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Archives of Women's Mental Health (2019) 22:37–53https://doi.org/10.1007/s00737-018-0869-3
REVIEW ARTICLE
The effectiveness of exercise-based interventions for preventing
or treating postpartum depression: a systematic review
and meta-analysis
Tim Carter 1 & Anastasios Bastounis 1 & Boliang Guo 1 & C Jane Morrell 1
Received: 31 January 2018 / Accepted: 24 May 2018 / Published online: 7 June 2018
# Springer-Verlag GmbH Austria, part of Springer Nature 2018
Abstract
Postpartum depression can have detrimental effects on both a mother’s physical and mental health and on her child’s growth and
emotional development. The aim of this study is to assess the effectiveness of exercise/physical activity-based interventions in
preventing and treating postpartum depressive symptoms in primiparous and multiparous women to the end of the postnatal
period at 52 weeks postpartum. Electronic databases were searched for published and unpublished randomised controlled trials of
exercise/physical activity-based interventions in preventing and treating depressive symptoms and increasing health-related
quality of life in women from 4 to 52 weeks postpartum. The results of the studies were meta-analysed and effect sizes with
confidence intervals were calculated. The Grading of Recommendations Assessment and Development and Evaluation
(GRADE) system was used to determine the confidence in the effect estimates. Eighteen trials conducted across a range of
countries met the inclusion criteria. Most of the exercise interventions were aerobic and coaching compared to usual care, non-
intervention and active controls. Small effect sizes of exercise-based interventions in reducing depressive symptoms were
observed collectively and the quality of evidence was low across the individual studies. Although exercise-based interventions
could create an alternative therapeutic approach for preventing major depression in postpartum women who experience sub-
threshold elevated depressive symptoms, the clinical effectiveness and the cost-effectiveness of exercise-based and physical
activity interventions need to be better established. There is a need for further more rigorous testing of such interventions in high-
quality randomised controlled trials against active control conditions before large-scale roll-out of these interventions in clinical
practice is proposed.
Keywords Exercise . Physical activity . Postpartum depression . Review . Meta-analysis
Introduction of the baby (Farías-Antúnez et al. 2017), with long-term costs
of £8.1bn (Bauer et al. 2014). A range of physical, genetic and
About 20% of women globally experience a perinatal mental socioeconomic factors put pregnant and postpartum women at
health disorder, mainly depression and anxiety, when they are risk of perinatal mental health problems whilst buffering fac-
pregnant or in the perinatal period up to 52 weeks after they tors (e.g. supportive partner) are protective (Austin et al.
have given birth (WHO 2017). The most severely affected 2010).
women can develop self-harm and suicidal ideations (Pope In the UK, early psychosocial or pharmacological interven-
et al. 2013; Wisner et al. 2013). Perinatal anxiety and depres- tions are recommended to reduce the prevalence of perinatal
sion can compromise the long-term growth and development anxiety and depression, benefit women and families and re-
duce costs (Morrell et al., 2009a, b; NICE 2014; Morrell et al.
2016; Saligheh et al. 2017).
The perinatal period is also characterised by difficulty in
* Tim Carter managing weight and engaging in physical activity (Gaston
timothy.carter@nottingham.ac.uk
and Cramp, 2011). A reduction in physical activity/exercise
throughout pregnancy can lead to lower self-ratings of quality
1
University of Nottingham, Nottingham, UK of life (Campolong 2017) and can have detrimental effects on
,38 T. Carter et al.
physical health (Fazzi, Saunders, Linton, Norman, & and the presentation of the findings conforms to PRISMA
Reynolds 2017). Sedentary behaviours have been associated (Moher et al. 2009). The primary outcome was depression
with increased risk for postnatal depressive symptoms, where- symptoms in postpartum women at post-intervention and the
as physical activity in pregnancy and postnatally has been secondary outcomes were symptoms of anxiety and health-
associated with decreased risk for developing depressive related quality of life (HRQoL).
symptoms (Claesson, Klein, Sydsjo, & Josefsson 2014;
Teychenne & York 2013). Given that engaging in sedentary Inclusion criteria
behaviours during pregnancy can be continued postpartum,
exercise-based interventions could yield multi-tiered benefits Population: primiparous or multiparous postnatal women
for the physical and mental health of perinatal women. Intervention: exercise-based (supervised, unsupervised,
Small to moderate effects on depression symptoms have coaching-based, motivational, behavioural-oriented, uni-
been found from exercise-based interventions in adults and versal, targeted or treatment based, in a community or
young people (standardised mean difference [SMD] − 0.62, clinical context)
95% confidence interval [CI] − 0.81, − 0.42), compared to Comparison: any type of control condition (e.g.
control conditions (Cooney et al. 2013; Carter et al. 2016). flexibility/stretching or social support sessions, UC, NI,
In postpartum populations, there is a promising evidence base AC, WLC)
for exercise-based interventions in preventing and treating de- Outcomes: depression symptoms using a validated as-
pressive symptoms (McCurdy et al. 2017; Poyatos-León et al. sessment tool (e.g. Edinburgh Postnatal Depression
2017). The content of these interventions covers aerobic ac- Scale (EPDS), Patient Health Questionnaire)
tivities, stretching, yoga and exercise-based coaching. In Study type: published or unpublished individual RCTs or
randomised controlled trials (RCTs), exercise-based interven- cluster RCTs
tions have been compared to control conditions of usual care
(UC) or non-intervention (NI), but few have been compared
against active control (AC) or waitlist control (WLC) Exclusion criteria
(Armstrong & Edwards 2004; LeCheminant et al. 2014).
Most exercise-based interventions have been tested in targeted Population: pregnant women; women with psychiatric
populations, such as women with elevated depression symp- diagnoses other than depression
toms (Buttner et al. 2015) or women with a previous history of Intervention: no details of the exercise component; inter-
depression (Lewis et al. 2014). vention delivered before 4 weeks or after 52 weeks
There is now a need for a robust evidence synthesis that Comparison: no comparison interventions were excluded
follows methodologically rigorous processes (Saligheh et al. Outcomes: no depression symptom measure; outcomes
2017) to systematically identify the components and charac- before 4 weeks postpartum
teristics of interventions, and analyse their effectiveness, to Study type: non-RCTs
promote the development of beneficial exercise-based inter-
ventions in clinical practice (Saligheh et al. 2017).
This review aims to synthesise evidence from RCTs for the Search strategy
clinical effectiveness of exercise-based interventions compared
to all types of control in preventing and treating depressive symp- Libraries and databases searched for papers published between
toms in primiparous and multiparous women from the possible 1974 and June 2017 were Allied and Complementary Medicine
onset at 4–6 weeks postnatally (Putman et al. 2017) to the end of Database (AMED), Applied Social Sciences Index and
the postpartum period (12 months after the birth of the baby). Abstracts (ASSIA), Cumulative Index to Nursing and Allied
Additionally, this review aims to identify factors associated with Health Literature (CINAHL), Current Controlled Trials,
the effectiveness of exercise-based interventions, testing the EMBASE (Excerpta Medica), ISRCTN Register, MEDLINE
moderating effects of the interventions: scope (universal vs. (including PubMed), National Institute for Health Research
targeted); content (strongly exercise-oriented vs. exercise con- Health Technology Assessment (NIHR HTA) programme da-
sulting and coaching); duration (short vs. long duration); and tabases, PROSPERO, PsycINFO, Scopus, Science Citation
control condition: AC vs. UC, NI, and WLC. Index and Conference Proceedings (Web of Science), The
Cochrane Library (Cochrane Database of Systematic
Reviews, Database of Abstracts of Reviews of Effects,
Methods Cochrane Central Register of Controlled Trials) and World
Health Organisation’s International Clinical Trials Registry
The protocol of this systematic review and meta-analysis was Platform (ICTRP). Online databases of grey literature searched
registered with PROSPERO (Carter 2017:CRD42017068376) were clinicaltrials.gov, International Standard Randomised
, The effectiveness of exercise-based interventions for preventing or treating postpartum depression: a... 39
Controlled Trials Number (ISRCTN) Register, OpenGrey and Data extraction
ProQuest Dissertations & Theses (PQDT).
The search strategy incorporated Medical Subject Heading Adapted versions of the Effective Practice and Organisation of
(MeSH) terms in five areas: Care (EPOC) Review Group data abstraction form and the
Cochrane Collaboration Form for extracting data from RCTs
Population: Postpartum Period; and Pregnant women/ were used to extract data from included studies. Two re-
OR Postnatal care/ OR Perinatal care. Depression/ OR viewers (TC and AB) extracted data independently and dis-
Depression, Postpartum/; Anxiety/ OR Anxiety agreements were resolved by discussion between the two re-
Disorders/ viewers who presented their arguments to each other until
Intervention: Exercise Test/ OR Exercise/ OR Exercise agreement was made. A third reviewer (JM) would have been
Therapy/ OR Exercise Movement Techniques/ the final arbiter, but this process was not required at any point
Outcome: Depression/ OR Depression, Postpartum/; in this review. Extracted data included information on study
Anxiety/ OR Anxiety Disorders/ authors, participant demographic characteristics, intervention
Study type: The search was optimised using the ‘RCTs and control conditions, study method, recruitment and com-
(plus cluster)’ clinical search filter recommended by the pletion rates, outcomes and measurement times, information
Centre for Reviews and Dissemination (CRD 2009) for assessment of risk of bias and quality. Experimental con-
ditions were coded as either (a) intervention, exercise or phys-
Hand-searches of public online databases and con- ical activity, yoga, coaching sessions with exercise and social
tacts with field experts were also conducted. Three syn- support with exercise, or (b) control, UC, AC (social support
tax sets were used in combination with the MeSH terms sessions), NI and WLC.
above for searching Medline, EMBASE and PsycINFO
(see Table 1). Quality assessment
Relevant authors were contacted when full text articles
were not available, there was insufficient information provid- The quality of included studies was assessed using the
ed for the inclusion criteria to be applied and there were insuf- Cochrane Collaboration tool for assessing risk of bias
ficient details reported on the outcomes. Lack of reply from (Higgins et al. 2011). Within each specified domain, adequate
authors led to one study being included only in the qualitative reporting resulted in a rating of low risk of bias, whereas
synthesis: LeCheminant et al.. (2014). evidence of bias resulted in a rating of high risk of bias.
Following initial screening of titles and abstracts, full texts When insufficient detail was reported for clear assessment, a
of all potentially relevant studies were assessed for inclusion rating of unclear risk of bias was given. There was also an
independently by two reviewers (TC and AB). Disagreements assessment of any additional threats of bias. Two researchers
were resolved by discussion, or a third reviewer (JM) was (TC and AB) independently rated the risk of bias for each
consulted. Reference lists of included articles were searched included study. Any disagreements were resolved after discus-
for potentially eligible studies. sion. The Grading of Recommendations Assessment and
Table 1 Search syntax for
Medline, EMBASE and PICO Syntax set
PsychINFO heading
Population postnatal.mp. OR post-natal.mp. OR perinatal.mp. OR peri-natal.mp. OR postpartum.mp. OR
post-partum.mp. OR puerperium.mp. OR puerperal.mp. OR pregnan$2.mp. OR post
pregnancy.mp. OR post-pregnancy.mp OR postpregnancy.mp. OR motherhood.mp. OR
wom#n.mp.
Intervention aerobic.mp. OR walking.ab. OR pram-walking.mp. OR exercise*.mp. OR (physical adj3
activity).mp. OR (physical adj3 exercise).mp. OR (exercise adj3 intervention).mp. OR
exercise program$3.mp. OR yoga.mp. OR tai-chi.mp. OR taichi.mp. OR tai chi.mp. OR tai
ji.mp. OR tai-ji.mp. OR (social adj3 support).mp. OR obesity.mp. OR diet.mp. OR
nutrition.mp. OR mindfulness.ab. OR weight loss.mp. OR physiotherapy.ab. OR physio
therapy.ab. OR physio-therapy.ab. OR fitness.mp. OR sport*.mp. OR muscle*.mp. OR
stretching.mp. OR leisure.mp. OR dance.mp. OR running.mp.
Outcome Depression.mp. OR Depressive.mp. OR Depressi$2 adj3 symptom*.mp. OR (risk* adj5
depress$3).ab. OR Anxiety adj3 symptom*.mp. OR Anxiety.mp. OR Therapy adj5
depression.mp. OR depression adj3 treatment.mp. OR Diagnosis adj3 depression.mp. OR
Prevention adj3 depression.mp. OR Stress.ab. OR Mood.ab. OR Mental health.mp. OR
Well-being.mp. OR Well being.mp. OR Wellbeing.mp.
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