Barriers, Not Benefits: Perceived Barriers as the Primary Predictor of Physical Activity Guideline Adherence among Pregnant Women in Three Chinese Provinces: A Cross-Sectional Study

Background Despite well-documented benefits of physical activity (PA) during pregnancy, global adherence to international guidelines remains low. While traditional health behavior theories emphasize perceived benefits and self-efficacy as primary motivators, emerging evidence suggests immediate, tangible barriers may exert stronger influence, particularly in resource-limited settings. However, few studies have examined these relationships in Chinese pregnant women, and multi-center studies verifying predictive mechanisms across diverse regional contexts are scarce. Objective This study aimed to (1) describe PA patterns and provincial variations among pregnant women in three Chinese provinces, and (2) identify independent predictors of meeting international PA recommendations. Methods A cross-sectional survey of 335 pregnant women across three provinces validated Chinese versions of the Pregnancy Physical Activity Questionnaire, Exercise Benefits/Barriers Scale, and Pregnancy Exercise Self-Efficacy Scale. PA adequacy was defined as meeting WHO guidelines (≥ 150 min moderate-intensity activity per week). Multivariate logistic regression adjusted for maternal age, gestational age, and education level. Results Provincial variations existed in sedentary time and light-to-moderate PA intensity (p < 0.05), but overall adequacy rates showed no significant inter-provincial difference (p > 0.05). Perceived barriers, benefits, and self-efficacy were homogeneous across provinces (all p > 0.05). Univariate analyses revealed all three factors as significant predictors: barriers (OR = 0.92, 95% CI 0.88–0.97, p < 0.001), benefits (OR = 1.03, 95% CI 1.01–1.05, p = 0.007), and self-efficacy (OR = 1.05, 95% CI 1.01–1.10, p = 0.024). However, multivariate analysis identified only perceived barriers as significant (adjusted OR = 0.93, 95% CI 0.88–0.98, p = 0.004), while benefits (p = 0.368) and self-efficacy (p = 0.137) were non-significant when barriers were accounted for. The model explained 12.9% of variance (Nagelkerke R²=0.129). Conclusions These findings challenge the “benefits-first” approach to prenatal health promotion. Perceived barriers demonstrate greater influence on PA behavior than Perceived benefits or self-efficacy, suggesting that removing practical barriers may be more effective than solely improving health literacy or self-confidence. Cross-provincial consistency supports generalizability across diverse Chinese contexts. The cross-sectional design limits causal inferences, and the model's modest explanatory power indicates the need to explore additional factors. Future longitudinal studies and randomized controlled trials should evaluate barrier-reduction strategies.