Promoting physical activity engagement in rural pregnant persons in the United States: a qualitative study

Rural-dwelling pregnant persons in the United States experience disproportionate morbidity and mortality relative to urban. While systems-level solutions are essential, behaviors like physical activity can improve outcomes during pregnancy and beyond. Despite recommendations, however, most pregnant individuals are insufficiently active. We aimed to understand factors affecting physical activity behavior during pregnancy among rural individuals and identify intervention recommendations. Between February 2022 and March 2023, we conducted semi-structured interviews, guided by health behavior theories, with 16 insufficiently active pregnant and early postpartum women living in the rural midwestern United States. Through inductive coding, we revealed data categories that aligned with the Capability, Opportunity, Motivation, and Behavior (COM-B) model. We subsequently adopted a deductive analytic approach, using the COM-B to aid in generating themes and intervention recommendations. We identified three themes that describe interconnected factors linked to physical activity motivation and behavior during pregnancy: (1) physical and psychological factors including pregnancy stage and symptoms; (2) opportunities in the physical environmental, including work and home; and (3) social support and gender norms and roles. Interventions to promote physical activity engagement in rural pregnant persons must accommodate stage of pregnancy, provide opportunities for social support, and align with local resources. • Findings drawn from qualitative interviews with rural pregnant and postpartum women. • Most rural pregnant individuals are insufficiently active despite its benefits. • Pregnancy stage, symptoms, and comorbidities influence physical activity engagement. • Pregnant individuals require resources like space and equipment to be active. • Interventions must be tailored for individual ability and community context.