EXERCISE INTERVENTIONS

Community-based postpartum exercise program

Yi-Li Ko, Chi-Li Yang, Chin-Lung Fang, Mei-Ying Lee and Pi-Chu Lin

Aims and objectives. To evaluate the effectiveness of an exercise programme for postpartum women to lose weight and
relieve fatigue and depression.
Background. The optimal period for weight loss is six months postpartum. However, most women cannot return to their
pre-pregnancy fitness level within that period of time.
Design. A quasi-experimental one-group pretest–post-test design was carried out.
Methods. A convenience sampling method was used to recruit 28 women at 2–6 months postpartum. The ‘Yoga and Pilates
Exercise Programme for Postpartum Woman’ was designed for this study and was delivered in group sessions once a week
for three months (12 times total) for 60 minutes each time by a professional coach. Of the participants, 23 completed the
entire program. The participants’ body composition and levels of depression and fatigue were measured before and after the
programme to identify differences.
Results. Women in the high-score group showed a significant decrease of 6
71 ± 5
71 points (t = 3
113, p = 0
021) in the
depression score after participating in the exercise programme. No significant difference was found for the level of fatigue
before and after the exercise programme (p > 0
05). Significant reductions in the participants’ body weight, body fat percent-
age, fat mass and basic metabolic rate were observed after the exercise programme (p < 0
001).
Conclusions. These physical activities benefited the physical and mental health of postpartum women and enhanced their
quality of life.
Relevance to clinical practice. It is worthwhile promoting a yoga and Pilates exercise programme for postpartum women in
communities.

Key words: Pilates, postpartum depression, postpartum exercise, postpartum fatigue, yoga

Accepted for publication: 3 October 2012

by six months postpartum; they were on average 8
3 kg

Introduction
heavier (Rooney & Schauberger 2002). Women whose
Postpartum weight retention refers to the difference postpartum weight retention exceeded 4
5 kg had a 14–
between postpartum and pre-pregnancy weight (IOM 25% chance of developing obesity (Linne & Rossner
1990). Weight retention is one of the most significant pre- 2003). However, 60% of women cannot return to their
dictors of weight change at long-term follow-up (Rooney pre-pregnancy weight by six months postpartum (Rooney
et al. 2005). Women who were able to lose the weight they & Schauberger 2002).
gained during pregnancy were only 2
4 kg heavier at In Taiwan, Lee et al. (2011) followed 120 pregnancy
10 years follow-up than women who had retained weight women and found that the women retained more than 6%

Authors: Yi-Li Ko, EdD, RN, Associate Professor, Department of Memorial Hospital, Taipei; Pi-Chu Lin, EdD, RN, Associate Pro-
Nursing, College of Medicine, Fu Jen Catholic University, Taipei; fessor, School of Nursing, College of Nursing, Taipei Medical Uni-
Chi-Li Yang, PhD, Professor, School of Liberal Education, Shih versity, Taipei, Taiwan
Chien University, Taipei; Chin-Lung Fang, PhD, Professor, Depart- Correspondence: Pi-Chu Lin, Associate Professor, School of
ment of Physical Education, National Taiwan Normal University, Nursing, College of Nursing, Taipei Medical University, No. 250,
Taipei; Mei-Ying Lee, BS, RN, Clinical Nurse, Department of Wuxing St., Taipei 11031, Taiwan. Telephone: +886 2 27361661.
Obstetrics and Gynecology Outpatient, Taipei Chang Gung E-mail: pclin@tmu.edu.tw

© 2013 Blackwell Publishing Ltd

2122 Journal of Clinical Nursing, 22, 2122–2131, doi: 10.1111/jocn.12117
Exercise Interventions Postpartum exercise program

of weight at six months postpartum compared with their exercising, and this can affect subsequent exercise habits
pre-pregnancy weight. Huang and Dai (2007) followed 602 (Ko & Chen 2010).
Taiwanese women and found that overweight and obese Limited studies in Taiwan have explored postpartum
conditions increased among subjects from 18
27% pre-preg- exercise, and few healthcare professionals have considered
nancy to 27
57% at six months after childbirth. Six months designing an exercise programme for women at 2–6 months
after birth, 61
3% exceeded IOM recommended weight postpartum. After the postpartum care period, many of
level by at least 1 kg and 24
6% exceeded this level by these women return to the workplace; they perform multi-
more than 5 kg (indicating tendency to develop obesity). ple roles of looking after their family, working and caring
Regarding postpartum women returning to their pre- for a baby. Therefore, implementing a postpartum exercise
pregnancy body weight, the Institute of Medicine (IOM programme will help postpartum women return to their
1991) suggests gradual weight loss (0
5 kg/week for lactat- pre-pregnant body weight and develop a lifestyle of regular
ing women). In a survey of women, 90% of respondents exercise.
were dissatisfied with their postpartum weight, and 71%
were actively attempting to prevent further weight gain
Aims
(Rompolski & Jakicic 2011). Therefore, numerous postpar-
tum women spend money participating in exercise pro- The purpose of this study was to evaluate a postpartum
grammes at general fitness centres. However, these often exercise programme for women in the mid-postpartum
vigorous aerobic exercise programmes designed for the gen- state. This study examined the differences in the body com-
eral public are not appropriate for postpartum women. If a position and levels of fatigue and depression of participants
woman does not appropriately exercise during the postpar- before and after participating in the exercise programme.
tum period, this may cause long-term abdominal muscle
weakness, back pain and postpartum stress urinary inconti-
Background
nence (Mason et al. 2010). Thus, a community-based post-
partum exercise programme that is appropriate for women
Exercise during the mid-postpartum period
at 2–6 months postpartum and is cost-effective must be
developed to improve cardiovascular endurance, enhance Because of the brief inpatient stay following delivery (the
recovery of the core muscles damaged during pregnancy National Health Insurance programme covers 3- and 5-day
and facilitate weight loss. inpatient stays for normal spontaneous deliveries (NSDs)
Postpartum depression (PPD) is an important health and cesarean sections (C-sections), respectively), nurses pri-
issue. The prevalence of PPD ranges 3
5–33% in Western marily focus on providing new mothers with instructions
women, depending on the definition, assessment and time on breastfeeding and caring for vaginal tears. After obtain-
since delivery. In Taiwan, a 40% prevalence of mild to ing normal examination results at six weeks postpartum,
severe PPD was reported at six weeks postpartum (Chen 75% of postpartum women are keen to receive instructions
et al. 2006). In a meta-analysis of 30 studies based only on regarding postpartum exercise and diet. However, these
structured clinical interview assessments, the point preva- instructions are not provided during postpartum visits
lence was estimated be 6
5–12
9%, including both major (Mottola 2002).
and minor depression at various times during the first post- Both NSDs and C-sections damage the perineum and pel-
partum year (Gaynes et al. 2005). The onset of depression vic muscles (Anthony 2002). Primiparas delivering vagi-
during this critical time interferes with a mother’s ability to nally were associated with a 22–35% reduction in pelvic
recognise and respond to their baby’s cries, and hinders the muscle strength between the pregnancy and postpartum
development of the mother–infant relationship. period (Sampselle et al. 1998). Therefore, a weakened abil-
Exercise increases the quantity of beta-endorphins, which ity to support the urinary system and maintain urethral clo-
boosts energy and reduces feelings of anger, confusion, sure leads to urinary incontinence. Training to tighten the
depression, fatigue and nervousness (Berger & Motl 2000). pelvic muscles also strengthens the muscles that control the
However, Chinese culture places great importance on ‘post- urinary system. In addition, spinal extension exercises pre-
partum preservation’ as critical to the overall wellness of a vent back pain, abdominal training improves abdominal
woman who has given birth. It emphasises that postpartum distention and constipation, and taking deep breaths and
women should eat high-caloric high-protein food, rest and relaxing enhances blood circulation and eases physical and
avoid going outdoors, in addition to taking care of the mental stress (Rooney & Schauberger 2002, Krummel
infant. Under this situation, the mother may reduce or stop et al. 2004).

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Journal of Clinical Nursing, 22, 2122–2131 2123
Y-L Ko et al.

At three months postpartum, gentle exercises such as yoga

Relationship of exercise with a return to the
and gymnastics can help recover muscle tone, muscle strength
pre-pregnancy body weight
and flexibility. Yoga and Pilates are popular physical fitness
activities that are simple, safe and involve extensible contrac- Relationships among pregnancy, childbirth and weight are
tions. These activities increase muscle strength and help main- complex and involve interactions of several factors. For
tain a slender figure, as well as facilitating recovery of the core example, the pre-pregnancy weight, gestational weight gain,
muscles that are injured during pregnancy and childbirth. The ethnicity, race, postpartum family roles, diet during preg-
American College of Sports Medicine recommends performing nancy and reduced physical activity all contribute to weight
aerobic exercise 3–5 times per week for 20–60 minutes each retention following childbirth. Therefore, weight loss can-
time. The exercise intensity should reach 40–85% of a per- not be attributed solely to exercise. Nevertheless, exercise
son’s heart rate reserve (HRR) or 12–16 points on the Rating facilitating weight reduction is consistent with the core con-
of Perceived Exertion Scale (RPE) (ACSM 2006). cept of weight loss, that is, ‘eat less and exercise more’.
Keller et al. (2008) reviewed six studies that targeted
weight management interventions for postpartum women.
Exercise improves postpartum fatigue and depression
All six interventions with diet and exercise had a significant
The incidences of PPD and postpartum fatigue are approxi- impact on the body composition of the targeted sample of
mately 13 and 90%, respectively (Ko & Lu 2003, Daley women. Sampselle et al. (1999) found that more-active
et al. 2007). Postpartum fatigue is ‘an overwhelming sus- women retained significantly less weight (8
6 lb  3
9 kg)
tained sense of exhaustion and decreased capacity for physi- than their less-active counterparts (11
3 lb  5
1 kg). Vig-
cal and mental work’ (Song et al. 2010). Unresolved orous exercisers demonstrated a consistent pattern of better
postpartum fatigue influences the mother’s health, role per- scores on measures of postpartum adaptation and were
formance and the parent–child relationship. Physical and more likely than non-exercisers to participate in fun activi-
mental factors such as an inclination toward depression, ties, such as socialising, hobbies and entertainment.
problems breastfeeding, sleep quality and social support were Chien (2003) developed a postpartum rhythmic gymnas-
found to be significantly associated with postpartum fatigue tics programme that incorporated exercise and music. The
(Ko & Lu 2003). Whether regular exercise decreases the results showed that regular participation (three times per
incidence or minimises the severity of PPD remains to be week for a total of 10 times) in this programme from
answered. Epidemiological research suggests that physical one week following childbirth significantly (p < 0
05)
activity may be associated with reduced symptoms of depres- improved the participants’ physical fitness in terms of
sion and a general sense of well-being (U.S. Department of weight, body fat, waist circumference, muscle endurance
Health & Human Services 2000). Exercise was shown to (one minutes of sit-ups), muscle strength (grip strength),
increase the level of serotonin in the brain and can often flexibility (seated forward flexion) and cardiovascular fit-
help relieve mild depressive symptoms (Vogel 2000). ness (three-minutes step test).
In a pilot randomised controlled trial (RCT) in Australia, The results of those studies demonstrate the benefits of
the effects of a 12-week multi-intervention programme exercise for postpartum women. Exercise not only helps
involving group pram-walking exercise sessions (three times women return to their pre-pregnancy body weight, but also
per week) plus social support (once per week) were com- enhances mental health, provides positive feelings and
pared to a control group who were asked to maintain their reduces depression.
usual exercise regime and social activities. Women in the
pram-walking group had significantly lower Edinburgh Post-
Methods
natal Depression Scale (EPDS) scores compared to women
in the control group (Hsiao et al. 2009). The results of
Study design
Dritsa et al. (2009) showed that home-based exercise was
effective in alleviating physical fatigue in women reporting This study adopted a quasi-experimental one-group pretest–
PPD, as measured using the EPDS. Reductions in physical post-test design and a convenience sampling method. Study
fatigue through exercise were partially mediated by reduc- participants performed the postpartum exercise programme
tions in perceived stress and increased exercise-related developed for this study, which was provided once a week for
energy expenditure. Sexton et al. (2012) reported that post- one hour each time and for a three-month period (12 sessions
partum women who more frequently engaged in physical total). The exercise programme was led by a professional
activities recovered better from prenatal depression. coach. Tests were conducted before and after the program.

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2124 Journal of Clinical Nursing, 22, 2122–2131
Exercise Interventions Postpartum exercise program

Yoga’ professor and whose license got from ‘Yoga Fit

Participants and setting
Worldwide Training Systems’ in USA.
This study recruited participants between April 2006–June
2006 from a postpartum outpatient clinic at a medical cen-
Instruments
tre in Taipei. Women at six weeks postpartum, who had
no maternal or neonatal complications and were willing to Study tools included a self-designed structured question-
participate, were enrolled in the study. In total, 28 women naire (including basic information and postpartum exer-
were enrolled, 23 of which completed the entire programme cise), a body composition analyser, the Fatigue Symptoms
and answered the questionnaires (for an 82
1% valid Checklist (FSC), and the Center for Epidemiologic Studies
response rate). Six women did not complete the three- Depression Scale (CES-D).
month exercise programme because of transportation or
child care reasons. Basic information
Basic information included age, height, pre-pregnancy
weight, weight gain during pregnancy, current weight, edu-
Experimental intervention
cational level, occupation, family type, annual household
Professional coach-led postpartum exercise income, pregnancy history, childbirth history and the cur-
The ‘Contemporary Postpartum Exercise Programme’ rent infant feeding method.
designed for women at 2–6 months postpartum was
developed by the principal investigator and the research Postpartum exercise
team based on their clinical experience and related stud- This evaluated whether participants were engaging in regu-
ies. Accompanied by music of different rhythms, the lar exercise, the exercise intensity, exercise conditions and
programme incorporated static stretching of yoga, exten- barriers to exercise.
sible contractions of Pilates and low-intensity aerobics.
Several movements were designed from the perspectives Body composition analyser
of physiology, anatomy and rehabilitative medicine. A body composition analyser was used to measure partici-
Because a lack of exercise during pregnancy results in pants’ height, weight [body mass index (BMI)], fat percent-
body fat accumulation and alters the body shape, and age, lean body mass and total body water (TBW).
considering the damage to the pelvis and abdominal
muscles through NSDs and C-sections, no large move- Fatigue Symptoms Checklist
ments were included in this exercise program. In addi- The FSC, developed by Yoshitake (1971), was designed for
tion, the developed movements conformed to ergonomics the National Institute of Occupational Safety and Health in
and emphasised correcting the tilt in the spine caused Japan to assess fatigue symptoms. The checklist contains 30
by pregnancy, modifying the body posture and training common fatigue symptoms that are categorised into the three
the core pelvic muscles. Harmony between breathing groups of sleepy and powerless (items 1–10), difficult concen-
and movement increases the oxygen level in the blood, trating (items 11–20) and partial abnormalities of the body
which increases metabolism, keeps the body in shape (items 21–30), and each item is associated with a dichotomous
and relieves tension. Yes/No (0–1) response. The total possible score ranges 0–30,
with a higher score suggesting more-severe fatigue.
Intervention process The FSC is a multidimensional scale that has good reli-
According to the ACSM recommendations, regular exercise ability and validity and is not excessively taxing for users.
should be performed three times a week. Considering that Milligan et al. (1997) used the FSC to measure postpartum
it is not easy for postnatal women to go out, and at the fatigue among 285 mothers immediately postpartum, dur-
same time, they are busy taking care of their baby, doing ing the hospitalisation period, and six weeks postpartum.
housework, and possibly working outside the home, the Those study results indicated that the internal consistency
exercise programme was only arranged once a week. of the scale ranged 0
82–0
95.
The exercise programme was conducted on a group basis.
Exercise sessions were provided at 10:30–11:30 AM every Center for Epidemiologic Studies Depression Scale
Saturday for three months in a fitness centre at an univer- This study adopted the Chinese CES-D Scale, which was
sity. The developed postpartum exercise protocol was translated by Chien and Cheng (1985). The scale contains
designed and coached by one certified ‘Pregnant Women 20 descriptions of feelings and behaviour. The translated

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Journal of Clinical Nursing, 22, 2122–2131 2125
Y-L Ko et al.

version was tested on 2901 high school students in Taiwan and

demonstrated good validity; Cronbach’s a of the scale was
Results
0
85–0
90. This study used the translated questionnaire after
Basic information of study participants
obtaining approval from the authors of the Chinese CES-D.
A scale of 0–3 points is applied to each item in the The average age of the 23 postpartum women was
Chinese CES-D, for a total score ranging 0–60 points. 34
07 ± 4
18 years. The average number of pregnancies
According to personal feelings or frequency of behaviour, among the participants was 2
00 ± 1
04; however, 12
the answers to each item are ‘<1 day per week’ (0 point), participants (52
2%) were primiparas. Most participants
‘1–2 days per week’ (1 point), ‘3–4 days per week’ (2 points) had an educational background of a college degree or
and ‘5–7 days per week’ (3 points). Answers to items 4, 8, above (73
9%). Additionally, most participants had a
12 and 16 are in the reverse order. A cut-off point at 15 was full-time job (69
6%). Nineteen (82
6%) women had
used to identify depression in populations of Taiwan. NSDs. About half of the participants provided exclusive
breastfeeding, while the others adopted mixed feeding.
Study tools and tests of reliability and validity Only 2 (8
7%) of the participants were exercising after
The scales adopted in this study are popular domestic and over- childbirth. Most of the participants lived in a nuclear
seas scales, all of which have good reliability. In this study, family (60
9%).
Cronbach’s a for both the FSC and the CES-D was 0
85. The mean score of depression at the pretest was
12
48 ± 8
45 points; the score ranged 0–35. Regarding their
depression scores at the pretest, five women (21
7%) scored
Ethical considerations
0–5 points, 5 (21
7%) scored 6–10 points, 6 (26
1%)
This study was approved by the Institute Review Board of women scored 11–14 points and seven women (30
5%)
the hospital where the study was conducted. The purpose scored  15 points. The mean score of fatigue at the pretest
and process of this study were explained to potential partic- was 9
70 ± 5
62; the subscale ‘sleepy and powerless’, exhib-
ipants. After signing an informed consent form, participants ited a higher score of 3
70 ± 2
22 (Table 1).
were enrolled in the study. Additionally, participants were
informed that they could withdraw from the study at any
time without loss of benefits. Table 1 Basic information of study participants (n = 23)

Characteristic n (%) Mean ± SD

Data collection procedure
Age (year) 34
07 ± 4
18
We first obtained consent from physicians and nurses of the Gravida 2
00 ± 1
04
Primipara 12 (52
2)
department to cooperate in this study. Nurses provided a
Education level
list of postpartum women, who were then contacted by the
 University 17 (73
9)
researcher. Postpartum women were enrolled in the study  College 6 (26
1)
after signing the informed consent form. A pretest was con- Work status
ducted before the first session of the exercise programme. Full-time job 16 (69
6)
The pretest collected data of the participants’ basic infor- Others 7 (30
4)
Method of delivery
mation, postpartum exercise habits, postpartum fatigue and
NSD 19 (82
6)
body composition. After the three-month exercise pro- C-section 4 (17
4)
gramme, a post-test was conducted to again measure post- Breastfeeding
partum fatigue and body composition. Exclusive 11 (47
8)
Mixed feeding 12 (52
2)
Exercise habits
Data analysis Yes 2 (8
7)
No 21 (91
3)
SPSS, version 11.0 was used for the statistical analyses (SPSS Family structure
Inc., Chicago, IL, USA). Participants’ basic information was Nuclear family 14 (60
9)
displayed using frequency, percentage, mean and standard Other 9 (39
1)
deviation (SD). A paired t-test was employed to identify dif- Fatigue (pretest) 9
70 ± 5
62
Depression (pretest) 12
48 ± 8
45
ferences in weight, body composition, fatigue and depres-
sion before and after the exercise programme. NSD, normal spontaneous delivery; C-section, cesarean section.

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2126 Journal of Clinical Nursing, 22, 2122–2131
Exercise Interventions Postpartum exercise program

in the low-score group completed the post-test. Compared

Fatigue and depression in study participants
to their depression score obtained in the pretest, the
A paired t-test was used to compare feelings of fatigue decrease of 0
44 points in their scores did not reach a
before and after the exercise intervention among the 23 significant level (t = 0
294, p = 0
772).
postpartum women (Table 2). The mean score of fatigue at
the pretest was 9
70 ± 5
62 points, and it was 8
30 ± 4
69
Changes in physiological indicators
points at the posttest. A reduction of 1
39 points did not
reach a significant level (t = 1
222, p = 0
234). The statisti- Changes in body composition before and after the exercise
cal power of the overall fatigue score between pre- and programme are shown in Table 2. Participants achieved an
post-test was 0
28. Cohen’s d statistics was 0
27, indicating average weight reduction of 1
74 kg, which reached a sig-
a medium effect size. On the subscale ‘sleepy and power- nificant level (p < 0
001), whereas the decrease in BMI was
less’, the mean score of physical fatigue was higher than not significant (t = 1
059, p = 0
301). Participants main-
that of psychological fatigue; the section on fatigue symp- tained a BMI of approximately 22 kg/m2. The participants
toms also exhibited a high score. achieved a 1
86% decrease in fat percentage, which reached
The mean depression score of the 23 postpartum women a significant level (p < 0
001); the differences in both fat
at the pretest was 12
48 ± 8
45 points, and it was mass (t = 6
541, p < 0
001) and fat loss (t = 6
227,
10
13 ± 6
02 points at the post-test. However, a decrease p < 0
001) also reached a significant level. However, differ-
in 2
35 points did not reach a significant level (t = 1
744, ences in the fat-free mass (t = 1
009, p = 0
324) and TBW
p = 0
095). The statistical power of the depression score (t = 0
024, p = 0
981) were not significant. These results
between the pre- and post-test was 0
34. Cohen’s d statis- showed that exercise significantly decreased body fat.
tics was 0
32, also indicating a medium effect size. Based
on the depression score at the pretest, the study participants
Discussion
were categorised into high- (  15 points) and low-score
(  14 points) groups, which respectively contained 8 and
Effectiveness of exercise for postpartum fatigue and
20 participants. Seven of the eight participants in the high-
depression
score group completed the post-test. Compared to their
depression score obtained in the pretest, these participants In this study, 30
5% of participants had a depression score
obtained a significant decrease of 6
71 ± 5
71 points of  15 points, the cut-off point indicating depression in a
(t = 3
113, p = 0
021) in their scores. Sixteen participants Taiwanese population, suggesting that these women were

Table 2 Body composition analysis (n = 23)

Pretest Post-test
Dimensions and subscales Mean ± SD Mean ± SD t p

Fatigue
Physical (items 1–10) 3
70 ± 2
22 3
39 ± 2
35 0
644 0
526
Psychological (items 11–20) 3
26 ± 2
49 2
52 ± 2
00 1
479 0
153
Symptoms (items 21–30) 2
74 ± 1
76 2
39 ± 1
56 0
735 0
470
Total score 9
70 ± 5
62 8
30 ± 4
69 1
222 0
234
Depression scores (n = 23) 12
48 ± 8
45 10
13 ± 6
02 1
744 0
095
 14 (n = 16) 8
31 ± 4
90 7
8750 ± 5
43 0
294 0
772
 15 (n = 7) 22
00 ± 7
01 15
29 ± 3
86 3
113 0
021*
Weight (kg) 58
83 ± 7
32 57
09 ± 7
04 5
987 <0
001**
Body mass index (kg/m2) 22
56 ± 2
66 22
25 ± 2
70 1
059 0
301
Body fat (%) 31
41 ± 5
93 29
55 ± 5
94 5
184 <0
001**
Basic metabolic rate 1257
91 ± 85
06 1239
65 ± 84
60 5
941 <0
001**
Fat mass 18
74 ± 5
45 17
16 ± 5
15 6
541 <0
001**
Free fat mass 38
76 ± 6
23 39
92 ± 3
33 1
009 0
324
Total body water 29
23 ± 2
32 29
23 ± 2
45 0
024 0
981
Fat loss 11
33 ± 5
25 9
71 ± 5
01 6
227 <0
001**

*p < 0
05; **p < 0
001.

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Journal of Clinical Nursing, 22, 2122–2131 2127
Y-L Ko et al.

prone to depression. However, the depression scores likely to have high depression scores after childbirth
obtained in this study were lower than those obtained by compared to women in the control group (p = 0
01). In con-
Chen et al. (1994), who found that in Taiwan, 40% of trast, among participants in the low-score group, the exercise
women six weeks postpartum suffer from postnatal depres- programme did not result in any significant differences in
sion (PND). Robertson et al. (2004) reported that the prev- their depression scores. Daley et al. (2009) reviewed five
alence rate of postpartum blues was 30–75%, which is also RCT or quasi-RCT studies that targeted PND management
higher than that obtained in this study. The occurrence of intervention for postpartum women. The results showed that
depressive illness following childbirth can be detrimental to compared with no exercise, exercise reduced symptoms of
the mother, her marital relationship and her children, and PND (with a standardised mean difference in the effect size
can have adverse long-term effects if untreated. For her of 0
8 and 95% confidence interval of 1
53 to 0
10).
children, a mother’s ongoing depression can contribute to Dritsa et al. (2009) indicated that exercise reduced ten-
later emotional, behavioural, cognitive and interpersonal sion and increased exercise-related energy consumption,
problems. Studies indicated that the postpartum mood is thus relieving postpartum fatigue. However, the effective-
associated with changes in hormone levels, including pro- ness of exercise in relieving fatigue was not observed in this
gesterone, oestrogen, cortisone, beta-endorphins, oxytocin study. Researchers suggested that a portion of postpartum
and prolactin (Yang et al. 2005); therefore, a number of fatigue depends on the characteristics of the infant and
postpartum women experience depression. Psychosocial fac- breastfeeding behaviour (Ko & Lu 2003), and exercise may
tors also play important roles. Robertson et al. (2004) indi- be ineffective for those factors. Furthermore, the compara-
cated that the strongest predictors of PPD included tively small sample size of this study may have concealed
depression during pregnancy, anxiety during pregnancy, the effectiveness of exercise for relieving fatigue.
experiencing stressful life events during pregnancy or the
early puerperium, low levels of social support, and a previ-
Influence of exercise on the body composition of
ous history of depression. The most critical period for
postpartum women
detecting PND is reported to be within six weeks of delivery
(Robertson et al. 2004). Daley et al. (2007) also pointed out Postpartum exercise aims to promote contraction of the
that the peak incidence of depression is within the first uterus and perineum muscles and strengthen the abdominal
4–6 weeks after birth. When hormone levels stabilise, the and pelvic floor muscles, to return to a pre-pregnancy state
depressed mood may improve. The time of data collection in and early restoration of body fitness. Our results revealed
this study was two months after delivery; therefore, the prev- that after the three-month exercise intervention, postpartum
alence of depression should have been lower than immedi- women had obtained significant decreases in weight, fat per-
ately after delivery. Postpartum women who obtain a high centage, BMR and fat mass. These findings are consistent
depression score should receive follow-up and be provided with those reported in previous studies (Chien 2003, Watson
with appropriate interventions for managing emotions to et al. 2005, Keller et al. 2008, Hsiao 2009). Chien (2003)
help them regain their mental health status and appropriately showed that postpartum rhythmic gymnastics helped women
perform their role as a mother. regain physical fitness. Watson et al. (2005) designed a
Results of this study showed that among the seven partici- 12-week group pram walking programme for pregnant
pants who reached the cut-off point (15 points) for depres- women in Australia and monitored those women until
sion, the three-month exercise programme contributed to a six months postpartum. The results demonstrated the effec-
significant decrease in their depression score. This finding is tiveness of the walking programme in regaining physical
consistent with those reported by Heh et al. (2008) and fitness and providing social benefits. In addition, the pro-
Daley et al. (2009), which suggested that exercise improves gramme helped participants reduce their weight and body
depression. Heh et al. (2008) investigated the effectiveness of fat and regain their previous figure, improving their confi-
exercise support in reducing the severity of PND. In their dence. Keller et al. (2008) found that exercise facilitated
study, 80 primiparas in Taiwan with an EPDS score of >10 postpartum fat and weight loss. In addition, Hsiao (2009)
at four weeks postpartum were allocated to either an inter- also found that postnatal women after receiving yoga teach-
vention group (provided with exercise support) or a control ing intervention, the experimental group had significant
group (provided with standard care) at six weeks postpar- differences on weight, BMI and flexibility. Liaw (2008) indi-
tum. The main outcome measure was their EPDS scores at cated that moderate-intensity exercise does not have negative
five months postpartum. The results revealed that women impacts on breast milk. Therefore, yoga and Pilates exercise
who received the exercise support programme were less is worth promoting postpartum exercise programme.

© 2013 Blackwell Publishing Ltd

2128 Journal of Clinical Nursing, 22, 2122–2131
Exercise Interventions Postpartum exercise program

Conclusions Relevance to clinical practice

The results of this study showed that among women at The postpartum yoga and Pilates exercise programme deve-
2–6 months postpartum, the three-month exercise interven- loped in this study was conducted by a professional coach.
tion significantly reduced the depression level in those who The results supported the safety and effectiveness of the pro-
were prone to depression. However, the intervention did gramme. Considering transportation convenience, regular
not yield significant differences in their fatigue levels. exercise programmes designed for women at 2–6 months
Regarding body composition, the exercise intervention sig- postpartum should be delivered in communities to develop
nificantly reduced participants’ weight, body fat percentage exercise habits among postpartum women. Currently, only
and fat mass, which positively contributed to them regain- one domestic study has investigated a postpartum exercise
ing their previous figure. intervention. Therefore, we encourage more experts and
scholars of obstetrics and gynecology and physical education
to participate in this research field, and call for greater train-
Study limitations and recommendations
ing of postpartum exercise instructors.
This was the first trial study of postpartum women at
2–6 months who participated in a group exercise programme
Acknowledgements
in the community in Taiwan. The results of this study were
limited by the use of a single-group pre- and post-test This research study is funded by a grant from National Science
design with only 12 sessions, so the results should be gener- Council (No. NSC 95-2413-H-255-001). The author thanks
alised with caution. However, it is very difficult to encour- the nurses in the Chang Gung Memorial Hospital, Taipei, for
age women to go outdoors for exercise due to the cultural assisting in the enrollment of the study participants.
issue of traditional postnatal care in Taiwan. Chinese cul-
ture attaches great postpartum regimen of ‘doing the
Contributions
month’. Women are expected by stay indoors for a full
month and avoid cold winds. Therefore, in the second post- Study design: Y-LK, C-LY, C-LF, P-CL; data collection and
partum month, women were more willing to go outdoors analysis: M-YL, Y-LK and manuscript preparation: Y-LK,
to attend an exercise programme which is worthy of praise. P-CL.
Further research is needed on adopting a qusai-experimen-
tal design that contains a control group. In addition, the
Conflicts of interest
sample size and exercise dose can be increased to improve
the ability to generalise the results. The authors declare that they have no conflicts of interest.

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