153–4.039) or had a postgraduate education level or above (adjusted odds ratio 2.116, 95% confidence interval 1.058–4.231) were more likely to be physically inactive during early pregnancy. Moreover, regular exercise before pregnancy contributed to maintaining sufficient physical activity in the first trimester (adjusted odds ratio 0.671, 95% confidence interval 0.500–0.900), but vaginal bleeding in early pregnancy resulted in less first trimester physical activity (adjusted odds ratio 1.504, 95% confidence interval 1.097–2.063). Women who had poor sleep quality in early pregnancy were 1.529 times more likely to be inactive in the first trimester than those who did not experience such symptoms (adjusted odds ratio 1.529, 95% confidence interval 1.133–2.063).

TABLE 4.

Multivariable logistic regression analysis of factors influencing physical inactivity in early pregnancy.

Variables	B	OR	95% CI	p
Age (years)
< 25	—	1.000	(Reference)	—
25–29	0.794	2.213	1.063–4.605	0.034 a
30–34	0.842	2.320	1.107–4.866	0.026 a
≥ 35	0.565	1.759	0.763–4.058	0.185
Education level
High school or below	—	1.000	(Reference)	—
College	0.769	2.158	1.153–4.039	0.016 a
Postgraduate or above	0.750	2.116	1.058–4.231	0.034 a
Medical workers support
Yes	0.227	1.255	0.889–1.772	0.196
Regular exercise before pregnancy
Yes	−0.400	0.671	0.500–0.900	0.008 a
Vaginal bleeding in early pregnancy
Yes	0.408	1.504	1.097–2.063	0.011 a
Poor sleep quality in early pregnancy
Yes	0.425	1.529	1.133–2.063	0.006 a
Pre‐pregnancy body mass index
Underweight	—	1.000	(Reference)	—
Normal weight	−0.254	0.775	0.510–1.179	0.234
Overweight	−0.094	0.911	0.525–1.578	0.739
Obese	−0.154	0.857	0.313–2.349	0.764
History of spontaneous abortions
Yes	0.066	1.068	0.695–1.641	0.764

Abbreviations: 95% CI, 95% confidence interval; OR, odds ratio.

^a p < 0.05.

3.2. Qualitative Results

Four main themes regarding the factors influencing physical inactivity in the first trimester of pregnancy were identified: (1) individual factors, (2) interpersonal factors, (3) social factors and (4) environmental factors.

3.2.1. Theme 1: Individual Factors

Commonly reported individual factors included a lack of time, pregnancy‐related physical discomfort, fears and worries, and a lack of confidence.

3.2.1.1. Lack of Time

Lack of time was one of the common influencing factors of physical inactivity in the first trimester, which is related to the current working status of pregnant women. Prioritising their limited energy for work and commuting seemed to diminish the disposable time for physical activity.

I often come home late from work, and sometimes dawdle around the office. It's usually about 8 o'clock in the evening when I get home, I don't really have time for exercise or…and I need to spend some time with my family.

Yeah, very difficult for me to do more physical activities since I came to Shanghai, you know, I usually get off work late and the commuting time is longer than before. Time, time is a problem, so, yeah, quite difficult.

3.2.1.2. Pregnancy‐Related Physical Discomfort

During the interview, most women described the increasing difficulty in performing physical activity during the first trimester owing to pregnancy‐related physical discomfort such as nausea and vomiting of pregnancy, stomachache, fatigue, lethargy, and chest tightness.

Nausea and vomiting are serious, so the amount of exercise is relatively decreased, and it's really different from that before pregnancy. Probably, when there is no vomiting or stomachache, I will take a walk in the housing estate.

I don't want to take more exercise. I am very sleepy and just want to sleep.

After pregnancy, I am always tired; I would rather lie in the bed. Sometimes I feel a little stuffy and don't want to move.

3.2.1.3. Fears and Worries

Most participants felt uncertain about the safety of physical activity during the first trimester because they had no way of knowing how their baby would be affected. They feared that being more physically active in early pregnancy could harm the fetus, and walking appeared to be the preferred form of physical activity.

I had a fetal stop before; it gave me more anxiety, more worries, many things that I never had before. I hope to be stable in early pregnancy. The intensity of dancing may not be too vigorous, but I would not do it because I am worried about the safety of the baby. What if something unexpected happened? I don't know.

I fear that too much exercise will harm the baby, after all, I had two miscarriages before. It's more about lying in the bed…and you know, this is an all or nothing event.

At most, sometimes I walk along the street after dinner, I dare not do other exercise.

3.2.1.4. Lack of Confidence

Recognising that exercise during pregnancy is beneficial to the health of the mother and fetus, some respondents agreed that regular exercise in the first trimester is necessary. However, owing to a lack of confidence, most pregnant women considered the prenatal physical activity guidelines to be reasonable but unrealistic and hard to persist in.

I did not achieve the goal of physical activity during pregnancy. I agree that when pregnant, we should engage in at least 150 min of moderate‐intensity exercise per week, but I don't believe that I can do it.

Exercise in the first trimester is necessary. But for me, I think, it's hard. If my body allows, I will get some exercise, but you know, it is impractical in this circumstance.

3.2.2. Theme 2: Interpersonal Factors

3.2.2.1. Social Support

Social support includes support from family, friends, and a significant other. The companionship of the husband played a pivotal role in physical activity during the first trimester.

My husband accompanies me for a walk, otherwise I don't want to move. He suggests I do some exercise, which is good for health. We can talk while walking; that makes me feel better.

I need to be accompanied when I walk; usually my husband accompanies me so that I don't feel so tired.

In contrast, some participants were dissuaded by friends or elders from doing more activities in early pregnancy in case it caused any harm to the baby.

I have a friend who lived on the sixth floor who had to climb the stairs. Poor darling, she lost her first child. You know how sad she is…so she told us to pay close attention.

Almost everyone told me not to exercise in the first trimester; Mom, Dad, or someone else—they just want me to lie down and rest more, not to move too much…yeah, something like that. Maybe, you know, they don't let me carry anything. I usually exercised more before conception, but now I cannot do that…except walking.

3.2.2.2. Professional Support and Non‐Professional Support

Limited knowledge about physical activity in the first trimester was common in this study, and conflicting advice regarding physical activity from medical workers confused many pregnant women. Participants mentioned that they did not receive much detailed information about physical activity in early pregnancy from medical workers, so they sought help from social media, a nonprofessional source.

I don't know. I don't know when to start, how much we need, and what kind of exercise should we take. I don't know anything about it.

Doctors only advised us to walk if conditions permit, like that. They never told us the specific exercise program. When I asked questions, they said if there were no special cases, you can…who knows what special cases means!

The community doctor told me to rest more. But, today, the clinician suggested that I could be walking more. I don't know who I should listen to.

You'd better rest more in early pregnancy, Google Chrome shows. Fitness coaches on Tik Tok or Little Red Book also suggest not to exercise more in the first trimester.

3.2.3. Theme 3: Social Factors

3.2.3.1. Lack of Resources

In interviews, some participants mentioned the lack of public resources, such as sports venues, as free places to exercise.

I came to Shanghai for work, but there is no free sports venue around…when I was in Suzhou before, I exercised after 18 o'clock, and the sports venue is also near where I live.

Where I stay is not close to the public gymnasium, and there are no cheap workout places around, so it's very inconvenient for me.

3.2.3.2. Policy and Consensus Development

Respondents' answers highlighted that under the current medical background in China, policies and consensuses that are conducive to prenatal physical activity should be established to ensure healthy behaviour among pregnant women.

I feel that our country does not pay attention to this. We all know that we should supplement with folic acid 3 months before pregnancy. This is a public health policy to prevent fetal neural tube defects, but we haven't heard that we need to exercise in early pregnancy. Unless women have gestational diabetes mellitus; then, the doctors tell them to take regular exercise to control blood sugar.

3.2.4. Theme 4: Environmental Factors

3.2.4.1. Natural Environment: Weather

Weather, as an uncertain environmental factor, is difficult to control. Being rainy or too hot influences the participation of pregnant women in exercise during the first trimester.

I did less exercise in early pregnancy, mainly because it is too hot and I would like to take a taxi to work. But sometimes I walk around at dusk on weekends when the weather is cooler.

It's too hot now, and I don't want to move.

It's always been rainy recently, so I walk less.

3.2.4.2. Social Environment: Traditional Culture

Many participants mentioned cultural beliefs during the interview, and they thought resting more in early pregnancy was synonymous with being safer. They noted that these beliefs were passed down through the generations and that they followed them without knowing the reason.

Most people think we should rest more in early pregnancy. I'm superstitious but believe in science. It feels like a root and sprout; the embryo had just landed, and he needs some time to stabilize.

Everyone says that during early pregnancy, ‘rest first, exercise second.’ It seems that this is a traditional Chinese concept. No one tells me why, they just say Do this, don't do that…you're pregnant. It's not stable yet.

4. Discussion

This study employed a mixed‐methods approach to integrate quantitative data and qualitative narratives on the factors influencing physical inactivity in the first trimester of pregnancy in Shanghai, China, aiming to provide a deeper understanding of the underlying reasons behind women's behaviours. Despite being aware of the benefits of prenatal physical activity, more than half of our participants remained physically inactive or preferred walking rather than moderate‐ or vigorous‐intensity activities. This was attributed to a range of factors at the individual, interpersonal, social, and environmental levels.

In the cross‐sectional survey, the prevalence of physical inactivity (< 600 metabolic equivalent min/week) in the first trimester was 51.2%, which was similar to the results of a multi‐centre investigation in China (Feng et al. 2019). However, this rate is significantly higher than those reported in Malaysia (38.3%) (Syed Nor et al. 2022) and Serbia (27.2%) (Todorovic et al. 2020). These disparities may be attributed to differences in study populations and settings, highlighting the high level of physical inactivity in the first trimester among Chinese pregnant women.

From an individual perspective, the first trimester of pregnancy is a period of physiological and psychological adjustments, which may lead to decreased physical activity levels. Pregnancy‐related physical discomfort such as nausea and vomiting of pregnancy, fatigue, lethargy, and chest tightness was commonly mentioned in the interviews. As common reasons for influencing physical activity levels, fatigue and lethargy have been frequently reported (Watson et al. 2016; Bauer et al. 2018; Sytsma et al. 2018). Similarly, the quantitative results of this study also indicated that poor sleep quality in early pregnancy led to more physical inactivity. Sytsma et al. (2018) found that nausea was the greatest barrier in early pregnancy whereas swollen legs and back pain were often mentioned in the mid to late stages of pregnancy (Shum et al. 2022; Koleilat et al. 2021). This discrepancy in different trimesters suggests that specific physical activity interventions should be developed according to different periods of pregnancy. Previous evidence (Petrov Fieril et al. 2014) also shows that women who participate in regular exercise during pregnancy can relieve nausea, fatigue, poor sleep quality, and other pregnancy‐related physical discomfort. Moreover, the quantitative data in this study showed that, as a contraindication of physical activity, vaginal bleeding in early pregnancy is also associated with the first trimester physical activity level.

Apart from physiological factors, the psychological status of pregnant women in the first trimester should not be ignored. The qualitative results from this study revealed that many women expressed fear and concern about engaging in physical activity, particularly vigorous exercise, due to perceived risks such as miscarriage or premature birth. Similar concerns have been reported in previous studies (Shum et al. 2022; Okafor and Goon 2022; Chen et al. 2024), where fetal safety concerns, negative pregnancy experiences, and low self‐efficacy were associated with reduced physical activity during early pregnancy. Tinius et al. (2022) also noted increased fear of physical activity following a diagnosis of fetal growth restriction. Other studies attribute such fear and worries to limited knowledge about prenatal physical activity (Koleilat et al. 2021; Okafor and Goon 2022) or the lack of convenient tools to monitor fetal health (Findley et al. 2020). Consequently, many women in this study reduced the intensity or duration of activities to protect their baby from any possible risks, with walking accounting for 97% of total metabolic equivalents in early pregnancy. This may explain why only 2.1% of the women met the recommended physical activity guidelines during early pregnancy and why 95.7% of women with sufficient physical activity (≥ 600 metabolic equivalent min/week) failed to meet the physical activity guideline recommendations (≥ 150 min/week of moderate‐intensity activity). However, the quantitative data of this study did not show that psychological status (such as anxiety and depression symptoms) in early pregnancy was pertinent to the physical activity levels during the first trimester, which is consistent with the findings of Santos et al. (2022, 2024). These differences may be owing to a lack of parallel questions about psychological status in early pregnancy to facilitate comparisons of the qualitative and quantitative data.

Of note, this study found that some individual objective factors, such as maternal age, education level, pre‐pregnancy exercise habits, and free time, were also associated with physical activity levels in early pregnancy. According to multivariable logistic regression, pregnant women who were younger than 25 years old were more willing to participate in physical activity. Alaglan et al. (2020) reported that women aged ≤ 30 years had stronger physical function and activity endurance and were more likely to achieve prenatal physical activity goals. Although previous studies have shown that women with higher education levels have a better scientific understanding of physical activity and engage in more activity during pregnancy (Lü et al. 2021; Nascimento et al. 2015), the findings of this study were contradictory. Considering that Shanghai is a modern metropolis where people have a fast‐paced and intensive work life, pregnant women with higher education levels may be busy working and lack the time to exercise (Shum et al. 2022), as reflected in this qualitative analysis. The quantitative data of this study also revealed that women who engaged in regular exercise before pregnancy were more likely to achieve adequate physical activity in early pregnancy, consistent with the findings of Xiang et al. (2019) and Walasik et al. (2020) However, during the interview, participants reported that it was a challenge to continue exercising as much as before pregnancy because they were discouraged by parents or friends.

Pregnant women have certain social attributes, and their awareness and behaviours are influenced by interpersonal factors. As an important component of interpersonal factors, family and friends can help to increase or to discourage physical activity participation during pregnancy. The companionship of the husband motivated pregnant women to take part in exercise during the first trimester, though this influence was limited to walking. However, most participants' family and friends persuaded them not to engage in more activities during the first trimester. Furthermore, suggestions regarding physical activity in early pregnancy from medical workers were ambiguous and contradictory, which confused pregnant women. To minimise pressure from family and friends and strike a balance between conflicting ideas regarding physical activity among medical workers, pregnant women may only engage in walking. Interviews in this study also indicated that pregnant women tend to seek nonprofessional advice on social media due to insufficient access to professional guidance on physical activity from medical staff, which aligns with the findings of Shum et al. (2022). An online survey also pointed out that only 2% of midwives accurately understand the prenatal physical activity guidelines (Hopkinson et al. 2018), which amplifies the fact that health professionals provide limited knowledge of physical activity to pregnant women. A study in the UK indicates that healthcare professionals play a crucial role in promoting physical activity (Eastwood et al. 2023). Therefore, it is incredibly important to strengthen training to improve knowledge about physical activity for pregnant women in the first trimester among medical workers.

Social factors, such as a lack of physical activity facilities or a long distance to physical fitness venues, are also related to the level of physical activity among pregnant women (Okafor and Goon 2022; Hoodbhoy et al. 2018), which is in line with our findings. Even in an economically developed area such as Shanghai, free places for pregnant women to exercise are lacking and policies regarding prenatal physical activity are not well developed, which both influence enthusiasm for participating in physical activity among pregnant women. In the current field of health promotion, there is a growing emphasis on advocating for community‐based physical activity (Baldwin et al. 2023). Through various interventions such as group activities, personalised guidance, optimising community green spaces, and increasing fitness facilities, a favourable community environment can be created for pregnant women to exercise in the early pregnancy. This also provides a supportive social network, which is of great significance in promoting the physical and mental health of pregnant women. In addition, the government and relevant public health departments should develop a consensus on physical activity and incorporate it into routine antenatal care to address external social factors related to physical inactivity among pregnant women.

Environmental factors, encompassing both natural and sociocultural environments, have a significant impact on first trimester physical activity. In this study, weather, as an element of the natural environment, plays an essential role. Okafor and Goon (2022) and Koleilat et al. (2021) indicated a correlation between cold climates and prenatal physical activity. In addition to cold and humid conditions, hot weather is also a key factor affecting physical activity levels among pregnant women. Compared with the past 20 years, the land surface temperature during the daytime in summer in China has increased by approximately 9°C, and the increasing urbanisation‐induced urban heat island effect has become critical in metropolises like Shanghai (Zhou, Zhao, et al. 2022). Exposure to extreme heat not only results in acute heat stress among pregnant women but also increases adverse obstetric outcomes, including preterm birth, congenital heart defects, low birth weight, and even stillbirth, especially during the first trimester (Wang et al. 2019). Therefore, it is crucial to account for the effects of extreme weather when disseminating knowledge about physical activity in early pregnancy. Meanwhile, Yi et al. (2024) collected data using GPS technology and found that consistent exposure to greenspace promotes physical activity during pregnancy, especially among women in early and late pregnancy, first‐time mothers, and those with a higher pre‐pregnancy BMI. Therefore, governments should take this into consideration when planning urban land use.

Deeply rooted in the environment of social traditional culture, Chinese society widely regards the first trimester of pregnancy as a vulnerable time during which pregnant women should ‘rest more, and exercise less’. This cultural belief conflicts with international evidence‐based physical activity guidelines, leading pregnant women to prefer walking over moderate‐ or vigorous‐intensity activities. Interestingly, in this study, some pregnant women described this cultural belief as a superstition passed down through the generations and indicated that they often follow it without knowing the reason. To some extent, this phenomenon can explain why most women in this study preferred walking during the first trimester, and only 2.1% reached the physical activity guideline recommendations. Such traditional concepts also exist in South Africa (Okafor and Goon 2022) and Singapore (Shum et al. 2022); in contrast, pregnant women in India are encouraged to be physically active in preparation for vaginal delivery (Withers et al. 2018). Husbands, elders, friends, and medical workers are members of a pregnant woman's social environment, and their attitudes are also deeply influenced by traditional Chinese culture. The current challenge remains addressing these traditional beliefs. In view of this, evidence‐based early exercise recommendations, comprehensive exercise programmes, and scientific modern technology should be provided to ensure the health and safety of both the mother and the developing baby.

5. Implications for Practice

The findings from the quantitative and qualitative approaches used in this study regarding factors influencing physical inactivity in early pregnancy have important implications for maternity clinical practice. Midwives or other medical workers must recognise their important role in decision‐making processes regarding physical activity behaviour in early pregnancy and assume the responsibility of providing reliable advice, which should be tailored to account for each woman's age, education level, pre‐pregnancy physical activity habits, spare time, pregnancy‐related physical discomfort and the degree of influence by traditional culture. Furthermore, appropriate support should be provided for the physical and psychological changes that women may experience in early pregnancy to help them feel more confident and safer rather than perceiving these symptoms as a threat, which can lead to reduced physical activity participation. Women who perceive their baby to be vulnerable could be identified in advance and provided with scientifically proven support measures to help reduce their concerns about physical activity in early pregnancy. Midwives or other medical workers should provide more detailed information on the types and intensities of activity that pregnant women can take part in during early pregnancy to reassure them about the safety of these activities and that they will not cause harm to the baby. At present, there is an urgent need for a culturally specific consensus statement or guideline regarding physical activity in the first trimester among Chinese pregnant women, which is based on discussions among experts in related fields, to guide and train midwives or relevant medical workers and provide recommendations for policymakers.

6. Limitations

This study had several limitations. First, physical activity data were collected using a self‐report questionnaire; however, the absence of objective data from wearable devices may lead to information bias. Second, the participants were from one hospital in Shanghai; thus, our findings lack certain representativeness. Whether the findings of this study can be applied to other populations requires further verification. Third, only the perspectives and attitudes of pregnant women were captured regarding physical activity in early pregnancy. Future research should explore opinions and suggestions regarding physical activity during the first trimester of pregnancy from health professionals and policymakers.

7. Conclusion

The first trimester of pregnancy is a crucial time for both mother and fetus. Health professionals urgently need to prioritise this time to implement appropriate physical activity interventions. The findings of this mixed‐methods study highlight the necessity for culturally sensitive physical activity consensus development and education, and social support for physical activity during early pregnancy. The intrinsic factors of pregnant women themselves are also important in diminishing perceived barriers. Developing scientific and culturally specific physical activity interventions for the first trimester may help pregnant women establish healthy habits earlier and promote maternal and child health.

Author Contributions

N.W. and Y.D. conceived and designed the study. T.Z. collected the data, conducted the analysis, and interpreted the data with support from Y.L., Y.D., and N.W. T.Z. wrote the first draft of the manuscript with subsequent thorough amendments by N.W. All authors approved the final version. There is a statistician on the author team, and she is the corresponding author, Na Wang.

Ethics Statement

The research was performed according to the Declaration of Helsinki, and the Ethics Committee of the Obstetrics and Gynaecology Hospital, Fudan University approved the study (No. 202123). Written informed consent was obtained from each participant.

Consent

All participants were provided with a written informed consent form and were informed that they could withdraw from the study at any time for any reason.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Data S1: nop270310‐sup‐0001‐Supinfo.docx.

Zhou, T. , Lin Y., Ding Y., and Wang N.. 2025. “Exploring Factors Influencing Physical Inactivity During the First Trimester of Pregnancy: A Convergent Mixed‐Methods Study.” Nursing Open 12, no. 11: e70310. 10.1002/nop2.70310.

Data Availability Statement

The data that support the findings of this study can be obtained by contacting the corresponding author (Na Wang), upon reasonable request.