The Need for Understanding Beliefs and Barriers Around Physical Activity Postpartum Among South Asian Immigrant Women to Improve Health Equity: A Commentary

Abstract

South Asian people (inclusive of Afghanistan, Bangladesh, Bhutan, India, Iran, Maldives, Nepal, Pakistan and Sri Lanka) represent one quarter of the global population and are an important and growing global demographic [1]. Among the South Asian population, a large majority of people live outside of their birth country [2] with women often being of reproductive age at the time of migration [3]. With increasing numbers of South Asian immigrant mothers to North America, it is necessary to align postpartum programming within the context of cultural beliefs to reduce the inequities in maternal health care experiences and outcomes seen in immigrant women [4].

Within this commentary, we focus on the importance of postpartum physical activity (as supported by recommendations from WHO) [5] and how to best align programming for South Asian immigrant women. Physical activity has numerous positive mental and physical health benefits for postpartum women [6] yet barriers to engagement are high among the broader Western population [7]. South Asian immigrant women engage in lower levels of physical activity compared to European women [8] and this physical activity gap is exacerbated through the perinatal and postpartum phase [9]. Lower physical activity may be due to the noted barriers of South Asian women perinatally, including negative views around exercise [10]. However, there is a paucity of research surrounding physical activity beliefs and practices after the birth of a child among South Asian women.

To date, postpartum women (largely European descent) have identified a lack of healthcare guidance and low confidence in physical activity engagement after the birth of a child to be predominant barriers [11]. It is not well understood whether the desire to engage in physical activity can outweigh the barriers faced by immigrant South Asian mothers, given the greater focus on familial demands and household expectations [12].

In our recent work, we found that household dynamics influence whether postpartum women feel that they can take time for themselves to engage in physical activity [13, 14]. In a predominately European sample, rethinking postpartum physical activity in this population (such as movement with one's infant and household duties) allowed postpartum women to engage in movement with greater self-compassion. Given the view that physical activity is seen as a self-serving behaviour [15] and the associated mom guilt (i.e., guilt mothers commonly experience with taking care of their own needs in the context of mothering) seen in Western populations [13], promoting physical activity that increases self-compassion is essential in supporting physical activity behaviour yet may be daunting within certain cultural contexts. Additionally, a lack of confidence in physical activity engagement has also been noted among immigrant South Asian women [16] and would likely be a barrier in physical activity postpartum, as noted in Western populations [17].

Physical activity reduces insulin resistance and promotes glucose regulation, while physical inactivity increases insulin resistance and elevates the risk of type 2 diabetes [18]. Among South Asian women, there is a 5.3 times higher incidence of type 2 diabetes when compared to white European women [19]. In addition, South Asian women are two times more likely to experience gestational diabetes during pregnancy than white European women [20]. Gestational diabetes carries a 10-fold risk of progression to type 2 diabetes [21] making this a concerning health inequity for South Asian women. There is an urgent need to intervene with effective measures to prevent this health disparity in South Asian women, with the postpartum period a beneficial time to establish positive health behaviours that may benefit physical and mental recovery [22, 23]. Specific to South Asians, a pooled meta-analysis indicated a 35% relative reduction in diabetes incidence when engaging in diet and physical activity interventions [24]. In addition to the concerning levels of gestational and type 2 diabetes among South Asian women, there is the elevated incidence of postpartum depression in this population, with a two-fold increase over European white women [25]. High rates of postpartum depression in this population have been associated with mental health stigma due to family dynamics with in-laws and gendered norms [26].

Despite the benefits of physical activity, South Asian immigrants, and particularly South Asian immigrant women, are largely physically inactive due to several factors, including work, culture, cost, time, family, health status and environmental factors [16]. Specifically, South Asian immigrant women engage in lower levels of physical activity, with only 17% meeting the current physical activity guidelines of 150 min of moderate-to-vigorous physical activity per week compared to 36% of European women [8]. While there is a paucity of data surrounding postpartum physical activity behaviours and beliefs among South Asian women, postpartum physical activity levels have been shown to remain low among largely Western European postpartum women (due to numerous barriers such as a lack of time and knowledge) given the multiple competing demands (household and childcare responsibilities) during this phase of life [13]. For example, South Asian women cite fear that exercise may worsen pregnancy symptoms as a barrier to engagement [20] yet it is unknown if this barrier may be present in the postpartum phase. In addition, South Asian immigrant women often engage in the traditional practice of rest and recovery for the first 40 days postpartum. While there are perceived benefits of this 40-day rest period [27], this period may enhance fear of movement throughout the postpartum period, when it is considered generally safe and beneficial for women to engage in moderate physical activity.

The postpartum transition is a time of change and challenge for many women as they navigate sleep deprivation, healing and changing bodies, and infant care. This experience may be more isolating among immigrant and minority women in North America due to language and cultural differences, negatively impacting mental well-being [25]. The importance of providing a positive postnatal experience has been highlighted as a primary recommendation from the World Health Organization to enhance the short- and long-term well-being of women [5]. This can be achieved by the recognition of postnatal challenges and providing support within one's cultural context. For instance, immigrant mothers often face incongruence between traditional cultural expectations postpartum and those that are embedded in their host country [28] due to ethnocultural and religious disparities, which may lead to barriers in postnatal care for the mother [29]. Incongruence between traditional cultural practices and host country postpartum practices has further led immigrant South Asian mothers to negate traditional practices due to a lack of cultural understanding by their host country and healthcare providers [30]. Failure to apply empathic, culturally inclusive and cohesive healthcare can exacerbate postpartum mental health challenges [30]. To increase uptake of physical activity after the birth of a child among South Asian immigrant women, there needs to be alignment with traditional practices.

Among the South Asian community, healthcare providers (e.g., physicians) are a respected profession and represent an important link in establishing physical activity beliefs and promoting uptake [12, 31]. Ensuring that healthcare providers are equipped with the knowledge and cultural competence to encourage physical activity postpartum would be a valuable consideration. Given the lack of an equivalent term for ‘physical activity’ in South Asian languages and culture, this is frequently replaced with the term ‘exercise’ which is associated with more vigorous forms of movement. Broadening the understanding of forms of movement that provide health benefits may be an important piece of the cultural context of physical activity postpartum in South Asian women just as we found Western mothers found the need to ‘rethink’ physical activity postpartum [11].

Health promotion interventions which are culturally inclusive have been shown to have greater uptake and adherence among culturally diverse populations [32]. In the case of physical activity promotion, cultural adaptation should align with the values and beliefs of South Asian women [33]. Strategies for culturally inclusive health messaging to South Asian postpartum women may diverge from physical activity promotion in the general population. Culturally inclusive messaging and targeted communication to both mothers and supporting family members may allow postpartum women to feel facilitated to engage in physical activity postpartum. Culturally inclusive physical activity resources for South Asian postpartum women should reflect the overall benefits of movement and how small bouts of movement and household activities are beneficial for health [34].

We have found culturally inclusive physical activity programming, Bhangra dance, to be effective at increasing physical activity uptake in the broader population of South Asian women [35]. Bhangra dance is a form of folk dance that originates from the Punjab area of India and consists of high-intensity jumps, kicks and upper body movement to Bhangra music. This represents one form of culturally inclusive physical activity programming that could be considered for new mothers (after a period of postpartum rehabilitation) as it was shown to have high adherence and motivation in South Asian women [34].

Further, group-based postpartum exercise has been shown to be beneficial in improving mental well-being and self-efficacy for exercise [36]; yet these programs typically reflect a westernised approach to physical activity engagement. South Asian women report social influences to be prominent in their likelihood of physical activity engagement perinatally [10] and therefore family member support may be integral to engagement postpartum, and South Asian mom and baby physical activity programming could be considered. Culturally inclusive strategies including women's only exercise interventions, childcare support for children and bilingual support should be included and considered in postpartum physical activity interventions [37]. For instance, we suggest family engaging exercise and programming that is of interest and enjoyable to South Asian women based on a thematic analysis of Canadian immigrant women with children under the age of five [38].

Broadly, physical activity promotion directed to South Asian women is lacking. Moreover, there is a gap in knowledge surrounding the benefits of physical activity for health and well-being [39]. There also continues to be a paucity of knowledge surrounding physical activity beliefs and barriers to engagement among South Asian women after the birth of a child. Future research is needed to better understand the cultural beliefs and barriers to physical activity postpartum among South Asian women in addition to preferences for engagement.

All authors contributed to the writing of this commentary.

The authors declare no conflicts of interest.