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International Journal of Nursing Practice 2014; ••: ••–••
RESEARCH PAPER
The effect of a home-based exercise intervention on postnatal depression and fatigue: A randomized controlled trial Fatemeh Mohammadi MSc Students’ Research Committee, Midwifery Department, Faculty of Nursing & Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
Jamileh Malakooti MSc Lecturer, Midwifery Department, Faculty of Nursing & Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
Jalil Babapoor heiroddin PhD Professor, Psychology Department, Faculty of Education & Psychology, University of Tabriz, Tabriz, Iran
Sakineh Mohammad-Alizadeh-Charandabi PhD Associate Professor, Midwifery Department, Faculty of Nursing & Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
Accepted for publication August 2013 Mohammadi F, Malakooti J, Babapoor J, Mohammad-Alizadeh-Charandabi S. International Journal of Nursing Practice 2014; ••: ••–•• The effect of a home-based exercise intervention on postnatal depression and fatigue: A randomized controlled trial This study aims to determine the effectiveness of home-based low-intensity stretching and breathing exercises on the reduction of 1 and 2 month post-partum depression (primary outcome) and fatigue (secondary outcome) scores. In this randomized controlled trial, 127 women at 26–32 weeks’ gestation with Edinburgh score less than 15, who attended 14 selected health centres in Tabriz, Iran, were randomly allocated into one of the following three groups: no intervention group, group receiving training for exercise during pregnancy, and group receiving training for exercise during pregnancy and post-partum period until 2 months after delivery. Depression and fatigue scores were measured using the Edinburgh Postnatal Depression Scale and Fatigue Identification Form, respectively, at baseline, 1 month and 2 months after delivery. The data were analysed with SPSS-ver. 13.0 (SPSS Inc, Chicago, IL, USA) using chi-square, Fisher’s exact and Kruskal– Wallis tests. Mean rank of the difference scores of depression and fatigue were not significantly different among the groups, both at 1 and 2 months post-partum (P > 0.05). Therefore, this study did not provide evidence to show that training women to do the home-based exercises during pregnancy or during pregnancy and post-partum period have a preventive effect on post-partum depression and fatigue. However, more studies are needed for making precise judgment. Key words: exercise, postnatal depression, postnatal fatigue.
Correspondence: Sakineh Mohammad-Alizadeh-Charandabi, Midwifery Department, Faculty of Nursing & Midwifery, Tabriz University of Medical Sciences, Shariati Street, Tabriz 5157984319, Iran. Email: [email protected] doi:10.1111/ijn.12259
© 2014 Wiley Publishing Asia Pty Ltd
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INTRODUCTION
METHODS
In becoming a mother, a woman often has to relinquish her autonomy, personal liberty, occupational identity, capacity to generate an income, and social and leisure activities in favour of caring for the infant. The adaptation to the new required roles, major responsibilities, moving from being in the childless generation to the parent generation, increased unpaid workload and, for some, harm to bodily integrity through unexpected adverse reproductive events place great demands both on individual psychological resources and on existing relationships.1 Postnatal fatigue and depression are the two major common problems occurring during the postnatal period reported and emphasized in the literature.2–5 In a meta-analysis of 59 studies from various countries, the estimated average prevalence of postpartum depression was 13%.6 The rate of suffering from post-partum depression is high in Asian women.7 Women from western industrialized nation have also ranked fatigue among their top five concerns after birth.5 Postnatal psychological problems can interfere with a new mother’s ability to care for her infant and might adversely affect her quality of life.8–12 The promotion of postnatal health has been emphasized by many health-care providers.13 To promote postnatal care, both the Society of Obstetricians and Gynecologists of Canada, Clinical Practice Obstetrics Committee/ Canadian Society for Exercise Physiology14 and the American College of Obstetricians and Gynecologists 15 have published guidelines for exercise during pregnancy and the postnatal period. The effect of exercise on postnatal depression and fatigue has been the subject of a few research studies. The results of some studies have shown the positive effect of exercise on reduction of depressive symptoms and/or fatigue,16–18 whereas some showed no significant effect.19 All of these studies examined the effect of postnatal exercise programme on treatment of postnatal depression and fatigue. To our knowledge, there is no research published about the effect of antenatal and postnatal exercise programme on postnatal depression and fatigue. Therefore, this study was designed to investigate the effect of a home-based antenatal and also antenatal plus postnatal exercise programme on depression (primary outcome) and fatigue (secondary outcome) score 1 and 2 months post-partum.
This study was a randomized trial with three parallel arms. Pregnant women at 26–32 weeks pregnancy were recruited for the study. Eligible women were not currently suffering from depression (Edinburgh score less than 1520) or other known psychiatric disorders, obstetrical complications and diseases that would limit exercise; did not have history of threatened abortion, placenta previa, the signs of preterm labour or pre-rupture of amniotic membrane in present pregnancy; were not currently participating in regular exercise programmes, and had access to landline at home or personal cell phone. The subjects were recruited from 14 public health centres in Tabriz, Iran, which had higher coverage of pregnant women care. The first author, responsible for data collection and interventions, recognized potential subjects from their medical records, called the women and after explaining the aim of study, invited them to attend the centres to complete the baseline questionnaire. Eligibility criteria were checked during the assessment of the medical reports, phone contacts and the attendance session. In the control group, women got antenatal and postnatal ordinary educations in a 40 min session. The women in the intervention1 group attended a theoretical and a practical educational session which lasted about 40 min. These sessions were mainly about the importance of exercise during pregnancy and how it should be performed. These women were recommended to do the exercise three times a week (for 20–30 min each), until delivery, according to the educational antenatal CD at their home. The exercises were low-intensity stretching and breathing practices. In the second intervention group, women were recommended to do a 2 month postnatal exercises in addition to getting the instructions given to the intervention 1 group. They were instructed to adjust the frequency and the duration of the exercises based on their own ability in the first month after delivery, but they were required to do the exercises regularly three times a week in the second month according to the educational postnatal CD. Due to similarity of postnatal exercises to antenatal one, they were not educated practically in this area. The content of the antenatal and postnatal CDs were approved by Ministry of Health and Medical Education of Iran. The Edinburgh Postnatal Depression Scale (EPDS) and Fatigue Identification Form (FIF) were used to evaluate
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Exercise for postnatal depression and fatigue
depression and fatigue score, respectively, in three time points: baseline (26–32 weeks of gestation), 1 month and 2 months post-partum. EPDS is a self-administered, widely used, valid and reliable 10-item measurement of perinatal mood. The items inquire about maternal mood in the past 7 days and are rated on a four-point scale (not at all/hardly ever/sometimes/very often).21 FIF, which is a dichotomous (yes/no) 30-item scale, can be used clinically to assess fatigue during pregnancy and postpartum.22 Total scores of EPDS and FIF ranged from 0 to 30. The higher the scores are, the worse the condition of the patient is. For evaluation of the study adherence, the first author called the participants in intervention 1 and intervention 2 groups at the end of the study and gathered information on the approximate number of exercise sessions each group performed. To determine the appropriate sample size, comparison of means formula was used. Mean scores and standard deviation (SD) of the EPDS in group with no intervention were taken from study of Abry Aghdam (m1 = 11, SD1 = 4.1).23 It was assumed that with the interventions, the SD would not change and mean scores will be reduced to at least 25% (m2 = 8.25). Considering 5% level of significance, 80% power and 10% loss to follow-up, the sample size was calculated as 42 persons for each group. Block randomization with block sizes of 6 and 9 in each participating centre was used to determine the allocation sequence. We used such randomization to achieve approximate balance of important characteristics among the treatment groups. A person not involved in enrolling participants generated the sequence using a computerized random number generator and put them in sequentially numbered opaque sealed envelopes to conceal the allocation sequence. The envelopes were opened after getting informed consent and collecting baseline data. Statistical analyses were performed using SPSS-ver. 13.0 (SPSS Inc., Chicago, IL, USA). Data were analysed on the basis of intention to treat. As the score of EPDS and FIF was not normally distributed, Kruskal–Wallis was used to test the effect of the interventions. Homogeneity of baseline characteristics among the groups was tested by chi-square and Fisher’s exact tests. P < 0.05 was considered significant. Ethical approval was obtained from Tabriz University of Medical Sciences. All participants signed the consent form after getting informed regarding the procedure of
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the study and safety of the exercises. This clinical trial was registered in Iranian Registry of Clinical Trials (http:// www.irct.ir/searchresult.php?id=3706&number=5) with IRCT201008193706N5 code before recruitment of the subjects.
RESULTS Figure 1 presents the flow of participants throughout the study. A total of 441 women were assessed for eligibility. Three hundred four were not eligible and 10 refused to participate in the study. One hundred twenty-seven women were randomized into three groups, 42 were allocated to the control, 43 to intervention 1 group and 42 to intervention 2 group.
Participant baseline characteristics The three groups were similar in terms of demographic and clinical characteristics, such as age, education, job situation, history of psychiatric disorders in women and their families, relationship between women and their husbands, occurrence of bad event in the past months, unwanted pregnancy and complicated pregnancy. Mean age was 25 years for all groups. The majority of participants were housewives. More than half were nullipar, had high school or higher (≥ 9 years) education, and reported a sufficient monthly income. Only one mother in the control group reported a history of psychiatric disorders. In each group, one to three participants reported a history of psychiatric disorders in their families, seven to eight reported experiencing a bad event in the recent months, and zero to two reported not having a good relationship with their husbands (Table 1).
EPDS scores As illustrated in Table 2, at the baseline assessment, 17% of control group, 14% of intervention 1 group and 26% of intervention 2 group had EPDS scores of ≥ 13. One month post-partum, these rates were 12%, 21% and 14%; and at 2 months post-partum were 14%, 8% and 8%, respectively. No significant differences were identified in mean rank of EPDS scores among the three groups at the baseline (P = 0.24), 1 month post-partum (P = 0.82) and 2 months post-partum (P = 0.70). There was 5 or over reduction in EPDS score (compared with the baseline) found in 14.5% of control group, 16% of intervention 1 group, 33.5% of intervention 2 group, 1 month post-partum; and 30%, 34% and 42% at © 2014 Wiley Publishing Asia Pty Ltd
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Assessed for eligibility n = 441 304 were not eligible 10 refused to participate
Randomly assigned n = 127
Control group n = 42
Intervention 1 n = 43
Intervention 2 n = 42
1 month post-partum completed questionnaire n = 35
1 month post-partum completed questionnaire n = 38
1 month post-partum completed questionnaire n = 35
2 months post-partum completed questionnaire n = 36
2 months post-partum completed questionnaire n = 38
2 months post-partum completed questionnaire n = 36
Analysed 1 month post-partum = 35 2 months post-partum = 36
Analysed 1 month post-partum = 38 2 months post-partum = 38
Analysed 1 month post-partum = 35 2 months post-partum = 36
Figure 1. Flow diagram of trial.
Table 1 Characteristics of participants in the study groups Characteristics
Age (years) 15–29 ≥ 30 Mean ± SD Education (years) 6–8 ≥9 Employed Sufficient family income Spouse education Elementary and intermediate High school and higher Live with her family or spouse Family History of psychiatric disorder History of psychiatric disorder In family Lack of good relation with her husband Occurrence of bad events in the recent months Unwanted pregnancy Complicated pregnancy Nulliparity History of abortion The data are given as n (%) unless otherwise specified.
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Control n = 42
Intervention 1 n = 43
Intervention 2 n = 42
34 (81) 8 (19) 25.3 ± 5.2
36 (84) 7 (16) 25.2 ± 4.7
33 (79) 9 (21) 25.5 ± 4.6
19 (45) 23 (55) 2 (5) 23 (55)
18 (42) 25 (58) 0 (0) 23 (53.5)
17 (40.5) 25 (59.5) 3 (7) 25 (59.5)
19 (45) 23 (55) 13 (31)
26 (60.5) 17 (39.5) 13 (30)
26 (62) 16 (38) 15 (36)
1 (2) 3 (7)
0 (0) 1 (2)
0 (0) 7 (17) 6 (14) 3 (7) 29 (69) 6 (14)
1 (2) 7 (16) 7 (16) 1 (2) 22 (51) 9 (21)
0 (0) 3 (7) 2 (5) 8 (19) 8 (19) 5 (12) 25 (59.5) 6 (14)
Exercise for postnatal depression and fatigue
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Table 2 Edinburgh Postnatal Depression Scale (EPDS) scores of the groups in the three time-points during study EPDS score
0–10 11–12 ≥ 13 Attrition Mean SD Median Percentile 25 Percentile 75 P†
Baseline
One month post-partum
Two months post-partum
C. n = 42
I.1 n = 43
I.2 n = 42
C. n = 35
I.1 n = 38
I.2 n = 35
C. n = 36
I.1 n = 38
I.2 n = 36
29 (69) 6 (14) 7 (17) — 8.14 3.94 8.5 5 11 0.24
30 (70) 7 (16) 6 (14) — 7.77 3.86 7 4 11
26 (62) 5 (12) 11 (26) — 9.07 3.91 9 7 13
26 (74) 5 (14) 4 (12) 7 (17) 7.46 4.50 6 5 11 0.82
24 (63) 6 (16) 8 (21) 5 (12) 7.66 5.46 7 3 12
27 (77) 3 (9) 5 (14) 7 (17) 8.03 4.95 7 5 10
28 (78) 3 (8) 5 (14) 6 (14) 6.50 5.12 5.5 2.25 9.75 0.70
30 (79) 5 (13) 3 (8) 6 (14) 6.58 4.63 6 3 9
31 (86) 2 (6) 3 (8) 6 (14) 6.58 4.63 6 3 9
†
Using Kruskal–Wallis test. The data are given as n (%) unless otherwise specified. C., no intervention; I.1, antenatal exercise; I.2, antenatal and postnatal exercise.
2 months postpartum, respectively. Mean rank of the difference scores was not significantly different among the groups, both 1 (P = 0.36) and 2 months post-partum (P = 0.75) (Fig. 2).
On the baseline assessment, 19% of control, 28% of intervention 1 and 16% of intervention 2 had FIF scores of ≥ 13. In 1 month post-partum, these rates were 17.5%, 29% and 20%; and in 2 months post-partum, they were 22%, 18% and 22%, respectively. No significant differences were identified in mean rank of FIF scores among the three groups at the baseline (P = 0.90), 1 month post-partum (P = 0.72) and 2 months post-partum (P = 0.89) (Table 3). There was 5 or over reduction in FIF scores (compared with the baseline) found in 20% of control, 21% of intervention 1, 23% of intervention 2 group, 1 month postpartum; and 25%, 29% and 19% of intervention 2 group 2 months post-partum, respectively. Mean rank of the difference scores was not significantly different among the groups, both 1 (P = 0.76) and 2 months post-partum (P = 0.87) (Fig. 3).
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EPDS score changes
FIF scores
15
5
0
–5
–10
–15 Control
Intervention 1
Intervention 2
Figure 2. Box plot showing Edinburgh Postnatal Depression Scale (EPDS) score changes 1 month and 2 months post-partum within the groups. Control: no intervention; Intervention 1: antenatal exercise; Intervention 2: antenatal and postnatal exercise. , EPDS score changes 1 month post-partum; , EPDS score changes 2 months post-partum. EPDS, Edinburgh Postnatal Depression Scale.
Adherence to the exercise programme Adherence to the exercise component of the programme (according to the participants’ reports at the end of study © 2014 Wiley Publishing Asia Pty Ltd
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Table 3 Fatigue Identification Form (FIF) scores of three interventional groups during study FIF score
0–3 4–12 13–19 ≥ 20 Attrition Mean SD Median Percentile 25 Percentile 75 P†
Baseline
One month post-partum
Two months post-partum
C. n = 42
I.1 n = 43
I.2 n = 42
C. n = 35
I.1 n = 38
I.2 n = 35
C. n = 36
I.1 n = 38
I.2 n = 36
6 (14) 28 (67) 6 (14) 2 (5) — 8.43 4.78 7.5 4.75 10.25 0.90
13 (30) 18 (42) 12 (28) 0 (0) — 8.09 5.60 7 3 13
7 (17) 28 (67) 5 (14) 1 (2) — 8.26 5.19 8 5 11
11 (31.5) 18 (51.5) 4 (11.5) 2 (6) 7 (17) 7.60 6.34 6 3 10 0.72
8 (21) 19 (50) 8 (21) 3 (8) 5 (21) 8.89 6.94 7 4 14.5
7 (20) 21 (60) 6 (17) 1 (3) 7 (17) 8.03 5.65 7 4 12
11 (31) 17 (47) 8 (22) 0 (0) 6 (14) 7.14 6.03 6 1.25 11.75 0.89
11 (29) 20 (53) 5 (13) 2 (5) 5 (12) 7.29 5.92 6 2.75 11.25
10 (28) 18 (50) 7 (19) 1 (3) 6 (14) 7.61 6.00 7.5 2 10.75
†
FIF score changes
Using Kruskal–Wallis test. The data are given as n (%) unless otherwise specified. C., no intervention; I.1, antenatal exercise; I.2, antenatal and postnatal exercise.
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Table 4 The number of exercise sessions performed by the intervention groups
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The number of sessions
Antenatal exercise in intervention 1 n = 38
Antenatal exercise in intervention 2 n = 36
Postnatal exercise in intervention 2 n = 36
< 10 10–20 > 20
16 (42) 13 (36) 9 (24)
14 (39) 10 (28) 12 (33)
24 (67) 12 (33)
10
0
–10
†
The data are given as n (%). † Total number of exercise session was assumed 30–40 sessions during pregnancy and maximum of 20 sessions during post-partum period.
–20 Control
Intervention 1
Intervention 2
Figure 3. Box plot showing FIF score changes 1 month and 2 months post-partum by the three groups. Control: no intervention; Intervention 1: antenatal exercise; Intervention 2: antenatal and postnatal exercise. , fatigue score changes 1 month post-partum; , fatigue score changes 2 months post-partum. FIF, Fatigue Identification Form.
period) was reported in Table 4. Although we called the experimental groups every 2–3 weeks to remind them to do the exercise programme, during the study most subjects in both groups did not regularly exercise. © 2014 Wiley Publishing Asia Pty Ltd
DISCUSSION The results from the study showed that EPDS and FIF score changes did not differ significantly between the three groups. Therefore, this study could not show a positive effect of the antenatal and postnatal home-based exercise on postnatal depression and fatigue. We found no study about the effect of exercise on preventing depression or fatigue. However, a few published studies have shown the positive effects of exercise interventions on the treatment of postnatal depression, postnatal fatigue or both.
Exercise for postnatal depression and fatigue
In a 12 week randomized-controlled trial, Armstrong and colleagues investigated the effects of a multiintervention programme of pram walking and social support on depressed women who had given birth in the past 12 months. The results showed that the women in the pram walking group had significantly lower EPDS scores than the women in the control group at both the 6 and 12 week intervention.16 In the second trial, by the same research team, the effect of a twice a week, group-based pram walking intervention was compared with the effects seen in a group who received a social support intervention. For the women in the exercise group, the score decreased significantly by the end of the 12 week intervention period, but not for the women in the social support group.17 In another Study, Ko and colleagues explored the effectiveness of an exercise programme that was conducted in six sessions, on reducing levels of depression and fatigue among post-partum women. There was no significant change in depression between the two groups. They explained that significant reductions in depression were very difficult to achieve in the brief time allowed for their study. Despite this, their results showed statistically significant differences between the two groups in terms of fatigue levels.19 In addition, Drista and colleagues evaluated the efficacy of a home-based exercise intervention in reducing fatigue scores in post-partum depressed women and found that compared with the control group, women in the exercise group showed significantly greater reduction in physical fatigue at posttreatment.18 The first possible reason for the differences in the findings is the type and the intensity of the exercise programmes. Based on a Cochrane review,24 mixed and resistance exercise can indicate large effect sizes and highintensity exercise might be more effective than lowintensity exercise. Exercises in our study were antenatal and postnatal low-intensity stretching and breathing practices, whereas the exercise programme in the previous studies included postnatal pram walking and combination of breathing, stretching, yoga, Pilates and muscle training practices. The second possible reason for the differences is the level of adherence to the exercise programme. The exercise programme in our study was home based and the level of adherence in this programme was low (Table 4). Low levels of adherence to the exercise programme can be considered a limitation of our study; not having enough
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time for physical activity was cited as the most common reason why women did not exercise. This study was a pragmatic trial25 which tested the home-based exercise in a ‘real life’ situation, when many subjects did not do the exercises as planned. In this study, we were not able to implement blinding. Also, data collection was done by the person who also allocated participants into the groups and educated them. These might have caused some bias including assessment bias. But this is somewhat negligible because the forms were filled in by the participants. Considering the study limitations, it is recommended to evaluate the effects of other suitable exercises like swimming and walking on post-partum depression and fatigue. To promote programme adherence, it might be better that exercise programme is provided in sport clubs.
ACKNOWLEDGEMENTS This article has been extracted from a Master of Science thesis. We would like to thank the Research Deputy of Tabriz University of Medical Sciences and the managers and staff of the health centres in Tabriz where the study was conducted. We also thank the mothers for their participation in the study.
REFERENCES 1 Fisher J, Cabral de Mello M, Izutsu T. Pregnancy, childbirth and the postpartum period. In: World Health Organization (ed.). Mental Health Aspects of Women’s Reproductive Health: A Global Review of the Literature. Geneva: World Health Organization, 2009; 8–30. 2 Albright A. Postpartum depression: An overview. Journal of Counseling and Development 1993; 71: 316–320. 3 Gardner DL, Campbell B. Assessing postpartum fatigue. MCN. The American Journal of Maternal Child Nursing 1991; 16: 264–266. 4 Lee KA, Zaffke ME. Longitudinal changes in fatigue and energy during pregnancy and the postpartum period. Journal of Obstetric, Gynecologic, and Neonatal Nursing 1999; 28: 183–191. 5 Troy NW. Is the significance of postpartum fatigue being overlooked in the lives of women? MCN. The American Journal of Maternal Child Nursing 2003; 28: 252–257. 6 O’Hara M, Swain A. Rates and risk of postnatal depression: A meta analysis. International Review of Psychiatry 1996; 8: 37–54. 7 Hearn G, Iliff A, Jones I et al. Postnatal depression in the community. British Journal of General Practice 1998; 48: 1064–1066. © 2014 Wiley Publishing Asia Pty Ltd
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8 Beck TC. Postpartum depression: It isn’t just the blues. The American Journal of Nursing 2006; 106: 40–50. 9 Pope SH. Postnatal Depression: A Systematic Review of Published Scientific Literature to 1999. Melbourne: National Health and Medical Research Council, 2000. 10 Ko YL. Postpartum fatigue. The Journal of Nursing 2004; 51: 75–79. 11 Milligan R, Lenz ER, Parks PL, Pugh LC, Kitzman H. Postpartum fatigue: Clarifying a concept. Scholarly Inquiry for Nursing Practice 1996; 10: 279–291. 12 Parks P, Lentz E, Milligan R, Han HR. What happens when fatigue lingers for 18 months after delivery? Journal of Obstetric, Gynecologic, and Neonatal Nursing 1999; 28: 87–93. 13 Walker LO, Wilging S. Rediscovering the ‘M’ in ‘MCH’: Maternal health promotion after childbirth. Journal of Obstetric, Gynecologic, and Neonatal Nursing 2000; 29: 229–236. 14 Davies GA, Wolfe LA, Mottola MF, MacKinnon C. Joint SOGC/CSEP clinical practice guideline: Exercise in pregnancy and the postpartum period. Canadian Journal of Applied Physiology 2003; 28: 330–341. 15 Artal R, O’Toole M. Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period. British Journal of Sports Medicine 2003; 37: 6–12. 16 Armstrong K, Edwards H. The effect of exercise and social support on mothers reporting depressive symptoms: A pilot randomized controlled trial. International Journal of Mental Health Nursing 2003; 12: 130–138. 17 Armstrong K, Edwards H. The effectiveness of pram walking exercise program in reducing depressive
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symptomatology for postnatal women. International Journal of Nursing Practice 2004; 10: 177–194. Drista M, Dupuis G, Khalife S. Effect of home-based exercise intervention on fatigue in postpartum depressed women: Results of randomized controlled trial. Annals of Behavioral Medicine 2008; 35: 179–187. Ko YL, Yang CL, Chiang LC. Effect of postpartum exercise program on fatigue and depression during ‘doing-the-month period’. Journal of Nursing Research 2008; 16: 177–186. Matthey S, Hendshaw C, Elliot S, Barnett B. Variability in use of cut-off scores and formats on the Edinburgh Postnatal Depression Scale—implications for clinical and research practice. Archives of Women’s Mental Health 2006; 9: 309–315. Cox J, Holden J, Sagovsky R. Detection of postnatal depression: Development of the 10 item Edinburgh Postnatal Depression Scale. The British Journal of Psychiatry 1987; 150: 782–786. Linda C. Clinical approaches in the assessment of childbearing fatigue. Journal of Obstetric, Gynecologic, and Neonatal Nursing 1998; 28: 74–80. Abry Aghdam N. Psychometric properties of Edinburgh postnatal depression scale in Tabriz. Unpublished M.D thesis, Tabriz Islamic Azad University of Medical Science, Iran, 2006 (in Persian). Mead GE, Morley W, Campbell P, Greig CA, McMurdo M, Lawlor DA. Exercise for depression. Cochrane Database of Systematic Review 2008; Cd004366. Zwarenstein M, Treweek S, Gagnier JJ. et al. Improving the reporting of pragmatic trials: An extension of the CONSORT statement. BMJ 2008; 337: a2390.
International Journal of Nursing Practice 2014; ••: ••–••
RESEARCH PAPER
The effect of a home-based exercise intervention on postnatal depression and fatigue: A randomized controlled trial Fatemeh Mohammadi MSc Students’ Research Committee, Midwifery Department, Faculty of Nursing & Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
Jamileh Malakooti MSc Lecturer, Midwifery Department, Faculty of Nursing & Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
Jalil Babapoor heiroddin PhD Professor, Psychology Department, Faculty of Education & Psychology, University of Tabriz, Tabriz, Iran
Sakineh Mohammad-Alizadeh-Charandabi PhD Associate Professor, Midwifery Department, Faculty of Nursing & Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
Accepted for publication August 2013 Mohammadi F, Malakooti J, Babapoor J, Mohammad-Alizadeh-Charandabi S. International Journal of Nursing Practice 2014; ••: ••–•• The effect of a home-based exercise intervention on postnatal depression and fatigue: A randomized controlled trial This study aims to determine the effectiveness of home-based low-intensity stretching and breathing exercises on the reduction of 1 and 2 month post-partum depression (primary outcome) and fatigue (secondary outcome) scores. In this randomized controlled trial, 127 women at 26–32 weeks’ gestation with Edinburgh score less than 15, who attended 14 selected health centres in Tabriz, Iran, were randomly allocated into one of the following three groups: no intervention group, group receiving training for exercise during pregnancy, and group receiving training for exercise during pregnancy and post-partum period until 2 months after delivery. Depression and fatigue scores were measured using the Edinburgh Postnatal Depression Scale and Fatigue Identification Form, respectively, at baseline, 1 month and 2 months after delivery. The data were analysed with SPSS-ver. 13.0 (SPSS Inc, Chicago, IL, USA) using chi-square, Fisher’s exact and Kruskal– Wallis tests. Mean rank of the difference scores of depression and fatigue were not significantly different among the groups, both at 1 and 2 months post-partum (P > 0.05). Therefore, this study did not provide evidence to show that training women to do the home-based exercises during pregnancy or during pregnancy and post-partum period have a preventive effect on post-partum depression and fatigue. However, more studies are needed for making precise judgment. Key words: exercise, postnatal depression, postnatal fatigue.
Correspondence: Sakineh Mohammad-Alizadeh-Charandabi, Midwifery Department, Faculty of Nursing & Midwifery, Tabriz University of Medical Sciences, Shariati Street, Tabriz 5157984319, Iran. Email: [email protected] doi:10.1111/ijn.12259
© 2014 Wiley Publishing Asia Pty Ltd
2
F Mohammadi et al.
INTRODUCTION
METHODS
In becoming a mother, a woman often has to relinquish her autonomy, personal liberty, occupational identity, capacity to generate an income, and social and leisure activities in favour of caring for the infant. The adaptation to the new required roles, major responsibilities, moving from being in the childless generation to the parent generation, increased unpaid workload and, for some, harm to bodily integrity through unexpected adverse reproductive events place great demands both on individual psychological resources and on existing relationships.1 Postnatal fatigue and depression are the two major common problems occurring during the postnatal period reported and emphasized in the literature.2–5 In a meta-analysis of 59 studies from various countries, the estimated average prevalence of postpartum depression was 13%.6 The rate of suffering from post-partum depression is high in Asian women.7 Women from western industrialized nation have also ranked fatigue among their top five concerns after birth.5 Postnatal psychological problems can interfere with a new mother’s ability to care for her infant and might adversely affect her quality of life.8–12 The promotion of postnatal health has been emphasized by many health-care providers.13 To promote postnatal care, both the Society of Obstetricians and Gynecologists of Canada, Clinical Practice Obstetrics Committee/ Canadian Society for Exercise Physiology14 and the American College of Obstetricians and Gynecologists 15 have published guidelines for exercise during pregnancy and the postnatal period. The effect of exercise on postnatal depression and fatigue has been the subject of a few research studies. The results of some studies have shown the positive effect of exercise on reduction of depressive symptoms and/or fatigue,16–18 whereas some showed no significant effect.19 All of these studies examined the effect of postnatal exercise programme on treatment of postnatal depression and fatigue. To our knowledge, there is no research published about the effect of antenatal and postnatal exercise programme on postnatal depression and fatigue. Therefore, this study was designed to investigate the effect of a home-based antenatal and also antenatal plus postnatal exercise programme on depression (primary outcome) and fatigue (secondary outcome) score 1 and 2 months post-partum.
This study was a randomized trial with three parallel arms. Pregnant women at 26–32 weeks pregnancy were recruited for the study. Eligible women were not currently suffering from depression (Edinburgh score less than 1520) or other known psychiatric disorders, obstetrical complications and diseases that would limit exercise; did not have history of threatened abortion, placenta previa, the signs of preterm labour or pre-rupture of amniotic membrane in present pregnancy; were not currently participating in regular exercise programmes, and had access to landline at home or personal cell phone. The subjects were recruited from 14 public health centres in Tabriz, Iran, which had higher coverage of pregnant women care. The first author, responsible for data collection and interventions, recognized potential subjects from their medical records, called the women and after explaining the aim of study, invited them to attend the centres to complete the baseline questionnaire. Eligibility criteria were checked during the assessment of the medical reports, phone contacts and the attendance session. In the control group, women got antenatal and postnatal ordinary educations in a 40 min session. The women in the intervention1 group attended a theoretical and a practical educational session which lasted about 40 min. These sessions were mainly about the importance of exercise during pregnancy and how it should be performed. These women were recommended to do the exercise three times a week (for 20–30 min each), until delivery, according to the educational antenatal CD at their home. The exercises were low-intensity stretching and breathing practices. In the second intervention group, women were recommended to do a 2 month postnatal exercises in addition to getting the instructions given to the intervention 1 group. They were instructed to adjust the frequency and the duration of the exercises based on their own ability in the first month after delivery, but they were required to do the exercises regularly three times a week in the second month according to the educational postnatal CD. Due to similarity of postnatal exercises to antenatal one, they were not educated practically in this area. The content of the antenatal and postnatal CDs were approved by Ministry of Health and Medical Education of Iran. The Edinburgh Postnatal Depression Scale (EPDS) and Fatigue Identification Form (FIF) were used to evaluate
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Exercise for postnatal depression and fatigue
depression and fatigue score, respectively, in three time points: baseline (26–32 weeks of gestation), 1 month and 2 months post-partum. EPDS is a self-administered, widely used, valid and reliable 10-item measurement of perinatal mood. The items inquire about maternal mood in the past 7 days and are rated on a four-point scale (not at all/hardly ever/sometimes/very often).21 FIF, which is a dichotomous (yes/no) 30-item scale, can be used clinically to assess fatigue during pregnancy and postpartum.22 Total scores of EPDS and FIF ranged from 0 to 30. The higher the scores are, the worse the condition of the patient is. For evaluation of the study adherence, the first author called the participants in intervention 1 and intervention 2 groups at the end of the study and gathered information on the approximate number of exercise sessions each group performed. To determine the appropriate sample size, comparison of means formula was used. Mean scores and standard deviation (SD) of the EPDS in group with no intervention were taken from study of Abry Aghdam (m1 = 11, SD1 = 4.1).23 It was assumed that with the interventions, the SD would not change and mean scores will be reduced to at least 25% (m2 = 8.25). Considering 5% level of significance, 80% power and 10% loss to follow-up, the sample size was calculated as 42 persons for each group. Block randomization with block sizes of 6 and 9 in each participating centre was used to determine the allocation sequence. We used such randomization to achieve approximate balance of important characteristics among the treatment groups. A person not involved in enrolling participants generated the sequence using a computerized random number generator and put them in sequentially numbered opaque sealed envelopes to conceal the allocation sequence. The envelopes were opened after getting informed consent and collecting baseline data. Statistical analyses were performed using SPSS-ver. 13.0 (SPSS Inc., Chicago, IL, USA). Data were analysed on the basis of intention to treat. As the score of EPDS and FIF was not normally distributed, Kruskal–Wallis was used to test the effect of the interventions. Homogeneity of baseline characteristics among the groups was tested by chi-square and Fisher’s exact tests. P < 0.05 was considered significant. Ethical approval was obtained from Tabriz University of Medical Sciences. All participants signed the consent form after getting informed regarding the procedure of
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the study and safety of the exercises. This clinical trial was registered in Iranian Registry of Clinical Trials (http:// www.irct.ir/searchresult.php?id=3706&number=5) with IRCT201008193706N5 code before recruitment of the subjects.
RESULTS Figure 1 presents the flow of participants throughout the study. A total of 441 women were assessed for eligibility. Three hundred four were not eligible and 10 refused to participate in the study. One hundred twenty-seven women were randomized into three groups, 42 were allocated to the control, 43 to intervention 1 group and 42 to intervention 2 group.
Participant baseline characteristics The three groups were similar in terms of demographic and clinical characteristics, such as age, education, job situation, history of psychiatric disorders in women and their families, relationship between women and their husbands, occurrence of bad event in the past months, unwanted pregnancy and complicated pregnancy. Mean age was 25 years for all groups. The majority of participants were housewives. More than half were nullipar, had high school or higher (≥ 9 years) education, and reported a sufficient monthly income. Only one mother in the control group reported a history of psychiatric disorders. In each group, one to three participants reported a history of psychiatric disorders in their families, seven to eight reported experiencing a bad event in the recent months, and zero to two reported not having a good relationship with their husbands (Table 1).
EPDS scores As illustrated in Table 2, at the baseline assessment, 17% of control group, 14% of intervention 1 group and 26% of intervention 2 group had EPDS scores of ≥ 13. One month post-partum, these rates were 12%, 21% and 14%; and at 2 months post-partum were 14%, 8% and 8%, respectively. No significant differences were identified in mean rank of EPDS scores among the three groups at the baseline (P = 0.24), 1 month post-partum (P = 0.82) and 2 months post-partum (P = 0.70). There was 5 or over reduction in EPDS score (compared with the baseline) found in 14.5% of control group, 16% of intervention 1 group, 33.5% of intervention 2 group, 1 month post-partum; and 30%, 34% and 42% at © 2014 Wiley Publishing Asia Pty Ltd
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Assessed for eligibility n = 441 304 were not eligible 10 refused to participate
Randomly assigned n = 127
Control group n = 42
Intervention 1 n = 43
Intervention 2 n = 42
1 month post-partum completed questionnaire n = 35
1 month post-partum completed questionnaire n = 38
1 month post-partum completed questionnaire n = 35
2 months post-partum completed questionnaire n = 36
2 months post-partum completed questionnaire n = 38
2 months post-partum completed questionnaire n = 36
Analysed 1 month post-partum = 35 2 months post-partum = 36
Analysed 1 month post-partum = 38 2 months post-partum = 38
Analysed 1 month post-partum = 35 2 months post-partum = 36
Figure 1. Flow diagram of trial.
Table 1 Characteristics of participants in the study groups Characteristics
Age (years) 15–29 ≥ 30 Mean ± SD Education (years) 6–8 ≥9 Employed Sufficient family income Spouse education Elementary and intermediate High school and higher Live with her family or spouse Family History of psychiatric disorder History of psychiatric disorder In family Lack of good relation with her husband Occurrence of bad events in the recent months Unwanted pregnancy Complicated pregnancy Nulliparity History of abortion The data are given as n (%) unless otherwise specified.
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Control n = 42
Intervention 1 n = 43
Intervention 2 n = 42
34 (81) 8 (19) 25.3 ± 5.2
36 (84) 7 (16) 25.2 ± 4.7
33 (79) 9 (21) 25.5 ± 4.6
19 (45) 23 (55) 2 (5) 23 (55)
18 (42) 25 (58) 0 (0) 23 (53.5)
17 (40.5) 25 (59.5) 3 (7) 25 (59.5)
19 (45) 23 (55) 13 (31)
26 (60.5) 17 (39.5) 13 (30)
26 (62) 16 (38) 15 (36)
1 (2) 3 (7)
0 (0) 1 (2)
0 (0) 7 (17) 6 (14) 3 (7) 29 (69) 6 (14)
1 (2) 7 (16) 7 (16) 1 (2) 22 (51) 9 (21)
0 (0) 3 (7) 2 (5) 8 (19) 8 (19) 5 (12) 25 (59.5) 6 (14)
Exercise for postnatal depression and fatigue
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Table 2 Edinburgh Postnatal Depression Scale (EPDS) scores of the groups in the three time-points during study EPDS score
0–10 11–12 ≥ 13 Attrition Mean SD Median Percentile 25 Percentile 75 P†
Baseline
One month post-partum
Two months post-partum
C. n = 42
I.1 n = 43
I.2 n = 42
C. n = 35
I.1 n = 38
I.2 n = 35
C. n = 36
I.1 n = 38
I.2 n = 36
29 (69) 6 (14) 7 (17) — 8.14 3.94 8.5 5 11 0.24
30 (70) 7 (16) 6 (14) — 7.77 3.86 7 4 11
26 (62) 5 (12) 11 (26) — 9.07 3.91 9 7 13
26 (74) 5 (14) 4 (12) 7 (17) 7.46 4.50 6 5 11 0.82
24 (63) 6 (16) 8 (21) 5 (12) 7.66 5.46 7 3 12
27 (77) 3 (9) 5 (14) 7 (17) 8.03 4.95 7 5 10
28 (78) 3 (8) 5 (14) 6 (14) 6.50 5.12 5.5 2.25 9.75 0.70
30 (79) 5 (13) 3 (8) 6 (14) 6.58 4.63 6 3 9
31 (86) 2 (6) 3 (8) 6 (14) 6.58 4.63 6 3 9
†
Using Kruskal–Wallis test. The data are given as n (%) unless otherwise specified. C., no intervention; I.1, antenatal exercise; I.2, antenatal and postnatal exercise.
2 months postpartum, respectively. Mean rank of the difference scores was not significantly different among the groups, both 1 (P = 0.36) and 2 months post-partum (P = 0.75) (Fig. 2).
On the baseline assessment, 19% of control, 28% of intervention 1 and 16% of intervention 2 had FIF scores of ≥ 13. In 1 month post-partum, these rates were 17.5%, 29% and 20%; and in 2 months post-partum, they were 22%, 18% and 22%, respectively. No significant differences were identified in mean rank of FIF scores among the three groups at the baseline (P = 0.90), 1 month post-partum (P = 0.72) and 2 months post-partum (P = 0.89) (Table 3). There was 5 or over reduction in FIF scores (compared with the baseline) found in 20% of control, 21% of intervention 1, 23% of intervention 2 group, 1 month postpartum; and 25%, 29% and 19% of intervention 2 group 2 months post-partum, respectively. Mean rank of the difference scores was not significantly different among the groups, both 1 (P = 0.76) and 2 months post-partum (P = 0.87) (Fig. 3).
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EPDS score changes
FIF scores
15
5
0
–5
–10
–15 Control
Intervention 1
Intervention 2
Figure 2. Box plot showing Edinburgh Postnatal Depression Scale (EPDS) score changes 1 month and 2 months post-partum within the groups. Control: no intervention; Intervention 1: antenatal exercise; Intervention 2: antenatal and postnatal exercise. , EPDS score changes 1 month post-partum; , EPDS score changes 2 months post-partum. EPDS, Edinburgh Postnatal Depression Scale.
Adherence to the exercise programme Adherence to the exercise component of the programme (according to the participants’ reports at the end of study © 2014 Wiley Publishing Asia Pty Ltd
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Table 3 Fatigue Identification Form (FIF) scores of three interventional groups during study FIF score
0–3 4–12 13–19 ≥ 20 Attrition Mean SD Median Percentile 25 Percentile 75 P†
Baseline
One month post-partum
Two months post-partum
C. n = 42
I.1 n = 43
I.2 n = 42
C. n = 35
I.1 n = 38
I.2 n = 35
C. n = 36
I.1 n = 38
I.2 n = 36
6 (14) 28 (67) 6 (14) 2 (5) — 8.43 4.78 7.5 4.75 10.25 0.90
13 (30) 18 (42) 12 (28) 0 (0) — 8.09 5.60 7 3 13
7 (17) 28 (67) 5 (14) 1 (2) — 8.26 5.19 8 5 11
11 (31.5) 18 (51.5) 4 (11.5) 2 (6) 7 (17) 7.60 6.34 6 3 10 0.72
8 (21) 19 (50) 8 (21) 3 (8) 5 (21) 8.89 6.94 7 4 14.5
7 (20) 21 (60) 6 (17) 1 (3) 7 (17) 8.03 5.65 7 4 12
11 (31) 17 (47) 8 (22) 0 (0) 6 (14) 7.14 6.03 6 1.25 11.75 0.89
11 (29) 20 (53) 5 (13) 2 (5) 5 (12) 7.29 5.92 6 2.75 11.25
10 (28) 18 (50) 7 (19) 1 (3) 6 (14) 7.61 6.00 7.5 2 10.75
†
FIF score changes
Using Kruskal–Wallis test. The data are given as n (%) unless otherwise specified. C., no intervention; I.1, antenatal exercise; I.2, antenatal and postnatal exercise.
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Table 4 The number of exercise sessions performed by the intervention groups
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The number of sessions
Antenatal exercise in intervention 1 n = 38
Antenatal exercise in intervention 2 n = 36
Postnatal exercise in intervention 2 n = 36
< 10 10–20 > 20
16 (42) 13 (36) 9 (24)
14 (39) 10 (28) 12 (33)
24 (67) 12 (33)
10
0
–10
†
The data are given as n (%). † Total number of exercise session was assumed 30–40 sessions during pregnancy and maximum of 20 sessions during post-partum period.
–20 Control
Intervention 1
Intervention 2
Figure 3. Box plot showing FIF score changes 1 month and 2 months post-partum by the three groups. Control: no intervention; Intervention 1: antenatal exercise; Intervention 2: antenatal and postnatal exercise. , fatigue score changes 1 month post-partum; , fatigue score changes 2 months post-partum. FIF, Fatigue Identification Form.
period) was reported in Table 4. Although we called the experimental groups every 2–3 weeks to remind them to do the exercise programme, during the study most subjects in both groups did not regularly exercise. © 2014 Wiley Publishing Asia Pty Ltd
DISCUSSION The results from the study showed that EPDS and FIF score changes did not differ significantly between the three groups. Therefore, this study could not show a positive effect of the antenatal and postnatal home-based exercise on postnatal depression and fatigue. We found no study about the effect of exercise on preventing depression or fatigue. However, a few published studies have shown the positive effects of exercise interventions on the treatment of postnatal depression, postnatal fatigue or both.
Exercise for postnatal depression and fatigue
In a 12 week randomized-controlled trial, Armstrong and colleagues investigated the effects of a multiintervention programme of pram walking and social support on depressed women who had given birth in the past 12 months. The results showed that the women in the pram walking group had significantly lower EPDS scores than the women in the control group at both the 6 and 12 week intervention.16 In the second trial, by the same research team, the effect of a twice a week, group-based pram walking intervention was compared with the effects seen in a group who received a social support intervention. For the women in the exercise group, the score decreased significantly by the end of the 12 week intervention period, but not for the women in the social support group.17 In another Study, Ko and colleagues explored the effectiveness of an exercise programme that was conducted in six sessions, on reducing levels of depression and fatigue among post-partum women. There was no significant change in depression between the two groups. They explained that significant reductions in depression were very difficult to achieve in the brief time allowed for their study. Despite this, their results showed statistically significant differences between the two groups in terms of fatigue levels.19 In addition, Drista and colleagues evaluated the efficacy of a home-based exercise intervention in reducing fatigue scores in post-partum depressed women and found that compared with the control group, women in the exercise group showed significantly greater reduction in physical fatigue at posttreatment.18 The first possible reason for the differences in the findings is the type and the intensity of the exercise programmes. Based on a Cochrane review,24 mixed and resistance exercise can indicate large effect sizes and highintensity exercise might be more effective than lowintensity exercise. Exercises in our study were antenatal and postnatal low-intensity stretching and breathing practices, whereas the exercise programme in the previous studies included postnatal pram walking and combination of breathing, stretching, yoga, Pilates and muscle training practices. The second possible reason for the differences is the level of adherence to the exercise programme. The exercise programme in our study was home based and the level of adherence in this programme was low (Table 4). Low levels of adherence to the exercise programme can be considered a limitation of our study; not having enough
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time for physical activity was cited as the most common reason why women did not exercise. This study was a pragmatic trial25 which tested the home-based exercise in a ‘real life’ situation, when many subjects did not do the exercises as planned. In this study, we were not able to implement blinding. Also, data collection was done by the person who also allocated participants into the groups and educated them. These might have caused some bias including assessment bias. But this is somewhat negligible because the forms were filled in by the participants. Considering the study limitations, it is recommended to evaluate the effects of other suitable exercises like swimming and walking on post-partum depression and fatigue. To promote programme adherence, it might be better that exercise programme is provided in sport clubs.
ACKNOWLEDGEMENTS This article has been extracted from a Master of Science thesis. We would like to thank the Research Deputy of Tabriz University of Medical Sciences and the managers and staff of the health centres in Tabriz where the study was conducted. We also thank the mothers for their participation in the study.
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8 Beck TC. Postpartum depression: It isn’t just the blues. The American Journal of Nursing 2006; 106: 40–50. 9 Pope SH. Postnatal Depression: A Systematic Review of Published Scientific Literature to 1999. Melbourne: National Health and Medical Research Council, 2000. 10 Ko YL. Postpartum fatigue. The Journal of Nursing 2004; 51: 75–79. 11 Milligan R, Lenz ER, Parks PL, Pugh LC, Kitzman H. Postpartum fatigue: Clarifying a concept. Scholarly Inquiry for Nursing Practice 1996; 10: 279–291. 12 Parks P, Lentz E, Milligan R, Han HR. What happens when fatigue lingers for 18 months after delivery? Journal of Obstetric, Gynecologic, and Neonatal Nursing 1999; 28: 87–93. 13 Walker LO, Wilging S. Rediscovering the ‘M’ in ‘MCH’: Maternal health promotion after childbirth. Journal of Obstetric, Gynecologic, and Neonatal Nursing 2000; 29: 229–236. 14 Davies GA, Wolfe LA, Mottola MF, MacKinnon C. Joint SOGC/CSEP clinical practice guideline: Exercise in pregnancy and the postpartum period. Canadian Journal of Applied Physiology 2003; 28: 330–341. 15 Artal R, O’Toole M. Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period. British Journal of Sports Medicine 2003; 37: 6–12. 16 Armstrong K, Edwards H. The effect of exercise and social support on mothers reporting depressive symptoms: A pilot randomized controlled trial. International Journal of Mental Health Nursing 2003; 12: 130–138. 17 Armstrong K, Edwards H. The effectiveness of pram walking exercise program in reducing depressive
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