Study on the Correlation Between Physical Activity During Pregnancy and Delivery Mode in Nulliparous Patients：A prospective cohort study

doi:10.21203/rs.3.rs-4929053/v1

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Study on the Correlation Between Physical Activity During Pregnancy and Delivery Mode in Nulliparous Patients：A prospective cohort study

https://doi.org/10.21203/rs.3.rs-4929053/v1

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BACKGROUND: Physical activity during pregnancy is a beneficial behavioral intervention aimed at enhancing pregnancy outcomes. Nevertheless, the association between prenatal physical activity and mode of delivery remains contentious. This study seeks to investigate whether physical activity during pregnancy correlates with the mode of delivery, with the ultimate objective of bolstering pregnant women's self-efficacy regarding physical activity and ameliorating pregnancy outcomes.

OBJECTIVE: This study aims to test the hypothesis that physical activity during pregnancy is associated with a reduced risk of cesarean delivery.

STUDY DESIGN: This prospective cohort study surveyed women with singleton pregnancies, free from contraindications to physical activity, utilizing the Chinese version of the Pregnancy Physical Activity Questionnaire. This instrument categorizes and quantifies physical activity by type and intensity. The primary outcome of interest is the mode of delivery. Univariate and multivariate binary logistic regression models were employed to ascertain the relationship between prenatal physical activity and mode of delivery.

RESULTS: A total of 217 women participated in the physical activity survey during pregnancy and subsequently gave birth at our hospital. The median energy expenditure from physical activity during pregnancy was 145.70 (111.92, 181.69) MET-h·wk⁻¹. The mean age of the participants was 30.20±3.71 years. Among the 217 primiparas, 131 experienced vaginal deliveries, while 86 underwent cesarean sections. After comprehensive adjustment for covariates, the risk of cesarean delivery was found to be reduced by 60% in the group that adhered to the recommended levels of physical activity during pregnancy compared to the group that did not (OR: 0.40, 95% CI: 0.20 to 0.83, P=0.0130).

CONCLUSION: Elevated levels of physical activity during pregnancy are associated with a reduced risk of cesarean delivery. Physical activity need not be confined to structured exercise programs; routine activities such as cleaning, shopping, and commuting on foot are effective means of increasing energy expenditure and achieving recommended physical activity levels.

Physical Activity

Pregnancy

Delivery way

Caesarean section

Nulliparous patients

Medically indicated cesarean section (CS) is a vital medical procedure that ensures the safety of both mother and child, thereby enhancing maternal and neonatal outcomes. However, the surge in non-indicated CS rates has precipitated a heightened risk of postpartum hemorrhage^[1], infection^[2], increased maternal mortality^[3], pulmonary embolism^[4], and depression^{[5, 6]}. Furthermore, infants born via CS may encounter adverse outcomes, including elevated perinatal mortality and diminished neonatal immune function and stress response^[7–9]. Current survey data indicate that the CS rate in China escalated from 28.8% in 2008 to 34.9% in 2014, and reached 36.7% in 2018^[10], significantly surpassing the ideal CS rate of 5%-15% recommended by the World Health Organization (WHO)^[11].

Physical activity is defined as any movement produced by skeletal muscles resulting in energy expenditure, encompassing planned and structured exercise, household chores, occupational activities, and transportation-related activities^[12]. Physical activity during pregnancy has been advocated as a beneficial behavioral approach to ameliorate pregnancy outcomes, owing to its potential to mitigate the risk of pregnancy complications and adverse birth outcomes^[13–16]. In 2020, the American College of Obstetricians and Gynecologists (ACOG) updated its guidelines on physical activity during pregnancy, recommending that, in the absence of contraindications, pregnant women should engage in moderate-intensity physical activity for 20–30 minutes daily^[17].

Some studies suggest that physical activity during pregnancy is a modifiable factor associated with CS^{[18, 19]}. Physical activity may influence metabolic and hormonal changes, enhance uterine contractility, and improve maternal endurance, thereby indirectly affecting the labor process and mode of delivery. Nevertheless, the evidence remains insufficient and contentious. Haakstad et al. found that regular exercise during pregnancy increased the rate of vaginal delivery^[20]. Morales et al. also reported similar findings^[21]. Conversely, several studies have found no association between physical activity and mode of delivery^{[22, 23]}. Most existing studies focus on specific prenatal exercise programs, such as yoga, birthing balls, and resistance training, and their impact on delivery outcomes^[24–26], overlooking daily activities such as household chores, occupational tasks, and commuting. These activities, although distinct from structured exercise programs, are also moderate-intensity activities that can influence the mode of delivery.

Given China's large population and the paucity of evidence from Chinese pregnant women compared to Western countries, and considering that previous studies have seldom included assessments of daily physical activities, this study aims to observe the relationship between physical activity during pregnancy and mode of delivery among Chinese primiparas. This research seeks to provide scientific evidence to reduce the CS rate and improve maternal and neonatal outcomes in China.

2.1Study Design and Participants

This prospective cohort study was conducted by collecting data from nulliparous patients who regularly attended prenatal check-ups at the obstetrics outpatient clinic of Shenzhen Second People's Hospital between May and October 2023 and subsequently gave birth in the obstetrics ward. The women were enrolled in the prospective cohort during their mid-pregnancy (14–27 weeks) prenatal check-ups and signed an informed consent form. They were then followed up in late pregnancy (28^+ 6 weeks to 32 weeks) until delivery. Inclusion criteria were: age ≥ 20 years; singleton pregnancy with no previous childbirth experience; no mental or cognitive impairments, enabling effective communication with researchers or independent completion of questionnaires; voluntary participation in the study and signing of an informed consent form; and being healthy prior to pregnancy, without conditions such as diabetes, hypertension, heart disease, or other physical defects. Exclusion criteria included adverse complications during pregnancy, such as placenta previa or threatened abortion; serious comorbidities during pregnancy, such as peripartum cardiomyopathy, liver diseases, and hematologic disorders; and a history of psychological or psychiatric illnesses^[27]. Drop-out criteria included participants with logical errors in questionnaire completion and those with incomplete data affecting the analysis of study results. This study was approved by the Ethics Review Committee of Shenzhen Second People's Hospital (Ethics Approval Number: 2023-015-02PJ).

2.2Exposure

The exposure variable in this study is physical activity during late pregnancy. The Pregnancy Physical Activity Questionnaire (PPAQ) was utilized to assess physical activity levels, recorded as a continuous variable. The PPAQ, originally developed by American scholars and localized into Chinese in 2012, exhibits a test-retest reliability of 0.944 and a content validity of 0.940, indicating robust reliability and validity, with a correlation with energy expenditure (r = 0.768, P < 0.001)^[28]. The PPAQ categorizes physical activity by type and intensity, effectively addressing the limitations of differentiating various types of physical activity and has been extensively employed to assess physical activity levels during pregnancy. The Chinese version of the PPAQ comprises four dimensions with 31 items: 13 items for household activities, 5 items for transportation, 8 items for recreational exercise, and 5 items for occupational activities. Based on the intensity of the activity, the energy expenditure value, or metabolic equivalent (MET), is calculated. Each item includes six options, each corresponding to a different weight coefficient, multiplied by the corresponding energy expenditure value to derive the weekly energy expenditure (MET-h·wk⁻¹). According to ACOG guidelines, achieving ≥ 7.5 MET-h·wk⁻¹ per week is considered meeting the recommended physical activity level during pregnancy, while < 7.5 MET-h·wk⁻¹ is considered not meeting the recommended level^[29].

2.3Outcomes

The primary outcome was the mode of delivery, categorized into vaginal delivery and cesarean section.

2.4Statistical Analysis

Continuous variables were expressed as mean ± standard deviation (for normal distribution) or median (interquartile range) (for skewed distribution), and categorical variables were expressed as frequencies or percentages. One-way analysis of variance (ANOVA) (for normal distribution), Kruskal-Wallis H test (for skewed distribution), and chi-square test (for categorical variables) were used to determine significant differences among the groups in terms of physical activity during pregnancy. According to ACOG guidelines, participants with weekly metabolic equivalent ≥ 7.5 MET-h·wk⁻¹ were classified as meeting the recommended physical activity levels, while those with < 7.5 MET-h·wk⁻¹ were classified as not meeting the recommended levels. Baseline characteristics were compared between these two groups.

Subsequently, univariate logistic regression was used to evaluate the association between variables and mode of delivery. Results were expressed as odds ratios (OR) and 95% confidence intervals (CI). For binary outcome variables, logistic regression models were employed. Both univariate and multivariate binary logistic regression models were constructed. Three different models were created: an unadjusted model (with no covariate adjustments), a minimally adjusted model (adjusting for sociodemographic variables only), and a fully adjusted model. Variables with variance inflation factors > 10 were excluded from the fully adjusted model.

Analyses were conducted using the statistical software packages R (http://www.R-project.org, The R Foundation) and EmpowerStats (http://www.empowerstats.com, X&Y Solutions, Inc, Boston, MA, USA). P values < 0.05 (two-sided) were considered statistically significant.

3.1Baseline Characteristics of Nulliparous Patients

A total of 239 participants were initially enrolled in the study. Four participants were excluded due to placenta previa, an absolute contraindication to physical activity. Five participants were excluded due to hypertensive disorders of pregnancy, and two were excluded due to pregnancy-related arrhythmias. Additionally, 11 participants were excluded due to loss to follow-up or missing physical activity data during pregnancy. Ultimately, 217 participants completed the survey, resulting in a follow-up completion rate of 91.21%. Details are provided in the flowchart (Fig. 1).

Figure 1

Description of participant inclusion and exclusion process.

3.2 Table 1 presents the baseline characteristics of primiparous women with varying levels of physical activity during pregnancy. The mean age of the participants was 30.20 ± 3.71 years. Of the 217 primiparous women, 131 (60.37%) experienced vaginal deliveries, while 86 (39.63%) underwent cesarean sections.

Table 1

Baseline Data of nulliparous patients with adequate and inadequate of physical activity during pregnancy
Maternal demographics	Inadequate Physical activity (n = 131)	Adequate Physical activity (n = 86)	P value
Maternal age, y	30.31 ± 3.82	30.02 ± 3.53	0.459
BMI (kg/m²)	20.89 ± 2.98	21.20 ± 2.70	0.299
GA weeks at delivery (wk)	38.92 ± 1.07	39.30 ± 1.04	0.007
Weight gain, g	13.22 ± 11.17	15.47 ± 13.25	0.145
Labor Fundal Height (cm)	34.82 ± 4.81	34.94 ± 2.50	0.219
Labor Abdominal Circumference (cm)	97.42 ± 5.98	99.06 ± 6.20	0.049
Birthweight, g	3118.82 ± 376.53	3189.36 ± 409.43	0.240
Birthhight, cm	48.62 ± 4.58	49.37 ± 1.65	0.147
Birthhead, cm	33.33 ± 1.28	33.08 ± 1.22	0.197
Advanced maternal age			0.340
No	115(87.79%)	79(91.86%)
Yes	16(12.21%)	7(8.14%)
Educational Level			0.670
High School and Below	15(11.45%)	9(10.47%)
Associate's or Bachelor's Degree	99(75.57%)	69(80.23%)
Graduate Degree and Above	17(12.98%)	8(9.30%)
Profession			0.585
Unemployed	22(16.79%)	12(13.95%)
Corporate Employee	89(67.94%)	64(74.42%)
Government Employee	20(15.27%)	10(11.63%)
Average Monthly Household Income Per Capita (Yuan)			0.231
< 10000	43(32.28%)	19(22.09%)
10000 ~ 20000	53(40.46%)	40(46.51%)
≥ 20000	35(26.72%)	27(31.40%)
Anticoagulant			0.370
No	119(90.84%)	81(94.19%)
Yes	12(9.16%)	5(5.81%)
pregnancy with Hypothyroidism			0.054
No	117(89.31%)	83(96.51%)
Yes	14(10.69%)	3(3.49%)
Pregnancy Complicated by COVID-19			0.131
No	10(7.63%)	12(13.95%)
Yes	121(92.37%)	74(86.05%)
Pregnancy Intention			0.016
Planned Pregnancy	107(81.68%)	58(67.44%)
Unplanned Pregnancy	24(18.32%)	28(32.56%)
Number of pregnancy			0.333
1	90(68.70%)	65(75.58%)
2	27(20.61%)	11(12.79%)
≥ 3	14(10.69%)	10(11.63%)
Oxytocin			0.128
No	88(67.18%)	49(56.98%)
Yes	43(32.82%)	37(32.02%)
Epidural			0.179
No	12(9.16%)	13(15.12%)
Yes	119(90.84%)	73(84.88%)
Newborn Gender			0.547
Male	74(56.49%)	45(52.33%)
Female	57(43.51%)	41(47.67%)
Anemia			0.994
No	50(38.17%)	33(38.37%)
Mild	39(29.77%)	26(30.23%)
Moderate	42(32.06%)	27(31.40%)

Table 1: Baseline Data of nulliparous patients with adequate and inadequate of physical activity during pregnancy

3.3 Among the cohort of 217 primiparous women, those who experienced vaginal deliveries exhibited a significantly higher adherence to the recommended levels of physical activity during pregnancy compared to those who underwent cesarean sections. Additionally, they demonstrated a correspondingly lower incidence of failing to meet these recommended levels, with the observed differences achieving statistical significance (P = 0.011). In terms of activity type and intensity, women with vaginal deliveries participated more frequently in household activities, recreational exercises, occupational tasks, moderate-intensity activities, and exhibited greater overall energy expenditure than their counterparts with cesarean sections; however, these variances did not reach statistical significance (P > 0.05) (Table 2).

Table 2

Comparison of Physical Activity Levels During Pregnancy Between Vaginal Delivery and Cesarean Section Groups (n = 217)
Item	Vaginal Delivery (n = 142)	Cesarean Section(n = 75)	X²/ Z	P
Meeting recommended physical activity levels during pregnancy			6.481	0.011
Met recommended levels	77(54.2%)	21(28.0%)
Did not meet recommended levels	65(45.8%)	54(72.0%)
Type of activity [M(P25, P75), MET-h•wk ^− 1]
Household activities	48.04(31.30, 74.03)	47.78(31.50, 71.05)	−0.115	0.909
Transportation activities	6.13(0.00, 14.88)	6.13(2.19, 14.00)	−0.066	0.948
Recreational exercise	5.38(1.13, 12.50)	2.63(0.88, 8.75)	−1.846	0.065
Occupational activities	33.25(0.00, 73.15)	19.25(0.00, 66.50)	−0.781	0.435
Occupational activities [M(P25, P75), MET-h•wk ^− 1]
Sedentary activities	19.25(10.50, 21.00)	21.00(17.50, 21.00)	−1.394	0.163
Low-intensity activities	68.08(35.88, 89.78)	70.88(33.08, 116.20)	−1.104	0.270
Moderate-intensity activities	20.51(9.75.36.13)	14.00(5.69, 31.69)	−1.736	0.083
High-intensity activities	0.00(0.00, 0.00)	0.00(0.00, 0.00)	−0.820	0.412
Total energy expenditure [M(P25, P75), MET-h•wk ^− 1]	109.75(61.90, 149.00)	100.63(54.78, 153.16)	−0.789	0.430

Table 2

Comparison of Physical Activity Levels During Pregnancy Between Vaginal Delivery and Cesarean Section Groups

3.4 Univariate Analysis of Mode of Delivery

The univariate analysis reveals significant associations between the mode of delivery and several maternal and neonatal factors, including maternal age, gestational age at delivery, abdominal circumference at delivery, neonatal head circumference, advanced maternal age, and the number of pregnancies (P < 0.05) (Table 3).

Table 3

Univariate analysis of delivery way
Maternal demographics	Statistics	95% CI	P value
Maternal age, y	30.20 ± 3.70	1.20(1.10, 1.31)	<0.0001
BMI (kg/m²)	21.01 ± 2.87	1.04(0.94, 1.15)	0.4426
GA weeks at delivery (wk)	39.07 ± 1.07	0.71(0.54, 0.92)	0.0111
Weight gain, g	14.11 ± 12.06	1.03(1.00, 1.06)	0.0657
Labor Fundal Height (cm)	34.87 ± 4.05	1.11(0.98, 1.24)	0.0892
Labor Abdominal Circumference (cm)	98.07 ± 6.11	1.06(1.01, 1.11)	0.0216
Birthweight, g	3146.77 ± 390.50	1.00(1.00, 1.00)	0.0801
Birthhight, cm	48.92 ± 3.72	1.07(0.93, 1.22)	0.3516
Birthhead, cm	33.23 ± 1.26	1.63(1.28, 2.08)	<0.0001
Advanced maternal age
No	194(89.40%)	1.0
Yes	23(1060%)	6.64(2.49, 17.70)	0.0002
Educational Level
High School and Below	24(11.06%)	1.0
Associate's or Bachelor's Degree	168(77.42%)	0.88(0.36, 2.13)	0.7749
Graduate Degree and Above	25(11.52%)	0.78(0.24, 2.55)	0.6862
Profession
Unemployed	34(15.67%)	1.0
Corporate Employee	153(70.51%)	1.00(0.46, 2.18)	1.0000
Government Employee	30(13.82%)	0.79(0.27, 2.25)	0.6529
Average Monthly Household Income Per Capita (Yuan)
< 10000	62(28.57%)	1.0
10000 ~ 20000	93(42.86%)	0.98(0.49, 1.93)	0.9446
≥ 20000	62(28.57%)	1.15(0.55, 2.40)	0.7075
Anticoagulant
No	200(92.17%)	1.0
Yes	17(7.83%)	2.28(0.84, 6.19)	0.1044
pregnancy with Hypothyroidism
No	200(92.17%)	1.0
Yes	17(7.83%)	0.77(0.26, 2.29)	0.6426
Pregnancy Complicated by COVID-19
No	22(10.14%)	1.0
Yes	195(89.86%)	1.15(0.45, 2.95)	0.7754
Pregnancy Intention
Planned Pregnancy	165(76.04%)	1.0
Unplanned Pregnancy	52(23.96%)	0.90(0.46, 1.74)	0.7451
Number of pregnancy
1	155(71.43%)	1.0
2	38(17.51%)	2.18(1.05, 4.52)	0.0369
≥ 3	24(11.06%)	5.38(2.15, 13.50)	0.0003
Oxytocin
No	137(63.13%)	1.0
Yes	80(36.87%)	0.00(0.00, 0.00)	0.9869
Epidural
No	25(11.52%)	1.0
Yes	192(88.48%)	0.00(0.00, 0.00)	0.9827
Newborn Gender
Male	119(54.84%)	1.0
Female	98(45.16%)	0.79(0.45, 1.39)	0.4106
Anemia
No	83(38.25%)	1.0
Mild	65(29.95%)	0.84(0.42, 1.67)	0.6261
Moderate	69(31.80%)	0.94(0.48, 1.84)	0.8613

Table 3 : Univariate analysis of delivery way

3.5Relationship Between Physical Activity and Mode of Delivery

Three models were employed to assess the relationship between physical activity during pregnancy and the mode of delivery (Table 4). In the unadjusted model, no linear relationship between physical activity during pregnancy and the mode of delivery was observed (P = 0.3415). However, it was found that the group meeting the recommended physical activity levels had a 54% lower likelihood of cesarean delivery compared to the group not meeting the recommended levels (OR: 0.46, 95% CI: 0.25 to 0.84, P = 0.0117).

Table 4

Relationship between Physical Activity and delivery way in different models
Variable	Non-adjusted M, P Value	Adjusted MI, P Value	Adjusted MII, P Value
Physical Activity	1.00(0.99, 1.00)0.3415	1.00(0.99, 1.00)0.2494	1.00(0.99, 1.00)0.3326
Physical Activity
Inadequate	1.0	1.0	1.0
Adequate	0.46(0.25, 0.84)0.0117	0.46(0.24, 0.86)0.0151	0.40(0.20, 0.83)0.0130
Physical Activity Trisection
Low Physical Activity level	1.0	1.0	1.0
Moderate Physical Activity level	0.57(0.28, 1.15)0.1150	0.62(0.30, 1.28)0.1950	0.75(0.34, 1.65)0.4732
High Physical Activity level	0.82(0.42, 1.61)0.5632	0.73(0.36, 1.49)0.3907	0.85(0.39, 1.85)0.6846
P for trend	0.5593	0.3896	0.6958
Non-adjusted M ( Non-adjusted model): No adjustment. Adjusted MI (adjusted model I): adjustment for age, education, profession, percapita monthly household income. Adjusted MII (adjusted model II): adjustment for age, education level, occupation, average monthly family income, number of pregnancies, anemia, BMI (kg/m2), GA weeks at delivery, Labor Abdominal Circumference, Birthhead, Advanced maternal age

This association persisted in Model I, where the odds ratio remained at 0.46 (95% CI: 0.24 to 0.86, P = 0.0151). In Model II, the group that met the recommended levels of physical activity exhibited a 60% lower risk of cesarean delivery compared to the group that did not meet the recommended levels (OR: 0.40, 95% CI: 0.20 to 0.83, P = 0.0130).

For sensitivity analysis, physical activity during pregnancy was transformed into a categorical variable based on tertiles, and P-values for the trend test were calculated. The results indicated no statistical significance (all P < 0.05).

Table 4: Relationship between Physical Activity and delivery way in different models

This study analyzed data from 217 primiparous women who delivered at the Department of Obstetrics in Shenzhen Second People's Hospital. After adjusting for confounding factors, it was found that those who met the recommended levels of physical activity during pregnancy had a 60% lower risk of cesarean delivery compared to those who did not (OR: 0.40, 95% CI: 0.20 to 0.83, P = 0.0130). This suggests that physical activity during pregnancy serves as a protective factor against cesarean delivery, underscoring the importance of enhancing health education on exercise during pregnancy.

Currently, there is considerable controversy regarding the relationship between physical activity during pregnancy and the mode of delivery. Our study found that women who met the recommended levels of physical activity during pregnancy had a 60% lower risk of cesarean delivery, consistent with the findings of Veisy et al. ^[30]. An epidemiological study by Meander et al. using data from the NorthPop study and the Swedish National Pregnancy Registry found that higher levels of physical activity were associated with a reduced risk of emergency cesarean sections and better self-reported health during pregnancy, while higher sedentary time was associated with poorer self-reported health during pregnancy^[31]. A meta-analysis by Teede et al. of 117 randomized controlled trials showed that physical activity during pregnancy significantly reduced the cesarean section rate (OR = 0.85, 95% CI: 0.75, 0.95)^[32]. This may be due to physical activity's benefits, including improved maximum oxygen uptake (VO2max), lower heart rate, reduced systolic and diastolic blood pressure, and enhanced cardiovascular health, which support the physical demands of vaginal delivery^[33–35]. A cohort study from Taiwan involving 150 pregnant women found that for each unit increase in physical activity during late pregnancy, the risk of cesarean delivery decreased by 36% (OR = 0.64, 95% CI: 0.43, 0.97), while physical activity levels in early and mid-pregnancy were not associated with the cesarean section rate^[36]. This may be because physical activity during pregnancy optimizes placental angiogenesis and endothelial function, reducing ischemic placental diseases such as preeclampsia. Through endothelial shear stress, it increases the expression of endothelial nitric oxide synthase (eNOS) and nitric oxide (NO) production in the placenta while reducing the production of reactive oxygen species (ROS). These changes benefit the vascular and antioxidant systems, lowering the risk of hypertensive disorders and diabetes during pregnancy, and improved placental function ensures adequate oxygen supply and acid-base balance during labor, reducing fetal distress and thus the cesarean section rate^{[37, 38]}.

However, several studies have drawn opposite conclusions. Laura et al.'s study did not find any differences in physical activity levels during pregnancy between different modes of delivery^[39]. A study from Denmark showed that increased physical activity levels in early and mid-pregnancy could reduce the risk of cesarean delivery, but increased physical activity levels in late pregnancy were not associated with cesarean delivery risk^[40]. We speculate that the differences in results may be due to the different study populations. Our study focused on the Chinese population, and unlike Laura et al., our study was a prospective cohort study. The scope of physical activity assessment also differed, as the aforementioned studies were limited to specific forms of exercise such as yoga and Pilates, whereas our study included all possible physical activities, including household chores, occupational activities, and commuting.

Previous research has shown that the cesarean section rate has a U-shaped relationship with adverse perinatal outcomes, where an increase in the cesarean section rate within a certain range is associated with increased risks of poor maternal and neonatal outcomes, such as postpartum hemorrhage, amniotic fluid embolism, and reduced neonatal immune function^{[41, 42]}. For nearly 30 years, China's cesarean section rate has remained high, topping the list of Asian countries^[43]. In our study, the cesarean section rate was 39.63%, significantly higher than the ideal cesarean section rate of 5%-15% recommended by the World Health Organization (WHO). The persistently high cesarean section rate has become an urgent global public health issue that needs to be addressed. Our findings suggest that physical activity during pregnancy is an important determinant of the mode of delivery, and promoting physical activity during pregnancy could be adopted as a simple and cost-effective intervention to reduce the cesarean section rate. Healthcare providers should develop physical activity plans for pregnant women, guide them in safe types and frequencies of physical activity, and regularly assess and discuss these activities during prenatal check-ups. Implementing these measures will help increase the vaginal delivery rate, reduce maternal and neonatal complications, and lessen the healthcare economic burden.

This study has several strengths. First, the assessment of physical activity during pregnancy covered the daily activities of pregnant women, not limited to specific forms of exercise. Second, the study included only primiparous women, which helped avoid confounding factors and better reflect the relationship between physical activity during pregnancy and mode of delivery. Healthcare providers should guide pregnant women in engaging in appropriate and correct physical activities to promote maternal and neonatal health.

However, this study also has some limitations. First, as an observational study, it is inevitably subject to confounding factors, despite our rigorous adjustments. Second, the data were collected from only one hospital, and the sample size was relatively small. Therefore, future studies should involve multicenter and larger sample sizes. Given these limitations, conducting higher-level clinical studies in more diverse populations is necessary to validate our findings.

This study concluded that pregnant women who met the recommended levels of physical activity had a 60% lower risk of cesarean delivery compared to those who did not meet the recommendations. Our findings suggest that everyday activities, such as cleaning, shopping, and walking to and from work, are effective ways to increase energy expenditure and help achieve the recommended levels of physical activity. By incorporating household chores and other daily activities into the scope of physical activity, pregnant women can more easily adopt a healthy lifestyle without overly relying on structured exercise programs. This diversified approach to physical activity not only helps maintain physical vitality but also reduces stress during pregnancy and improves overall quality of life. Future research can further explore the quantitative relationship between different types and intensities of physical activity and delivery outcomes, especially for mothers with pregnancy complications. Additionally, studies could investigate the use of wearable devices to accurately monitor the intensity and patterns of physical activity in pregnant women.

Ethics approval and consent to participate

This study has obtained approval from the Ethics Committee of the Second People’s Hospital of Shenzhen (Approval No: 202301502PJ) and the protocol was registered with ClinicalTrials.gov (registration number: ChiCTR2300078381, registration date: December 7, 2023). This study was conducted in accordance with the principles of the Declaration of Helsinki. The participants provided their written informed consent to participate in this study.

Consent for publication

Not Applicable.

Availability of data and materials

The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request.

Competing interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding

This study was not funded.

Authors’ contributions

Shu-Qun Ren: Formal analysis, Methodology, Writing– original draft, Writing – review & editing. Xiao-Ming Zhang: Writing – review & editing. Liyin Luo: Investigation, Writing – review & editing. Qian Zhao: Resources, Validation, Writing – review & editing. Lei-E Li: Funding acquisition, Methodology, Resources, Writing – review & editing.

Acknowledgments

We would like to express our sincere gratitude to Dr Linlin Jiang for their valuable guidance and assistance with study design and content. We would also like to acknowledge the financial support provided by Shenzhen Second People’s Hospital for this study. Their contributions were essential to the successful completion of this research project.

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Study on the Correlation Between Physical Activity During Pregnancy and Delivery Mode in Nulliparous Patients：A prospective cohort study

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Abstract

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1. Introduction

2. Materials and Methods

2.1Study Design and Participants

2.2Exposure

2.3Outcomes

2.4Statistical Analysis

3. Results

3.1Baseline Characteristics of Nulliparous Patients

3.4 Univariate Analysis of Mode of Delivery

3.5Relationship Between Physical Activity and Mode of Delivery

4. Discussion

5. Conclusion

Declarations

References

Additional Declarations

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Version 1