Background

The postpartum period, defined as the first six months following childbirth, is a critical phase for maternal health and recovery [1]. Regular physical activity during this period offers numerous benefits including enhanced cardiovascular fitness, improved mental health, facilitated weight management, and reduced risk of postpartum depression [2,3]. The World Health Organization (WHO) recommends that postpartum women engage in at least 150 minutes of moderate-intensity aerobic physical activity per week, with a gradual return to exercise based on individual recovery and mode of delivery [4].

Despite these well-documented benefits and clear guidelines, postpartum women worldwide demonstrate low levels of physical activity engagement, with rates ranging from 14% to 45% across different settings [5,6]. In low- and middle-income countries (LMICs), where maternal health resources are often limited, understanding the factors influencing postpartum physical activity becomes even more crucial for designing contextually appropriate interventions [7].

Knowledge, attitudes, and practices (KAP) represent key determinants of health behaviours. Previous research has identified significant gaps between what women know about exercise benefits and their actual practice [8,9]. Factors such as mode of delivery, particularly caesarean section, have been associated with delayed return to physical activity [10]. Cultural beliefs, family support, healthcare provider counselling, and practical barriers such as childcare responsibilities and fatigue further complicate the postpartum exercise landscape [11,12].

In Zambia, while research has examined exercise during pregnancy [13-16], the postpartum period remains understudied. The existing gap in knowledge about postpartum physical activity patterns and determinants limits the development of evidence-based interventions tailored to the Zambian context. Understanding current knowledge levels, attitudes, and actual practices among postpartum women is essential for informing healthcare provider training, designing targeted health education programs, and ultimately improving maternal health outcomes.

Study Rationale and Objectives

This study addresses this critical knowledge gap by examining physical activity knowledge, attitudes, and practices among postpartum women in Lusaka, Zambia. Specifically, the study aimed to:

• Assess the level of knowledge regarding postpartum physical activity among women attending postnatal care
• Determine attitudes toward postpartum exercise engagement
• Describe actual physical activity practices during the postpartum period
• Identify factors associated with postpartum physical activity engagement
• Explore barriers and facilitators to postpartum exercise practice

The findings will provide baseline data to inform the development of contextually relevant interventions to promote postpartum physical activity in Zambian healthcare settings and similar LMIC contexts.

Study Design and Setting

This was a facility-based cross-sectional study conducted in first level one hospitals in Lusaka District, Zambia, between November 2024 and September 2025. Lusaka is the capital city with a population of approximately 2.5 million people. The study was conducted at four purposively selected public health facilities: [Facility 1], [Facility 2], [Facility 3], and [Facility 4]. These facilities were selected based on their high patient volumes and provision of comprehensive postnatal care services, ensuring access to a diverse sample of postpartum women.

Study Population and Sampling

The target population comprised postpartum women aged 18-45 years attending postnatal care services. Inclusion criteria were: (1) women between 6 weeks and 6 months postpartum; (2) singleton pregnancy and delivery; (3) residing in Lusaka District; and (4) willingness to provide informed consent. Women were excluded if they had medical contraindications to exercise (e.g., severe postpartum complications, cardiovascular disease, uncontrolled hypertension), mental health conditions that would impair their ability to complete the questionnaire, or pregnancy complications requiring ongoing specialized care.

Sample Size Calculation

The sample size was calculated using the formula for estimating a single proportion: n = Z²p (1-p)/d², where Z = 1.96 (95% confidence level), p = estimated prevalence of postpartum exercise practice (assumed at 25% based on similar studies in sub-Saharan Africa), and d = margin of error (5%). This yielded a minimum sample of 289. Adjusting for a 10% non-response rate and design effect of 1.5 for multi-site sampling, the final sample size was 420 participants. Participants were consecutively sampled from the four health facilities proportional to their monthly postnatal clinic attendance volumes.

Data Collection Instrument

Data were collected using a structured interviewer-administered questionnaire developed through a multi-step process:

Literature Review and Adaptation: Questionnaire items were adapted from validated instruments used in previous studies on postpartum physical activity [17,18] and our team's prior research on pregnancy exercise in Zambia [13-16]. The instrument drew on the Health Belief Model and Theory of Planned Behaviour.

Content Validity: The instrument was reviewed by a panel of seven experts including physiotherapists (n=3), obstetricians (n=2), a public health specialist, and a research methodologist. Experts rated each item for relevance, clarity, and cultural appropriateness. The overall scale-level content validity index was 0.89, indicating excellent content validity.

Pre-testing and Refinement: The questionnaire was pre-tested among 30 postpartum women (not included in the main study) at a non-study facility. Based on feedback, modifications were made to simplify language, clarify ambiguous items, and enhance cultural appropriateness. The average completion time was 27 minutes.

The final questionnaire comprised five sections:

Section A - Sociodemographic Characteristics: Age, educational level, marital status, occupation, household income, number of children, and living arrangements.

Section B - Obstetric History: Mode of current delivery, indication for caesarean section if applicable, previous deliveries, pregnancy complications, postpartum complications, birth weight, current postpartum period, and birth spacing.

Section C - Knowledge Assessment: Fifteen multiple-choice questions covering: (1) definition and types of physical activity suitable for postpartum period; (2) recommended timing for resuming exercise after vaginal and caesarean delivery; (3) benefits of postpartum exercise; (4) contraindications and warning signs; (5) principles of safe progression; (6) pelvic floor exercises; (7) impact on breastfeeding. Each correct response scored 1 point (range 0-15). Knowledge was categorized as: Good (≥75%, 12-15 correct), Moderate (50-74%, 8-11 correct), Poor (<50%, 0-7 correct).

Section D - Attitude Assessment: Ten statements rated on a 5-point Likert scale (1=strongly disagree to 5=strongly agree), assessing perceived importance, self-efficacy, cultural acceptability, breastfeeding concerns, and family support. Total attitude score range: 10-50, categorized as Negative (<25), Neutral (25-35), Positive (>35). The attitude scale demonstrated good internal consistency (Cronbach's alpha = 0.76).

Section E - Practice Assessment and Barriers: Current engagement in physical activity; type, frequency, duration, and intensity; timing of exercise initiation postpartum; sources of information; receipt of healthcare provider counselling; barriers to exercise (pre-coded list with multiple selection); and facilitators.

Data Collection Procedures

Eight trained research assistants with healthcare backgrounds and fluency in English and local languages (Nyanja, Bemba) conducted face-to-face interviews in private spaces within the health facilities. Each interview lasted approximately 25-30 minutes. Research assistants underwent a comprehensive two-day training covering research ethics, informed consent procedures, questionnaire administration, and data quality assurance. Field supervision was conducted daily by the principal investigator.

Data Management and Analysis

Data were checked daily for completeness and consistency. Questionnaires with >10% missing data were excluded (n=3, 0.7%). Data were double-entered into EpiData version 3.1 by two independent data clerks to ensure accuracy, then exported to Statistical Package for Social Sciences (SPSS) version 26 for analysis.

Descriptive Analysis: Descriptive statistics included frequencies and percentages for categorical variables and means with standard deviations for continuous variables.

Bivariate Analysis: Chi-square tests (or Fisher's exact test when expected cell counts were <5) examined associations between independent variables and postpartum physical activity practice (dichotomized as regular exercise ≥150 minutes/week vs. <150 minutes/week). Variables with p<0.25 were considered for multivariable analysis.

Multivariable Analysis: Binary logistic regression using backward elimination method identified independent predictors of postpartum physical activity practice. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were reported for variables remaining in the final model, with statistical significance set at p<0.05. Model fit was assessed using the Hosmer-Lemeshow goodness-of-fit test and Nagelkerke R². Multicollinearity was assessed using variance inflation factors (VIF<3).

Ethical Considerations

Ethical approval was obtained from University of Zambia, School of Health Sciences Research Ethics Committee (Protocol Number: 2023270503). Permission to conduct the study was granted by the Lusaka District Health Management Team and facility administrators. Written informed consent was obtained from all participants after providing detailed explanation of the study purpose, procedures, potential risks and benefits, voluntary participation, confidentiality measures, and right to withdraw. Participants who could not write provided thumbprint consent witnessed by an impartial third party. Participants received no monetary compensation but were provided with culturally appropriate health education materials on postpartum exercise. All data were de-identified and stored securely.

A total of 423 postpartum women were approached, of whom 420 consented and completed the questionnaire (response rate 99.3%). Three women declined participation due to time constraints.

Sociodemographic and Obstetric Characteristics

Table 1 presents the sociodemographic and obstetric characteristics of the 420 participants. The mean age was 28.4±5.6 years (range 18-45), with the majority (52.4%, n=220) in the 25-34 years age group. Most participants were married (78.1%, n=328), had attained secondary education (58.3%, n=245), and were unemployed (62.4%, n=262). Regarding obstetric characteristics, 45.5% (n=191) had delivered via caesarean section, while 54.5% (n=229) had vaginal deliveries. Among women who had caesarean sections, the most common indications were previous caesarean section (34.0%), prolonged labor (28.8%), and fetal distress (22.5%). Multiparous women comprised 64.3% (n=270) of the sample, and most participants (68.6%, n=288) were in the 6 weeks to 3 months postpartum period.

Table 1: Sociodemographic and Obstetric Characteristics of Participants (N=420).

Knowledge of Postpartum Physical Activity

Only 38.6% (n=162) of participants demonstrated good knowledge (≥75% correct responses), while 44.0% (n=185) had moderate knowledge (50-74%) and 17.4% (n=73) had poor knowledge (<50%). The mean knowledge score was 9.8±3.2 out of 15.

Table 2 details responses to specific knowledge questions. While 82.4% correctly identified walking as suitable postpartum exercise, only 45.2% knew the recommended timing for resuming exercise after caesarean section. Common knowledge gaps included understanding intensity levels (38.6% correct), knowing contraindications (42.1%), and recognizing warning signs (39.5%). Educational level was significantly associated with knowledge level (p<0.001), with tertiary-educated women demonstrating better knowledge than those with primary education.

Table 2: Knowledge of Postpartum Physical Activity (N=420).

Attitudes toward Postpartum Physical Activity

Overall, 45.7% (n=192) of participants had positive attitudes (score >35), 38.6% (n=162) had neutral attitudes, and 15.7% (n=66) had negative attitudes toward postpartum exercise. The mean total attitude score was 33.2±7.8.

Most women agreed that exercise is important for postpartum recovery (mean score 4.1±0.9) and can help with weight management (4.0±1.0). However, concerns were evident regarding impact on breastfeeding (mean score 3.2±1.2), with 48.3% expressing worry that exercise might reduce milk supply. Cultural beliefs presented mixed attitudes, with 54.3% agreeing that "women should rest rather than exercise after childbirth" (mean score 3.6±1.1).

Table 3: Attitudes toward Postpartum Physical Activity (N=420).

^*5-point Likert scale: 1=Strongly Disagree, 2=Disagree, 3=Neutral, 4=Agree, 5=Strongly Agree

Physical Activity Practice

Only 24.3% (n=102) of participants reported engaging in regular physical activity during the postpartum period (defined as at least 150 minutes per week of moderate-intensity activity as per WHO guidelines). Among those who exercised, walking was the most common form (87.3%, n=89), followed by household chores (56.9%, n=58) and light aerobics/dancing (18.6%, n=19). The majority (73.5%, n=75) exercised 3-4 days per week, with sessions lasting 20-30 minutes (64.7%, n=66). Most exercise was light intensity (65.7%) and conducted at home (76.5%).

Table 4: Physical Activity Practices Among Active Participants (n=102).

Knowledge-Practice Gap

A substantial knowledge-practice gap was evident. Among women with good knowledge, only 41.4% actually practiced regular exercise, while 58.6% with good knowledge were not exercising. This gap was even wider among those with moderate knowledge (18.9% practicing) and poor knowledge (8.2% practicing).

Healthcare Provider Counselling

Only 32.1% (n=135) of participants reported receiving counselling on postpartum exercise from healthcare providers. Of those who received counselling, 71.1% (n=96) found it helpful. Women who received counselling were significantly more likely to engage in postpartum exercise compared to those who did not (OR=3.21, 95%CI: 2.01-5.13, p<0.001).

Barriers to Postpartum Physical Activity

Table 5 presents barriers to postpartum exercise. The most frequently cited barriers were lack of time due to childcare responsibilities (68.3%, n=287), fatigue and lack of energy (62.1%, n=261), and cultural beliefs about needing to rest postpartum (54.8%, n=230). Other significant barriers included lack of healthcare provider guidance (55.7%, n=234), no available postnatal exercise programs (50.5%, n=212), lack of childcare support (48.6%, n=204), belief that exercise reduces breast milk (48.3%, n=203), and pain from delivery (47.1%, n=198).

Table 5: Barriers to Postpartum Physical Activity (N=420).

Multiple responses were allowed; percentages do not sum to 100%

Factors Associated with Postpartum Physical Activity Practice

Table 6 shows results from multivariable logistic regression analysis. After controlling for confounders, six factors emerged as significant independent predictors of postpartum exercise engagement.

Table 6: Factors Associated with Postpartum Physical Activity Practice - Multivariable Logistic Regression Analysis (N=420).

OR = Odds Ratio; CI = Confidence Interval; ref = reference category Hosmer-Lemeshow goodness-of-fit test: χ² = 8.34, p = 0.401; Nagelkerke R² = 0.423

Significant independent predictors were: (1) Mode of delivery - women with vaginal delivery were 2.34 times more likely to exercise (p<0.001); (2) Healthcare provider counselling - women who received counselling were 3.21 times more likely to exercise (p<0.001); (3) Educational level - women with tertiary education were 2.87 times more likely to exercise compared to those with primary education (p=0.001); (4) Good knowledge - 2.15 times more likely to exercise (p=0.012); (5) Positive attitudes - 1.98 times more likely (p=0.035); (6) Primiparity - 1.76 times more likely (p=0.020).

This study provides the first comprehensive assessment of postpartum physical activity knowledge, attitudes, and practices among Zambian women. The findings reveal a significant knowledge-practice gap, with only 24.3% of postpartum women engaging in regular physical activity despite 38.6% having good knowledge and 45.7% holding positive attitudes toward exercise. This gap is considerably larger than observed in high-income countries where 40-55% of postpartum women meet physical activity recommendations [19,20], suggesting context-specific barriers operating in the Zambian setting.

Knowledge of Postpartum Physical Activity

The finding that only 38.6% of participants demonstrated good knowledge aligns with previous studies from sub-Saharan Africa showing knowledge deficits regarding maternal health behaviours [21,22]. Our earlier research on pregnancy exercise in Zambia found similar knowledge levels (42.3% good knowledge) [13], suggesting continuity in knowledge gaps across the perinatal period. Specific knowledge deficits identified particularly regarding safe timing for resuming exercise after caesarean section, appropriate exercise intensity, and recognition of warning signs have direct implications for women's safety and confidence in exercising postpartum.

The strong association between educational level and knowledge (p<0.001) reflects broader patterns in health literacy across socioeconomic gradients. This finding emphasizes the need for health education approaches that are accessible to women with varying literacy levels, utilizing visual aids, demonstrations, and culturally appropriate communication strategies rather than relying solely on written materials.

Attitudes toward Postpartum Exercise

The mixed attitudes observed, particularly the cultural belief that women should rest rather than exercise postpartum (endorsed by 54.3%), reflects the intersection of traditional postpartum practices with modern health recommendations. In many African cultures, the postpartum period is traditionally a time for rest, family support, and focus on infant care [23,24]. While rest is indeed important for recovery, particularly in the immediate postpartum weeks, these cultural expectations may extend beyond the physiological recovery period and inadvertently discourage beneficial physical activity.

The concern about exercise affecting breastfeeding (expressed by 48.3% of participants) is noteworthy, as research consistently shows that moderate physical activity does not negatively impact lactation [25,26]. This misconception represents a clear target for educational interventions, requiring evidence-based counseling from healthcare providers to address maternal concerns while promoting safe exercise engagement.

Low Physical Activity Practice

The finding that only 24.3% of postpartum women engaged in regular physical activity is concerning from a public health perspective, given the documented benefits of postpartum exercise for physical recovery, mental health, and chronic disease prevention [2,3]. This rate is lower than reported in some African studies (Kenya: 32%, South Africa: 28%) [27,28] but consistent with findings from other resource-limited settings. The predominance of walking and household activities as primary forms of exercise reflects both cultural practices and limited access to structured exercise facilities or programs.

Knowledge-Practice Gap and Its Determinants

The substantial knowledge-practice gap observed where 58.6% of women with good knowledge were not exercising indicates that knowledge alone is insufficient to drive behavior change. This finding aligns with health behavior theories emphasizing that practice is influenced by multiple interconnecting factors beyond knowledge and attitudes [29]. The multivariable analysis identified several key determinants:

Mode of Delivery

Women who delivered via caesarean section were significantly less likely to exercise (AOR=2.34 for vaginal delivery). This is consistent with international literature showing delayed return to physical activity following caesarean birth due to pain, mobility restrictions, and prolonged recovery [10,30]. Our previous research documented gaps in physiotherapy management following caesarean section in Zambian hospitals [31], suggesting that women may not receive adequate guidance on safe, and progressive exercise resumption. This represents a critical area for intervention, particularly given that 45.5% of our sample had caesarean deliveries a rate aligned with increasing caesarean section trends in urban African settings [32].

Healthcare Provider Counselling

The finding that only 32.1% of women received exercise counseling, yet those who did were 3.21 times more likely to exercise, underscores a major gap in postnatal care quality. Postnatal care visits represent crucial touchpoints for health promotion, yet exercise counseling appears to be systematically neglected. This may reflect competing clinical priorities, time constraints, lack of provider training on postpartum exercise recommendations, or perception that exercise counseling is not a priority in resource-limited settings. Integrating structured exercise counseling into standard postnatal care protocols could significantly impact maternal health behaviors.

Educational Level and Socioeconomic Factors

The association between tertiary education and exercise practice (AOR=2.87) likely reflects multiple mechanisms including health literacy, access to information, economic resources enabling exercise (childcare, appropriate clothing, facility access), and differing cultural expectations by social class. Interventions must address these socioeconomic gradients through equitable access strategies.

Barriers to Postpartum Exercise

The barriers identified provide actionable insights for intervention design. Lack of time (68.3%) and fatigue (62.1%) are near-universal challenges for postpartum women globally [33,34], reflecting the demands of newborn care, sleep deprivation, and recovery. However, solutions may differ by context. In Zambian settings where extended family support is traditionally strong, interventions might leverage family engagement to facilitate childcare support during exercise time. Community-based exercise programs allowing mothers to bring infants, or brief home-based exercise routines requiring minimal time, may be more feasible than expecting facility attendance.

Cultural beliefs about postpartum rest (54.8%) require sensitive navigation. Rather than dismissing traditional practices, interventions should acknowledge the wisdom in protecting maternal recovery while providing evidence-based guidance on when and how to safely incorporate activity. Engaging traditional birth attendants, community health workers, and respected elders in health education may bridge this cultural gap more effectively than messages from external authorities alone.

The barrier of inadequate knowledge about safe exercises (42.9%), despite earlier findings on knowledge levels, suggests that even women classified as having "moderate" or "good" knowledge may lack specific practical guidance. This supports the need for not just information provision but practical demonstration, supervised initial sessions, and ongoing support.

Clinical and Public Health Implications

These findings have several important implications:

1. Integration into Postnatal Care: Postpartum exercise counseling should be standardized in postnatal care protocols, with healthcare providers receiving training on evidence-based recommendations, counseling techniques, and how to tailor advice based on mode of delivery and individual recovery.
2. Mode-of-Delivery-Specific Guidance: Given the significant impact of delivery mode, women who have caesarean sections require targeted attention with clear, progressive guidelines on exercise resumption, addressing pain management, and building confidence in safe movement.
3. Culturally Tailored Interventions: Programs must respect and work within cultural postpartum practices, finding synergies between traditional rest periods and gradual activity resumption, and addressing breastfeeding concerns with evidence-based information.
4. Community-Based Approaches: Given time and childcare barriers, community-based group exercise sessions, mother-baby exercise classes, or digital health interventions may be more accessible than facility-based programs.
5. Multi-Level Interventions: Addressing the knowledge-practice gap requires interventions at multiple levels-individual (knowledge, skills, self-efficacy), interpersonal (family support), healthcare system (provider training, counselling integration), and community (cultural norms, physical environment).

Study Limitations

Several limitations should be acknowledged. The cross-sectional design precludes causal inference; associations identified may reflect bi-directional relationships or unmeasured confounding. Self-reported physical activity may be subject to recall bias or social desirability bias, potentially overestimating actual practice levels. The study was conducted in urban Lusaka facilities, limiting generalizability to rural areas where access to healthcare, cultural practices, and physical activity opportunities may differ substantially. Consecutive sampling, while practical, may introduce selection bias if women who attend postnatal care differ systematically from those who do not. The study did not assess pregnancy physical activity levels, precluding examination of continuity from pregnancy to postpartum or postpartum-specific changes. Finally, the KAP survey approach, while informative, may not capture the full complexity of decision-making and social influences on postpartum exercise behaviours.

This study reveals low postpartum physical activity engagement among Zambian women despite moderate knowledge levels and generally positive attitudes, indicating a substantial knowledge-practice gap. Mode of delivery, particularly caesarean section, significantly reduces exercise likelihood, while healthcare provider counselling emerges as a powerful yet underutilized facilitator. Major barriers include time constraints, fatigue, and cultural beliefs about postpartum rest.

To address these findings, we recommend: (1) Integration of standardized postpartum exercise counselling into routine postnatal care with specific attention to women recovering from caesarean delivery; (2) Healthcare provider training on postpartum exercise recommendations and behaviour change counselling; (3) Development of culturally sensitive, practically feasible exercise interventions addressing identified barriers; (4) Community engagement strategies leveraging family support systems; and (5) Further research on implementation strategies to bridge the knowledge-practice gap in Zambian and similar LMIC contexts.

These findings provide essential baseline data for designing evidence-based interventions to promote postpartum physical activity as a key component of maternal health and wellbeing in Zambia.

The authors would like to thank all the postpartum women who participated in this study. We are grateful to the Lusaka District Health Management Team and the administrators and staff at the participating health facilities for their support. We thank the research assistants for their dedication to data collection and the expert panel who reviewed the study instruments.

Author Contributions

OLAB and LAN conceptualized and designed the study, developed data collection instruments, supervised data collection, conducted data analysis, drafted and revised the manuscript. MM contributed to study design, data interpretation, and manuscript revision. GM contributed to statistical analysis and manuscript revision. All authors read and approved the final manuscript.

Funding

This study was not in any way funded

Competing Interests

The authors declare that they have no competing interests.

Data Availability Statement

The datasets generated and analysed during the current study are available from the corresponding author on reasonable request.

Ethics Approval and Consent to Participate

This study was approved by the University of Zambia, School of Health Sciences Research Ethics Committee (Protocol Number: 2023270503,). All participants provided written informed consent prior to participation. The study was conducted in accordance with the Declaration of Helsinki.

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