bs_bs_banner

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: alizades@tbzmed.ac.ir

doi:10.1111/ijn.12259 © 2014 Wiley Publishing Asia Pty Ltd

2 F Mohammadi et al.
INTRODUCTION
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 adapta-
tion 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 exist-
ing 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 post-
partum 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 exer-
cise programme on treatment of postnatal depression and
fatigue. To our knowledge, there is no research published
about the effect of antenatal and postnatal exercise pro-
gramme 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.
© 2014 Wiley Publishing Asia Pty Ltd
METHODS
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 cur-
rently suffering from depression (Edinburgh score less
than 1520) or other known psychiatric disorders, obstetri-
cal 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 cur-
rently 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 postna-
tal ordinary educations in a 40 min session. The women in
the intervention1 group attended a theoretical and a prac-
tical 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 recom-
mended 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
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 post-
partum.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 allo-
cation 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 alloca-
tion 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
3
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 partici-
pants 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 (com-
pared 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
4 F Mohammadi et al.

Assessed for eligibility

n = 441

304 were not eligible

10 refused to participate

Randomly assigned
n = 127

Control group Intervention 1 Intervention 2

n = 42 n = 43 n = 42

1 month post-partum completed 1 month post-partum completed 1 month post-partum completed

questionnaire questionnaire questionnaire
n = 35 n = 38 n = 35

2 months post-partum completed 2 months post-partum completed 2 months post-partum completed

questionnaire questionnaire questionnaire
n = 36 n = 38 n = 36

Analysed Analysed Analysed

1 month post-partum = 35 1 month post-partum = 38 1 month post-partum = 35
2 months post-partum = 36 2 months post-partum = 38 2 months post-partum = 36 Figure 1. Flow diagram of trial.

Table 1 Characteristics of participants in the study groups

Characteristics Control Intervention 1 Intervention 2

n = 42 n = 43 n = 42

Age (years)
15–29 34 (81) 36 (84) 33 (79)
≥ 30 8 (19) 7 (16) 9 (21)
Mean ± SD 25.3 ± 5.2 25.2 ± 4.7 25.5 ± 4.6
Education (years)
6–8 19 (45) 18 (42) 17 (40.5)
≥9 23 (55) 25 (58) 25 (59.5)
Employed 2 (5) 0 (0) 3 (7)
Sufficient family income 23 (55) 23 (53.5) 25 (59.5)
Spouse education
Elementary and intermediate 19 (45) 26 (60.5) 26 (62)
High school and higher 23 (55) 17 (39.5) 16 (38)
Live with her family or spouse 13 (31) 13 (30) 15 (36)
Family
History of psychiatric disorder 1 (2) 0 (0) 0 (0)
History of psychiatric disorder 3 (7) 1 (2) 3 (7)
In family
Lack of good relation with her husband 0 (0) 1 (2) 2 (5)
Occurrence of bad events in the recent months 7 (17) 7 (16) 8 (19)
Unwanted pregnancy 6 (14) 7 (16) 8 (19)
Complicated pregnancy 3 (7) 1 (2) 5 (12)
Nulliparity 29 (69) 22 (51) 25 (59.5)
History of abortion 6 (14) 9 (21) 6 (14)

The data are given as n (%) unless otherwise specified.

© 2014 Wiley Publishing Asia Pty Ltd

Exercise for postnatal depression and fatigue 5

Table 2 Edinburgh Postnatal Depression Scale (EPDS) scores of the groups in the three time-points during study

EPDS score Baseline One month post-partum Two months post-partum

C. I.1 I.2 C. I.1 I.2 C. I.1 I.2

n = 42 n = 43 n = 42 n = 35 n = 38 n = 35 n = 36 n = 38 n = 36

0–10 29 (69) 30 (70) 26 (62) 26 (74) 24 (63) 27 (77) 28 (78) 30 (79) 31 (86)
11–12 6 (14) 7 (16) 5 (12) 5 (14) 6 (16) 3 (9) 3 (8) 5 (13) 2 (6)
≥ 13 7 (17) 6 (14) 11 (26) 4 (12) 8 (21) 5 (14) 5 (14) 3 (8) 3 (8)
Attrition — — — 7 (17) 5 (12) 7 (17) 6 (14) 6 (14) 6 (14)
Mean 8.14 7.77 9.07 7.46 7.66 8.03 6.50 6.58 6.58
SD 3.94 3.86 3.91 4.50 5.46 4.95 5.12 4.63 4.63
Median 8.5 7 9 6 7 7 5.5 6 6
Percentile 25 5 4 7 5 3 5 2.25 3 3
Percentile 75 11 11 13 11 12 10 9.75 9 9
P† 0.24 0.82 0.70

†
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 15

difference scores was not significantly different among
the groups, both 1 (P = 0.36) and 2 months post-partum
10
(P = 0.75) (Fig. 2).
EPDS score changes

5
FIF scores
On the baseline assessment, 19% of control, 28% of inter-
vention 1 and 16% of intervention 2 had FIF scores of 0
≥ 13. In 1 month post-partum, these rates were 17.5%,
29% and 20%; and in 2 months post-partum, they were –5
22%, 18% and 22%, respectively.
No significant differences were identified in mean rank –10
of FIF scores among the three groups at the baseline
(P = 0.90), 1 month post-partum (P = 0.72) and 2
–15
months post-partum (P = 0.89) (Table 3).
There was 5 or over reduction in FIF scores (compared Control Intervention 1 Intervention 2
with the baseline) found in 20% of control, 21% of inter-
Figure 2. Box plot showing Edinburgh Postnatal Depression Scale
vention 1, 23% of intervention 2 group, 1 month post-
(EPDS) score changes 1 month and 2 months post-partum within the
partum; and 25%, 29% and 19% of intervention 2 group
groups. Control: no intervention; Intervention 1: antenatal exercise;
2 months post-partum, respectively. Mean rank of the
Intervention 2: antenatal and postnatal exercise. , EPDS score
difference scores was not significantly different among the
changes 1 month post-partum; , EPDS score changes 2 months
groups, both 1 (P = 0.76) and 2 months post-partum
post-partum. EPDS, Edinburgh Postnatal Depression Scale.
(P = 0.87) (Fig. 3).

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

6 F Mohammadi et al.

Table 3 Fatigue Identification Form (FIF) scores of three interventional groups during study

FIF score Baseline One month post-partum Two months post-partum

C. I.1 I.2 C. I.1 I.2 C. I.1 I.2

n = 42 n = 43 n = 42 n = 35 n = 38 n = 35 n = 36 n = 38 n = 36

0–3 6 (14) 13 (30) 7 (17) 11 (31.5) 8 (21) 7 (20) 11 (31) 11 (29) 10 (28)
4–12 28 (67) 18 (42) 28 (67) 18 (51.5) 19 (50) 21 (60) 17 (47) 20 (53) 18 (50)
13–19 6 (14) 12 (28) 5 (14) 4 (11.5) 8 (21) 6 (17) 8 (22) 5 (13) 7 (19)
≥ 20 2 (5) 0 (0) 1 (2) 2 (6) 3 (8) 1 (3) 0 (0) 2 (5) 1 (3)
Attrition — — — 7 (17) 5 (21) 7 (17) 6 (14) 5 (12) 6 (14)
Mean 8.43 8.09 8.26 7.60 8.89 8.03 7.14 7.29 7.61
SD 4.78 5.60 5.19 6.34 6.94 5.65 6.03 5.92 6.00
Median 7.5 7 8 6 7 7 6 6 7.5
Percentile 25 4.75 3 5 3 4 4 1.25 2.75 2
Percentile 75 10.25 13 11 10 14.5 12 11.75 11.25 10.75
P† 0.90 0.72 0.89

†
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.

Table 4 The number of exercise sessions performed by the inter-

30
vention groups

The number Antenatal Antenatal Postnatal

20
of sessions exercise in exercise in exercise in
intervention 1 intervention 2 intervention 2
FIF score changes

10 n = 38 n = 36 n = 36

< 10 16 (42) 14 (39) 24 (67)

0 10–20 13 (36) 10 (28) 12 (33)
> 20 9 (24) 12 (33) †

–10
The data are given as n (%). † Total number of exercise session
was assumed 30–40 sessions during pregnancy and maximum of
–20 20 sessions during post-partum period.

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; Interven-
tion 1: antenatal exercise; Intervention 2: antenatal and postnatal exer-
cise. , 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 sub-
jects in both groups did not regularly exercise.
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.

© 2014 Wiley Publishing Asia Pty Ltd

Exercise for postnatal depression and fatigue
In a 12 week randomized-controlled trial, Armstrong
and colleagues investigated the effects of a multi-
intervention 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 inter-
vention 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 signifi-
cantly 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 effec-
tiveness 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 sig-
nificant 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 high-
intensity exercise might be more effective than low-
intensity exercise. Exercises in our study were antenatal
and postnatal low-intensity stretching and breathing prac-
tices, 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 exer-
cise 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
7
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
8 F Mohammadi et al.
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 Obstet-
ric, 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 Obstet-
ric, 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 preg-
nancy 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 preg-
nancy 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
© 2014 Wiley Publishing Asia Pty Ltd
symptomatology for postnatal women. International Journal
of Nursing Practice 2004; 10: 177–194.
18 Drista M, Dupuis G, Khalife S. Effect of home-based exer-
cise intervention on fatigue in postpartum depressed
women: Results of randomized controlled trial. Annals of
Behavioral Medicine 2008; 35: 179–187.
19 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.
20 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.
21 Cox J, Holden J, Sagovsky R. Detection of postnatal
depression: Development of the 10 item Edinburgh Post-
natal Depression Scale. The British Journal of Psychiatry 1987;
150: 782–786.
22 Linda C. Clinical approaches in the assessment of childbear-
ing fatigue. Journal of Obstetric, Gynecologic, and Neonatal
Nursing 1998; 28: 74–80.
23 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).
24 Mead GE, Morley W, Campbell P, Greig CA, McMurdo
M, Lawlor DA. Exercise for depression. Cochrane Database
of Systematic Review 2008; Cd004366.
25 Zwarenstein M, Treweek S, Gagnier JJ. et al. Improving
the reporting of pragmatic trials: An extension of the
CONSORT statement. BMJ 2008; 337: a2390.