Objective: This study evaluated the effectiveness of a 10-week exercise intervention in reducing depression and fatigue in women with postpartum depression. Design: A one-group pretest/ posttest quasi-experiment was conducted. Setting: A postpartum ward in a medical center in Taipei city was used. Participants: Nineteen women at 7 - 12 weeks postpartum with an Edinburgh Postnatal Depression Scale score ≥ 9 were recruited. Methods: The women participated in a postpartum exercise support program 1 hour per week for 10 weeks. The program was led by a professional coach; it integrated yoga, Pilates, elastic band exercise, low-intensity aerobics, and motherhood role experience sharing. Results: After the postpartum exercise support program intervention, depression scores decreased from 10.4 ± 3.29 to 7.80 ± 2.73 ( t = 3.632, P = 0.003); fatigue scores decreased from 8.73 ± 5.02 to 5.40 ± 3.89 ( t = 2.988, P = 0.010). Conclusion: PESP administered to women with postpartum depression appeared to benefit their psychological wellbeing.
Postpartum depression (PPD) is a prominent health issue. Few multidisciplinary studies, combining physical- exercise and nursing, have been conducted. The prevalence of PPD reports 10% - 15% in Western country [
In Taiwan, if postpartum women exhibit depressive symptoms, physicians often consult psychiatrists to prescribe antidepressants; however, mothers are typically worried about exposing infants to the adverse side effects of drugs through breastfeeding; they are generally afraid to take medicine. Epidemiological research has suggested that physical activity may be associated with reduced symptoms of depression. Few studies have investigated the effect of exercise programs on women’s psychological health during the postpartum period. However, concerns have been expressed regarding the methodological quality of these studies [
Chinese culture considers “postpartum preservation” as critical to the overall wellness of a woman who has given birth. In Chinese culture, postpartum women should eat high-calorie and high-protein food, rest, and avoid the outdoor environment in addition to caring for their infants. In this period, mothers may reduce or stop exercising, which can affect subsequent exercise habits [
Despite limited evidence regarding women with PPD, the National Institute for Health and Clinical Excellence in the United Kingdom recommended in their postnatal mental-health guidelines that health professionals should consider exercise as a management strategy for women experiencing mild-to-moderate PPD.
The purpose of this study was to evaluate the effectiveness of a postpartum exercise support program (PESP) in reducing fatigue and depression in women with PPD.
This study adopted a quasi-experimental one-group pretest/posttest design and a convenience sampling method. Study participants, who were at 7 - 12 weeks postpartum, participated in a 10-week exercise program developed in this study, one session perweek.
Participants were recruited between May and July 2013 at a medical center in Taipei. The inclusion criteria were as follows: being postpartum, aged between 20 and 40 years, exhibiting no maternal or neonatal complications, having an EPDS score ≥ 9, and willing to participate in the study.
Research assistants (RAs) used the EPDS to assess women at 1 - 3 days after giving birth in the postpartum ward. When women exhibited an EPDS score ≥ 9, Ras obtained written consent after explaining research the purpose and process, and left a contact telephone number. Researchers arranged women to participate in a PESP until 7 - 12 weeks postpartum.
After the initial recruited, 50 women with an EPDS score ≥ 9 accepted the invitation; however, after 1 - 2 months, having completed 1 month, several women left the program, causing a small sample size in this study. The reasons of withdrawal from the study included the following: women were living in Southern Taiwan (their parents’ home, which was far from the study site); women had to work on the day of class; women felt tired, had no motivation, and did not feel comfortable letting others take care of their baby.
Overall, 19 women were enrolled, 15 of whom completed the entire program and answered the questionnaires (a 79% valid response rate). Four women did not complete the 10-week exercise program for work or childcare reasons.
The PESP was designed for women who were considered to have mild PPD. The exercise support program consisted of the following: 1) 10-minute warm-up and 10-minute cool-down; 2) a 40-minute whole body stretching exercise, integrated Pilates, yoga, and elastic band exercise, which achieved a target heart rate (HR) of 60% - 75% of maximal HR; 3) after-exercise program with a 30-minute experience-sharing session, including breastfeeding and talking about adapting to the new role as a mother; 4) RAs created an exercise program video and upload edit to Facebook; the participants were encouraged to practice the exercises based on the video at home at least twice perweek. In addition, the RAs reminded the participants to attend the exercise class every week using Line (a mobile device application).
The postpartum exercise program was led by a professional coach who was one of researchers. The coach has a doctor of philosophy degree and is licensed to teach postpartum yoga and Pilates. The postpartum exercise program was conducted in a group once per week; it lasted from 10:30 to 11:30 a.m. every Saturday for a 3-month period (total 10 sessions) in a gym at a university.
Ras used Line to maintain weekly contact with the postpartum women to monitor home exercise, provide remote care, and remind the women to continue with the program. To encourage participation: a gift was presented after each week (e.g. a pedometeror gift certificate).
The stadium is a professional venue with wooden floor classrooms and spacious, comfortable areas; there is a beautiful surrounding landscape with numerous trees and large areas of grassland that provide bright and sunny spaces. The researcher and Ras joined the weekly program, to help with taking care of the babies when necessary; in addition, female family members of the participants were allowed to attend classes.
The study tools comprised a structured questionnaire designed in this study, including basic information, postpartum exercise status, the Fatigue Symptoms Checklist (FSC), and the EPDS.
Basic Information: The basic information obtained was age, height, prepregnancy weight, weight gain during pregnancy, current weight, education level, occupation, family type, annual household income, pregnancy history, childbirth history, and the current infant feeding method.
Postpartum Exercise Status: The data obtained were used to evaluate whether participants were engaging in regular exercise, their exercise intensity, exercise conditions, and barriers to exercise after giving birth.
FSC: The FSC, developed by Yoshitake, [
The FSC is a multidimensional scale that exhibits strong reliability and validity and is not excessively taxing to complete. Milligan et al. [
EPDS: The EPDS has been determined to exhibit higher validity than the BDI regarding sensitivity and specificity [
Study Tools and Tests of Reliability and Validity: The scales adopted in this study were widely used domestic and international scales, all of which exhibit good reliability. In this study, the Cronbach α obtained for both the FSC and the EPDS was 0.86.
This study was approved by the institutional review board of the hospital where the study was conducted (IRB No. 12MMHIS161). The purpose and process were explained to the participants, and after signing an informed consent form, they were enrolled in the study. In addition, participants were informed that they could withdraw from the study at any time without a loss of benefits. The women were assured that involvement in the study would not affect their medical care and that all information obtained from the questionnaire would be treated confidentially and used only for research purposes.
Our RA recruited eligible women with PPD in the postpartum ward in a medical center in Taipei by describing the purpose of the study. Because Taiwanese have a “doing-the-month” culture whereby, after delivery, postpartum women are discharged from the hospital and expected to stay at home for an entire month; therefore, our RA called the women regarding follow-up care during this month.
A pretest was conducted before the first session of the exercise program. The pretest was used to collect basic participant information, postpartum exercise habits, postpartum fatigue, and body composition. After the participants had attended 10 sessions of the program, a posttest was conducted to obtain measurements regarding postpartum fatigue and depression.
SPSS version 19.0 was used to analyze data and significant level was set as 0.05 (SPSS, Chicago, IL, USA). Participants’ basic information was exhibited according to frequency, percentage, mean, and standard deviation (SD). A paired t test was employed to identify differences in fatigue and depression before and after the exercise program.
The average age of the 15 postpartum women was 34.3 ± 3.8 years. The average number of pregnancies among the participants was 1.27 ± 0.46; 12 participants (80%) were primiparas. All participants had a college degree or above (100%). In addition, most participants had a full-time job (60%). Twelve (80%) participants had NSDs, whereas 20% had CS. Six (40%) participants breastfed exclusively, and the others adopted mixed feeding methods. Only four (26.7%) of the participants exercised after childbirth. Six of the participants (40%) lived in a nuclear family (
The mean score of depression in the pretest was 10.40 ± 3.29 points; the scores ranged between 0 and 30. Three women (20%) scored ≥12 points on the EPDS. The mean depression score was 7.80 ± 2.73 points in the posttest. The decrease of 2.60 points was significant (t = 3.632, P = 0.003).
The mean score of fatigue in the pretest was 8.73 ± 5.02 points, and 5.40 ± 3.89 points in the posttest. A paired t test was used to compare feelings of fatigue before and after the exercise intervention; the decrease of 3.33 points was significant (t = 2.988, P = 0.010). Comparing the scores of fatigue subscales revealed significant differences in physical and psychological scores before and after the intervention (t = 2.525, P = 0.024; t = 2.824, P = 0.014). No significant difference was observed in the symptom score before and after the test (t = 1.234, P = 0.238;
Characteristic | n (%) | M ± SD |
---|---|---|
Age (year) | 34.33 ± 3.84 | |
Gravida | 1.27 ± 0.46 | |
Primipara | 12 (80%) | |
Education level | ||
≥University | 13 (86.7%) | |
≤College | 2 (13.3%) | |
Work status | ||
―Full-time job | 9 (60%) | |
―Housewife | 6 (40%) | |
Method of delivery | ||
―NSD | 12 (80%) | |
―Cesarean section | 3 (20%) | |
Breastfeeding | ||
―Exclusive | 6 (40%) | |
―Formula | 1 (6.7%) | |
―Mixed feeding | 8 (53.3%) | |
Exercise habits (pretest) | ||
―Yes | 4 (26.7%) | |
―No | 11 (73.3%) | |
Family structure | ||
―Nuclear family | 6 (40%) | |
―Other | 9 (60%) |
Note. NSD: normal spontaneous delivery; C: section, cesarean section.
Dimensions and subscales | Pretest M ± SD | Post-test M ± SD | t | P |
---|---|---|---|---|
Fatigue | ||||
―Physical (items 1 - 10) | 4.13 ± 2.13 | 2.40 ± 1.77 | 2.525 | 0.024* |
―Psychological (items 11 - 20) | 2.40 ± 2.20 | 1.47 ± 1.77 | 2.824 | 0.014* |
―Symptoms (items 21 - 30) | 2.20 ± 2.15 | 1.53 ± 1.51 | 1.234 | 0.238 |
―Total score | 8.73 ± 5.02 | 5.40 ± 3.89 | 2.988 | 0.010* |
Depression scores (n = 15) | 10.40 ± 3.29 | 7.80 ± 2.73 | 3.632 | 0.003* |
*P < 0.05; **P < 0.001.
In this study, 20% of participants who were 7 - 12 weeks postpartum exhibited a depression score of ≥12 points in the pretest, which is the cutoff point indicating depression in Taiwan; this suggests that these women were prone to depression. However, the depression scores obtained in this study were lower than those obtained by Chen’s et al. study, [
The results of this study demonstrated that our PESP reduced physical and psychological fatigue and depression. This finding is consistent with those reported by previous studies, they suggested that exercise reduces depression severity [
Dritsa, et al. indicated that exercise reduced tension and raised exercise-related energy consumption, thereby relieving postpartum fatigue [
In addition, in the after-program experience-sharing sessions, postpartum women stated that participating in the exercise program had the following advantages: the location was near an Mass Rapid Transit (MRT) station; the teacher and venue were professional; the program content was interesting; the surroundings were beautiful and helped participants to relax; the elastic band could be taken home and used to exercise there; there was a full-time assistant to help take care of babies during exercises; and after they completed the PESP program, the women received a gift voucher. The intimate design of this program can be adapted for future interventions to enhance the recruitment rate.
The results of this study indicate that among women who are 7 - 12 weeks postpartum, the 10-week exercise intervention significantly reduces the fatigue and depression levels in those who are prone to depression.
This is the first trial study of women with PPD at 7 - 12 weeks postpartum who participate in a PESP in a gym. The results of this study are limited by the single-group pretest/posttest design, a study length of only 10 weeks, and a small sample size; therefore, the results should be generalized with caution. Encouraging women with PPD to leave their homes to engage in exercise is difficult. Therefore, recruiting numerous women with PPD who are willing to attend an exercise program is difficult. Further research that adopts a quasi-experimental design and involves a control group to enable comparing the effectiveness is necessary. In addition, the sample size and amount of exercise can be increased to improve the generalizability of the results. Regarding the high loss of participants in this study, future studies should consider how to encourage women with depressive tendencies to leave their homes to participate in an exercise program.
I hereby, thank all the pregnant women who participate in this research for their cooperation. The financial support from the National Science Council (NSC 101-2410-H-030-085) is greatly appreciated.
Yi-LiKo,Pi-ChuLin,Chi-LiYang,Chie-PeinChen,Huai-JungShih, (2015) Pilot Study on an Integrated Pilates and Yoga Program for Decreasing Postpartum Depression in Women. Open Journal of Nursing,05,885-892. doi: 10.4236/ojn.2015.510093