**4. Discussion**

The aim of this study was to investigate relationships between PA and QoL in women in the second and third trimesters of pregnancy. The respondents' declarations from the PPAQ-PL and WHOQoL-Bref questionnaires were analyzed. Although studies have used these questionnaires in recent years [16,18], this is, to our knowledge, the first such study in Poland. Such research is also important because previous findings concerning PA in women in various stages of pregnancy have been ambiguous. Some authors have found increases in PA, for example, Huberty et al. [10] in the first and second trimesters, and Ko, Chen, Lin [38] from the second trimester, while others have documented a decline in overall PA [38] in the first trimester, Evenson and Wen [39] in the third trimester, and a decreasing percentage of physically active women in consecutive trimesters of pregnancy [2]. Borodulin et al. [8] argued that the overall physical activity level slightly decreased between 17–22 and 27–30 weeks of gestation, particularly in duration and volume of care, outdoor household, and recreational activity. Santos et al. [40] emphasized that a decline in PA from the first to the second trimester concerned total, light and moderate intensities, while Richardsen et al. [41], documented a decline in moderate and vigorous PA in the period between early pregnancy and mid-pregnancy.

Similar to findings published by Mourady et al. [16], our findings showed that the respondents in different trimesters of pregnancy did not differ in terms of *total PA*, and *total activity of light intensity and above*. However, they differed in the intensity of activities, especially in *energy expenditure* during *moderate activity* (in favor of those in the second trimester). The women in the third trimester of pregnancy reported significantly more energy expenditure on *sedentary activity* and *inactivity*, which is not an isolated phenomenon in the world [10]. According to Santos et al. [40], energy expenditure for particular types of PA (e.g., occupational activity, household activity, sports activity) changes significantly in individual trimesters of pregnancy. Pregnant women spent most of their weekly time on domestic, occupational and leisure time activities, except for sports activities. Similarly, the majority of the respondents' energy expenditure in the respondents surveyed in our study was spent on *household*/*caregiving activities*. This suggests that despite many campaigns to raise awareness of Polish women, such as: Pregnancy: Conscious Maternity, Find Out Whether You Are a Conscious Parent, or Different State, Different Treatment (Ci ˛aza- ˙ Swiadome Macierzy ´ ´ nstwo, Sprawd´z czy jeste´s swiadomym rodzicem, Odmienny stan, odmienne traktowanie), the role of the benefits of PA during ´ pregnancy remains underestimated. In the public's opinion, healthy nutrition is more often perceived as more important for the health of mothers and children than involvement in physical activity [42]. Therefore, the low levels of energy expenditure related to *sport*/*exercise activity* found in the present study in both groups of women surveyed seem unsurprising. Perhaps, as argued by Clarke and Gross [11] and Guelfi et al. [43], women perceive relaxation as a safer behavior, which is more beneficial for ensuring full-term pregnancy rather than regular exercise and maintaining an active lifestyle. The reasons also include misconceptions about physical exercise [44], the inconveniences of late pregnancy, fatigue, poor moods, or being absorbed in numerous occupational duties [45,46]. There are also other determinants that represent barriers to physical exercise. For example, low physical activity during pregnancy occurs more often in mature and married women, as well as those financially less well-off and the less educated [47]. It seems, however, that regardless of the adversities, the role of physicians is also critical as they have the greatest effect on the beliefs of pregnan<sup>t</sup> women, including their ideas on exercise during pregnancy [48]. Unfortunately, as Santos et al. [40] argued, medical staff often fail to recommend PA during pregnancy. Furthermore, according to Krans et al. [48], a low percentage of physicians help their patients to prepare physical exercise programs. Despite their knowledge, physicians do not always explain the need for physical exercise, both during pregnancy and in later decades of life [49]. They do not inform patients that it is necessary to consult both physicians and coaches before starting physical exercise in order to exclude medical contraindications and choose the right type of exercises and the load.

Knowledge about the quality of life plays a significant role both in diagnosis and patient care [50]. Despite being ambiguous, studies have widely documented the correlations between physical activity and quality of life. According to the literature review published by Poudevigne et al. [47], there is scientific evidence that inactivity during pregnancy is associated with poorer mood, whereas increasing participation in sports or physical activity from the period of pregnancy to that after birth leads to better overall well-being [51]. Mourady et al. [16] demonstrated that total and light intensity of PA are positively significantly correlated with the psychological domain of quality of life and social relationships; while sedentary PA is significantly correlated only with social relationships. Arizabaleta et al. [19] documented improvements in HRQoL in the physical component summary, physical function domain, the bodily pain domain and general health domain following a three-month program of aerobic exercise. However, there are also publications that showed no improvements in self-rated QoL caused by regular exercise such as water exercise [22].

Analysis of QoL of the women surveyed showed that there were no significant differences in self-rated domains of WHOOoL-Bref between pregnan<sup>t</sup> women in the second and third trimesters of pregnancy. Similarly, Mourady et al. [16], who analyzed all the trimesters, also found no differences except in the environmental domain. In this case, the quality of life was significantly higher in the women in the third trimester compared to those in the first trimester.

In our study, we found higher QoL scores in the *environment domain* in women in the second trimester who declared higher *sport*/*exercise activity.* It should also be noted that *sport*/*exercise activity* of the respondents studied was also positively correlated with the *physical domain* in women in the second trimester and with *overall quality of life* and *general health* in women in the third.

Our findings are consistent with those presented by Mourady et al. [16], who showed that sports/exercise was significantly correlated with the majority of quality of life domains such as general quality of life, physical and psychological health, social relationships and the environmental domain. This is unsurprising since apart from its well-documented health benefits, sport [5–7] offers joy, relaxation and enhances psychological well-being [52]. Obviously, there have also been studies in the literature that have failed to support such findings. For example, Gustafsson et al. [53] indicated that a 12-week exercise program including aerobic and strength training during pregnancy is unlikely to influence the psychological and self-perceived well-being of healthy pregnan<sup>t</sup> women. Kolu et al. [17] showed a decline in the overall HRQoL index during pregnancy, although they emphasized that this decrease was lower in women who were physically active during pregnancy. Nascimento et al. [23] argued that physical exercise does not significantly affect the perception of the quality of life of pregnan<sup>t</sup> women because, regardless of their participation in the exercise program, the quality of life of women (in the physical and social domains) during pregnancy fell significantly.

An interesting finding of our study is that pregnan<sup>t</sup> women who assessed QoL as higher in the field of *physical health* (both in the second and third trimester) were characterized by a higher energy expenditure during *occupational activity*. The explanation for this finding seems to be obvious; women with better self-rated physical well-being tend to work more. We are aware, however, that the explanation for this phenomenon may be more complex. The study published by Blum et al. [51] showed that women with older infants or no other children reported higher household/caregiving and lower occupation pre-pregnancy to postpartum activity. Physical activity in pregnancy may depend on the socio-economic status and support of a partner, friends or family [54,55]. These factors may, to a large extent, determine the quality of life [56]. Unfortunately, due to the lack of the above-mentioned information in our study, the impact of these factors was impossible to determine. Some limitations of this study should be mentioned and taken into consideration. First of all, a limited number of participants and the place where the women were selected (fitness clubs and antenatal classes) lead to a lack of representativeness of the total population with possible effects on the results. This in turn makes it impossible to draw general conclusions for the whole population of pregnan<sup>t</sup> women. Furthermore, the lack of detailed information on socio-economic and psychological factors and data about pathologies makes the interpretation of the results difficult.
