Comparison of Nutrition Practices, Knowledge and Exercise between Pregnant Women in China and Zambia ()
1. Introduction
The significance of nutrition and exercise during pregnancy has proven to be of critical importance for the best maternal and fetal outcomes, especially in developing nations [1]. The World Health Organization (WHO) stated in a release in 2023 that nutrition education and counseling might bring about desired gestational weight gain (i.e. neither insufficient nor excessive), reduce the risk of pregnancy-related anemia, lower the risks of preterm delivery and increased risk of low birth weight and small for gestational age infants [1] if put into practice. A healthy lifestyle including eating habits, enhances the success of achieving good pregnancy outcomes [1] and prevents conditions like gestational diabetes [2] [3]. It is, therefore, significant that foods rich in essential and polyunsaturated fats, carbohydrates rich in fiber and also vegetables be prioritized, especially in obese, overweight or diabetic women. Adequate intake of micronutrients including iron, calcium, folate and vitamin D is too important for pregnancy and breastfeeding to prevent neural tubal defects, preterm birth and low birth weight [4].
Moderate physical activity throughout pregnancy improves muscle tone and function, decreasing the risk of pre-eclampsia, gestational diabetes and postpartum overweight [5] [6]. In another release in October 2022, the WHO encouraged women without contraindication to do at least 150 minutes of moderate physical activities throughout the week, and should limit the amount of time being sedentary or inactive which in turn reduces the risks of pre-eclampsia, gestational hypertension, delivery and newborn complications including adiposity or macrosomia. Physical activity reduces sleep deprivation and poor cardiometabolic health. It also improves postpartum recovery time, and reduces the prevalence of depressive disorders.
However, different countries or regions have different attitudes towards nutrition and exercise, and pregnant women may have different behavioral attitudes towards nutrition and exercise. China and Zambia are both developing countries. Nevertheless, there is currently no research comparing the nutrition and exercise approaches of pregnant women between the two countries. We are very interested in this and plan on conducting related future studies.
Conclusively, the findings in this study will increase our understanding of the lifestyle habits of the two groups, which will give a better and deeper understanding of the differences between Chinese and Zambian pregnant women. This will further increase the knowledge of physicians from both groups so that they can make improvements, adjustments, and timely interventions where needed.
2. Methods
2.1. Subjects
This is a cross-sectional study with data that was collected in Chingola City, Zambia, and Hangzhou City, China, using an online survey between September 1, 2023 and February 28, 2024. Participants were recruited from the two hospitals according to the following criteria: each individual 1) agreed to participate in the study and gave their informed consent; 2) was pregnant; 3) had no history of mental diseases. This was a study to explore potential differences between the two groups and there was no quantifiable hypothesis to test in advance. Thus, we referred to a rough estimation method with 5 - 10 times the number of variables to calculate the sample size [7]. A total of 11 variables were included in the study; therefore, the required sample size was 55 (11 × 5). Considering a sample loss of 20.0%, the minimum sample size required for this study was 69 participants. We recruited as many eligible subjects as possible. In total, 210 respondents who completed the questionnaire were included in the final analysis (we recorded a 100% response rate).
The subjects were divided into two groups (the China group and the Zambia group) according to their nationality. All the study procedures were approved by the ethics committee of Hangzhou Women’s Hospital (Hangzhou Maternity and Child Health Care Hospital).
2.2. Questionnaire
Our questionnaire was developed to assess the similarities and differences in lifestyle habits during pregnancy between the two countries, which was designed based on existing literature (Appendix).
The questionnaire was structured into three parts: the first part consists of respondents’ socio-demographic information which included nationality, age, gestational age, parity, married status, employment status, self-assessed income level and education. The second part was about nutrition and eating habits which included 9 yes or no questions: intake of pregnancy supplements, consumption of take-out meals weekly, daily consumption of breakfast, vegetables, and fruits. Tea and coffee consumption on a daily basis, proactively acquiring nutrition knowledge and putting the nutritional knowledge into practice. The third part was about exercise which had two main constructs: 1) type of exercise, ranging from no exercise, mild (e.g walking…), moderate (e.g climbing stairs/cycling/jogging/Yoga…) to intense (e.g running/swimming…) activities; 2) Daily time of exercise recorded in minutes, categorized as < 15 minutes, 15 - 30 minutes, 30 - 60 minutes, and >60 minutes.
We used Cronbach alpha to determine the reliability of the questionnaire. The value was 0.734, which indicated that the study questionnaire was reliable.
2.3. Data Analysis
All the questionnaires were evaluated by the same person who was not responsible for either recruitment, allocation of randomization, or collection of completed questionnaires. Continuous data were compared using the independent samples t-test and analysis of variance. Chi-squared analysis was used for categorical variables. Our data were analyzed using the SPSS version 25.0 (SPSS, Armonk, NY, USA), and P < 0.05 was considered to indicate a significant difference. All tests were two-tailed analyses.
3. Results
3.1. Characteristics of the Study Population
As shown in Table 1, a total of 210 participants completed all the procedures in the study, 104 from China and 106 from Zambia. The age of the Chinese group was significantly higher than that of the Zambian group (P < 0.01). Compared with the Zambia group, the marriage rate, self-assessed income level and education level in the Chinese group were also significantly higher (P < 0.01). Overall, no significant differences were observed between the China group and Zambia group in terms of gestational age, parity, and employment status (Table 1).
3.2. Nutrition and Eating Habits
In terms of nutrient supplementation and whether to choose takeout weekly, 100% of Chinese pregnant women chose yes, while 100% of Zambian pregnant women chose no (P < 0.01) (Table 2).
Table 1. Participant demography.
| Variables |
China group (n = 104) |
Zambia group (n = 106) |
t/χ2 |
p |
| Age |
|
31.30 ± 4.93 |
26.62 ± 5.83 |
6.28 |
<0.001** |
| Gestational age |
<14 weeks |
4 (3.8) |
7 (6.6) |
3.53 |
0.171 |
| 14 - 28 weeks |
66 (63.5) |
54 (50.9) |
| ≥28 weeks |
34 (32.7) |
45 (42.5) |
| Parity |
Nulliparous |
24 (23.1) |
36 (34.0) |
3.05 |
0.081 |
| Multiparous |
80 (76.9) |
70 (66.0) |
| Married |
Yes |
91 (87.5) |
66 (62.3) |
17.72 |
<0.001** |
| No |
13 (12.5) |
40 (37.7) |
| Employment status |
Full time |
37 (35.6) |
30 (28.3) |
1.28 |
0.260 |
| Unemployed |
67 (64.4) |
76 (71.7) |
| Self-assessed income level |
Below average |
23 (22.1) |
40 (37.7) |
6.16 |
0.046* |
| Similar to the average level |
34 (32.7) |
29 (27.4) |
| Above average |
47 (45.2) |
37 (34.9) |
| Education |
Less than senior middle school |
13 (12.5) |
26 (24.5) |
59.52 |
<0.001** |
| Senior middle school |
14 (13.5) |
57 (53.8) |
| Bachelor and more |
77 (74.0) |
23 (21.7) |
Note: *p < 0.05; **p < 0.01.
Table 2. Nutrition and eating habits.
| Variables |
China group (n = 104) |
Zambia group (n = 106) |
χ2 |
p |
| Nutrients supplementation |
Yes |
104 (100.0) |
0 (0.00) |
210.00 |
<0.001** |
| No |
0 (0.00) |
106 (100.0) |
| Take out weekly |
Yes |
104 (100.0) |
0 (0.00) |
210.00 |
<0.001** |
| No |
0 (0.00) |
106 (100) |
| Have breakfast daily |
Yes |
96 (92.3) |
89 (84.0) |
3.48 |
0.062 |
| No |
8 (7.7) |
17 (16.0) |
| Vegetable consumption daily |
Yes |
82 (78.8) |
98 (92.5) |
7.94 |
0.005** |
| No |
22 (21.2) |
8 (7.5) |
| Fruits consumption daily |
Yes |
95 (91.3) |
76 (71.7) |
13.40 |
<0.001** |
| No |
9 (8.7) |
30 (28.3) |
| Tea consumption daily |
Yes |
7 (6.7) |
82 (77.4) |
107.23 |
<0.001** |
| No |
97 (93.3) |
24 (22.6) |
| Coffee consumption daily |
Yes |
12 (11.5) |
12 (11.3) |
0.002 |
0.960 |
| No |
92 (88.5) |
94 (88.7) |
| Proactively acquiring nutrition knowledge |
Yes |
50 (48.1) |
63 (59.4) |
2.72 |
0.099 |
| No |
54 (51.9) |
43 (40.6) |
| Applying nutritional knowledge to practice |
Yes |
90 (86.5) |
15 (14.2) |
110.03 |
<0.001** |
| No |
14 (13.5) |
91 (85.8) |
Note: *p < 0.05; **p < 0.01.
There was a significant difference between the two groups in the vegetable consumption daily (P < 0.01). Among the Chinese women, 78.8% ate vegetables daily, whereas 92.5% in the Zambia group ate vegetables daily. The fruit consumption in the Chinese group was significantly higher than that of the Zambian group (91.3% vs. 71.7%, P < 0.01) (Table 2).
The proportion of tea consumption in the China group was significantly lower than that of the Zambia group (P < 0.01), however, there was no significant difference in the proportion of coffee consumption between the two groups (P > 0.05) (Table 2).
Although the proactively acquiring nutrition knowledge rate of the China group (48.1%) was lower than that of the Zambia group (59.4%), there was no significant difference between the two groups (P > 0.05) (Table 2). In terms of applying nutritional knowledge to practice, 86.5% of the Chinese group were able to practice their nutrition knowledge, which was significantly higher than that of the Zambia group (14.2%, P < 0.01) (Table 2).
3.3. Exercise
Despite the differences in exercise intensity between the two groups, the vast majority of pregnant women chose mild activities (82.7% in the China group vs. 92.5% in the Zambia group). Among them, the proportion of pregnant women in the China group choosing moderate or intense activities was higher than that of the Zambia group (Table 3).
Table 3. Exercise status.
| Variables |
China group (n = 104) |
Zambia group (n = 106) |
χ2 |
p |
| Exercise intensity |
Hardly ever |
10 (9.6) |
8 (7.5) |
8.99 |
0.029* |
| Mild activities |
86 (82.7) |
98 (92.5) |
| Moderate activities |
7 (6.7) |
0 (0.00) |
| Intense activities |
1 (1.0) |
0 (0.00) |
| Exercise time daily (minutes) |
<15 |
34 (32.7) |
78 (73.5) |
39.11 |
<0.001** |
| 15 - 30 |
59 (56.7) |
20 (18.9) |
| 30 - 60 |
9 (8.7) |
4 (3.8) |
| > 60 |
2 (1.9) |
4 (3.8) |
Note: *p < 0.05; **p < 0.01.
Regarding daily exercise in minutes, a significantly higher proportion of Chinese pregnant women chose between 13 - 30 minutes or 30 - 60 minutes while a significantly lower proportion was recorded in the Zambian pregnant women (P < 0.01) (Table 3).
4. Discussion
From the findings in our present study, it can be observed that although pregnancy is a journey that many women may experience, lifestyle habits during pregnancy can vary from culture to culture or ethnicity, and outcomes are uncertain [8]. For China, our results show that close attention is paid with regard to proper nutrition including the intake of pregnancy supplements, and folic acid intake which has the likelihood of providing a protective barrier for the risk of gestational diabetes (GDM) [9] [10], as it is an increasing public health and worldwide concern, posing a threat to both fetal and maternal outcomes [11], and shows a significant difference in comparison to Zambia. Another significant difference that was observed was that the Chinese group consumed more takeaway meals during pregnancy. The benefits of prenatal exercise reduce gestational weight gain and the risk of GDM for overweight and obese women reinforcing the benefits of exercise during pregnancy [12]. After the two-child policy was implemented, GDM became an epidemic causing a health and economic burden in China [13]. However, the implementations of physical activity (PA) have shown great benefits in reducing gestational weight gain and the risk of GDM for overweight and obese women [14]. As observed from our results, there was a significant difference observed in the amount of time spent exercising between Chinese and Zambian women.
Studies show that the lifestyle habits of pregnant women in Zambia are not sufficient, however, sub-Sahara Africa experiences similar responses due to the vulnerability that comes with pregnancy. Maternal mortality rates are closely linked to maternal nutrition among African women with causes including poor dietary nutrition quality and inadequate food intake [15]. Another study reported that the prevalence of iron deficiency anemia in Africa is the most common among pregnant women and has severe consequences on both the mother and fetus [16].
For pregnant women with no evidence of medical and obstetrical complications, they were encouraged to maintain an active lifestyle. Just like our study, a meta-analysis on African pregnant women and exercise showed that antenatal exercise in Africa is low in comparison to other continents [17]. In Zambia, pregnant women may not know the specific exercises suitable during antenatal and mostly depend on walking and daily household chores to compensate as a means of exercise during pregnancy [18]. A community based cross-sectional study, indicated inadequate practice of antenatal exercise [19], while another literature review showed that physical activity (PA) among African pregnant women is clearly low and there need to be interventions in order to improve and promote better health for the continent [20]. In South Africa, a study showed that the majority of women did not meet the recommended 150 minutes of moderate-intensity/light-intensity activity per week [21]. Women who participate in prenatal exercises may experience benefits including having calmer babies with enhanced mental and neurological functions and better adaptability to new environments [22]. Limited data access and knowledge about the benefits of physical activity (PA) during pregnancy and its contribution to adverse outcomes have also been shown to be a contributing factor in low-middle-income countries [23].
Due to the insufficient nutrition that take-out meals contain, Chinese women should be encouraged to consume less of these meals during pregnancy as 100% of them from our study did. It is imperative that Zambian women pay more attention to taking pregnancy supplements in order to ensure good pregnancy outcomes including proper growth of the baby and prevent conditions like neural tubal defects [24], iron deficiency anemia [25], pre-eclampsia and lower the risks of pre-term birth [26]. The Zambian women should also be admonished to eat more fruits, especially those that are a source of essential vitamins, fiber and folate. Moderation of tea consumption should be taken into consideration in relation to the effects of excess caffeine intake which include gestational weight gain (GWA) and small for gestational age (SGA) [27]. The results showed that a larger number of pregnant women in Zambia drink tea. While having nutrition knowledge is a good start for better nutrition, it is more important to put the knowledge into practice to ensure good health outcomes for both mother and baby. Therefore, the Zambia group should adhere to putting their nutrition knowledge into practice. The Zambia group also had low scores in relation to the average time of exercise, compared to the China group. Pregnant women should be encouraged to understand the benefits of minimal exercises deemed fit for pregnancy such as walking, climbing stairs, cycling on a stationary bike, and swimming [28], as they may help with the management of anxiety [29], can be a conservative means of managing varicose veins, and deep vein thrombosis (DVT).
While a one-size-fits-all approach may work globally, it is important to put into consideration individualistic factors that may affect the mothers’ overall nutritional status. Our study used nutrition guidelines related to maternal nutrition and lifestyle habits during pregnancy. Despite the limitations of studies and inconsistent existing recommendations, some research work has shown that personalized nutrition offers women the opportunity to improve their health by using strategic uniquely tailored plans to meet their nutritional needs. More personalized approaches have the potential to optimize mothers and their offsprings health outcomes more appropriately to their nutrition needs during and after pregnancy [30].
Future studies can be more involving and diverse in that research work should not just be left for the senior health care practitioners but, young health care providers should be encouraged to actively participate with access to proper funding that would bring about the desirable results.
We recommend developing countries involve the governments and health care policymakers to support various nutrition and lifestyle interventions so that researchers can invest their time in conducting thorough research and provide timely interventions with decisions that stem from well-informed quality and empirical evidence. The governments and healthcare policymakers should aim to provide more recommendations, improve nutrition education, and develop novel approaches to improve consistent adherence to dietary and lifestyle interventions.
Several study limitations must be considered. First, the sample size was small, and it could have been expanded further. Second, although both China and Zambia are developing countries, Zambia’s income level is lower than China’s. Considering the different cost levels in the two countries, we did not use specific “household income” when collecting data before. Instead, we asked the subjects to evaluate the relationship between their household income level and the social average level, which may better assess the potential impact of socioeconomic level in this study. Third, our questionnaire design only includes yes/no options and does not include measurement of dietary intake. Nonetheless, this study is a preliminary exploration, and more detailed studies are needed in the future regarding this topic.
In conclusion, from the findings in our present study, it can be observed that although pregnancy is an experience that many women may go through, lifestyle habits during pregnancy can vary from culture to culture or ethnicity.
Fund
This work was supported by the “Pioneer” and “Leading goose” R&D Program of Zhejiang (2022C03102).
Appendix: The Questionnaire Used in the Study
| Maternal health quality questionnaire |
| Name:___________Age: ____________ |
Gestational age: ____weeks___dayslast menstrual period: ____Y___M___D |
| Parity: □Nulliparous □Multiparous |
Married: □Yes □No |
| Nationality: □China □Zambia |
Employment status: □Full time □Unemployed |
| Education:□Less than senior middle school□Senior middle school□Bachelor and more |
What do you think of your family’s income level?□Below average□Similar to the average level□Above average |
| A-nutrition and eating habits |
| 1. Do you regularly take nutrient supplementation during pregnancy? □Yes □No2. Do you eat take out every week? □Yes □No3. Do you have breakfast every day? □Yes □No4. Do you eat vegetables every day? □Yes □No5. Do you eat fruits every day? □Yes □No6. Do you drink tea every day? □Yes □No7. Do you drink coffee every day? □Yes □No8. Do you actively acquire knowledge of nutrition? □Yes □No9. Do you put the nutrition knowledge you know into practice? □Yes □No |
| B-exercise status |
| 1. How is your exercise intensity?□Hardly ever□Mild activities (e.g walking…)□Moderate activities (e.g climbing stairs/cycling/jogging/Yoga…)□Intense activities (e.g running / swimming…)2. What is your average daily exercise time? (minutes)□ <15□ 15 - 30□ 30 - 60□ >60 |
| Investigator：_____________ Date: _____________ |