Contactless exercise intervention in prenatal and postnatal period during COVID-19 lowers the risk of postpartum depression

doi:10.21203/rs.3.rs-2987919/v1

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Contactless exercise intervention in prenatal and postnatal period during COVID-19 lowers the risk of postpartum depression

https://doi.org/10.21203/rs.3.rs-2987919/v1

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published 29 Apr, 2024

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The COVID-19 pandemic has had a substantial adverse impact on the physical and mental health of pregnant and postpartum women, thereby increasing the risk of postpartum depression (PPD). This study aimed to evaluate the effectiveness of a continuous contactless exercise intervention in reducing the risk of PPD during the prenatal and postnatal periods. The study utilized a real-time contactless exercise program consisting of Pilates for eight weeks during pregnancy and eight weeks after childbirth. Metabolic and psychological factors related to PPD, including pain, stress, and stress-response markers, were analyzed. The results showed that the exercise intervention significantly alleviated PPD by improving pain and stress factors caused by physical structural imbalances in postpartum women. Additionally, the intervention improved the metabolic imbalances commonly observed after childbirth, including reductions in triglyceride (TG), insulin, leptin, and cortisol levels, which are recognized risk factors for PPD. Taken together, these findings suggest that contactless online exercise interventions can mitigate postpartum depression by addressing metabolic dysregulation that frequently occurs after delivery, especially in situations of social isolation caused by the pandemic.

Health sciences/Health care

Health sciences/Risk factors

The coronavirus disease (COVID-19) pandemic has brought many changes to our daily lives, culture, society, and economy worldwide^[1]. To prevent viral infections, most people stayed at home, and obesity and other complications increased significantly as physical activity decreased ^[2]. In particular, pregnant women were classified as high-risk groups, and were excluded from vaccination, thereby increasing psychological burdens such as fear of infection and anxiety; quarantine increased the level of physical inactivity and the prospect of depression^{[3, 4]}. In general, pregnant women show unstable psychological conditions due to changes in female hormones, and the symptoms can worsen depending on social or environmental factors that can cause gestational depression^[5]. Several researchers have reported that continuous fear and stress caused by COVID-19 are highly correlated with the development of postpartum depression (PPD) and obesity in case of pregnant women ^{[6, 7]}. To prevent these problems, maternal care, such as prenatal care, meditation, and exercise, was implemented; however, as all educational programs were suspended after COVID-19, women's health was widely threatened^[8].

PPD is a mental illness that has negative consequences on the mother's health status and the physical development of offspring after childbirth; approximately 40% of women experience PPD after childbirth^[9]. The pathological mechanisms of PPD have not been clearly identified; however, physical problems such as repetitive housework, back pain, obesity, lack of sleep, loss of self-identity, appearance dissatisfaction, and environmental factors can cause PPD^{[10, 11]}. In relation to COVID-19, increased stress during the pandemic had a substantial impact on PPD outbreaks, and the resurgence of the virus further increased stress, anxiety, and depression levels in women. ^{[12, 13]}.

As such, PPD induction has a combination of various causes, and active physical activity is recommended for both preventive and therapeutic purposes^{[14, 15]}. The benefits of exercise have already been proven in many studies, and Pilates, a combination of aerobic and anaerobic exercises, is known to improve women's health before and after childbirth. According to related studies, Pilates is effective in correcting body balance by strengthening core and pelvic muscles, relieving back pain in pregnant women, and strengthening the muscles around hip joints^{[16, 17]}. Regular Pilates exercise reduces the levels of triglycerides (TG), low-density lipoprotein (LDL) cholesterol, and insulin resistance, thereby preventing gestational diabetes; it also reduces the fear of childbirth, anxiety, fatigue, and stress during pregnancy^[18]. Postpartum women's participation in Pilates also reduces the levels of visual analog scale (VAS) and Oswestry Disability Index (ODI), which are back pain indices, and have a significant effect on weight, waist circumference, and WHR reduction after childbirth^{[19, 20]}.

However, after COVID-19, it has become difficult for women to exercise, and there is a significant lack of alternative methods for prenatal management. Accordingly, the American College of Obstetrics and Gynecologists (ACOG) recommended participating in home-training or online exercise for more than 150 min per week^[21]. Several studies have verified the effect of non-face-to-face exercise. Only a few studies are available on online exercise in pregnant women during COVID-19; Ramachandra^{[19, 22]} found that tele-physical therapy in 29 weeks pregnant women with severe pelvic girdle pain reduced back pain,^[22], and Pilates, with the help of a real-time video chat application, reduced back pain and pelvic pain in women after childbirth^[23]. In addition, postpartum online Pilates was effective in preventing PPD and diet effects^[24]. These results suggest that prenatal and postpartum exercises are effective in preventing depression, regardless of the form (face-to-face or non-face-to-face). Nevertheless, women are not properly managed, and epidemiological investigations of PPD over the past two to three years are insufficient. Ebrahimian et al. reported that 90% of postpartum women experience a feeling of melancholy, which is a pre-depression stage, but most of them do not recognize it as a disease; missing treatment for severe PPD can lead to serious social problems such as loss of judgment, infant murder, or suicide^[9]. Accordingly, the American Society of Obstetrics and Gynecology recommended that women be screened for anxiety and depression periodically at 1, 2, and 4 months after childbirth and emphasized the importance of national administrative support and management^[22].

Considering that PPD is caused by emotional problems in pregnant women and failure to manage prenatal conditions, including obesity, and that biochemical changes related to pregnancy obesity are closely correlated with postpartum psychological diseases^[3], continuous exercise participation from pregnancy to the postpartum period can act as an important variable. However, to date, most PPD-related studies have been conducted separately in pregnant and postpartum women, and few studies have examined the relationship between PPD and biological changes in pregnant women, reflecting environmental characteristics such as COVID-19. Therefore, this study aimed to investigate the effect of continuous online training before and after childbirth, on PPD risk factors and to determine its correlation with obesity.

Changes of body composition in non-exercised and exercised postpartum women.

Postpartum women typically experience changes in body composition (BC), and these changes might have various health implications. Therefore, understanding the association between BC and postpartum women is crucial for identifying the potential health risks and developing therapeutic options. The BC parameters measured before and after the continuous online exercise program in postpartum women are presented in Table 2. No significant group-by-time interactions were observed in BC parameters (Table 2). However, in the exercised group, beneficial changes in the fat ratio were observed in comparison with the non-exercised group, with a larger effect size (d = -0.86). Unexpectedly, the exercise group showed a decrease in lean mass; however, the effect size was small (d = -0.23). Thus, our results suggest that continuous exercise participation using an online platform in a socially isolated situation increases the body’s metabolic rate, which helps postpartum women to burn more calories and reduce body fat.

Impact of continuous home-based contactless exercise participation via an online platform on metabolic parameters in postpartum women.

During pregnancy, a women’s body undergoes significant changes in lipid metabolism, which may persist for some time after delivery. Continuous exercise participation via an online platform altered the metabolic parameters, showing a tendency to decrease in both the non-exercised and exercised groups of postpartum women (Table 2). A significant group-by-time interaction was identified only for TG level (F = 5.907, p = 0.05). During the postpartum period, all participants exhibited a significant decrease in TG levels (F = 62.68, p < 0.001), with a large effect size (d = -2.79); however, only postpartum women who exercised, showed a greater reduction in TG levels compared to the non-exercised group (p < 0.001). In terms of HDL, it is generally expected that exercise is effective in increasing the level of HDL; however, the results showed a decreasing tendency in both the non-exercise and exercise group, although that of the exercise group was significantly higher (p = 0.048, table 2).

Hormonal changes mediated by continuous contactless exercise via an online platform during postpartum period.

Previous studies have shown that postpartum women experience significant hormonal changes that may contribute to metabolic dysfunction, postpartum depression, or other health issues. Therefore, we measured the hormonal axes that may contribute to metabolic dysfunction and mood disorders in postpartum women (Fig. 2). A significant group-by-time interaction was identified between insulin (F= 4.716, p = 0.032; Fig. 2A) and cortisol (F = 26.37, p < 0.001; Fig. 2A) levels. Postpartum women assigned to continuous contactless exercise participation showed a greater reduction in serum insulin and cortisol levels in comparison to the corresponding pre-value (insulin: p < 0.001; cortisol: p < .001) and control (insulin: p = 0.003; cortisol: p < 0.001), although both non-exercised and exercised groups showed a significant decrease in the hormones after delivery (insulin: p = 0.003; cortisol: p = 0.004). However, there were no significant differences in leptin and serotonin levels, with a tendency to decrease leptin and increase serotonin levels after continuous contactless exercise participation.

Evaluation of functional state and psychological factors

After being assigned to home-based exercise, self-reported survey-based assessments of stress, pain, and the probability of depression in postpartum women were analyzed (Fig. 3). A significant group-by-time interaction was identified for all the indices (ODI: F = 169.1, p < 0.001; EPDS: F = 46.36, p < 0.001; PSS: F = 152.6, p < 0.001; Fig. 3A, C, and E). During the postpartum period, continuous contactless exercise participation via an online platform resulted in a significantly decreased scores in ODI (p < 0.001, Fig. 3A), EPSD (p < 0.001, Fig. 3C), and PSS (p < 0.001, Fig. 3E), with a remarkable improvement in functional state (ODI: p < 0.001, Fig. 3B) and emotional distress (EPDS: p < 0.001; ΔPSS: p < 0.001, Fig. 3D and F) in postpartum women.

Association between biological parameters and psychological functioning

Pearson’s correlation coefficient analysis was performed to determine whether changes in biological parameters mediated by continuous home-based contactless exercise participation via an online platform during the postpartum period were associated with emotional stress (EPDS and PSS) (Figure 4). The EPDS scores were positively correlated with the fat ratio (r = 0.15, p < 0.05), TG (r = 0.42, p < 0.01), CRP (r = 0.36, p < 0.01), cortisol (r = 0.49, p < 0.01), insulin (r = 0.42, p < 0.01), and leptin (r = 0.72, p < 0.01), respectively as shown in Figure 4A. Moreover, the PSS score was positively correlated with the fat ratio (r = 0.33, p < 0.01), TG (r = 0.56, p < 0.05), CRP (r = 0.3, p < 0.05), cortisol (r = 0.66, p < 0.01), insulin (r = 0.39, p < 0.01), and leptin (r = 0.67, p < 0.01), respectively and negatively correlated with HDL (r = -0.25, p < 0.05), as shown in Supplementary Fig. S1. More importantly, EPSD and SPP scores were mutually correlated (see Supplementary Fig. S1 online).

Through this is a Continuous Excellence partitioning via an online platform (CEOP) study, we identified several notable results. First, exercise conducted during pregnancy and after childbirth alleviated postpartum depression by improving the pain and stress factors caused by the mother's physical structural imbalance. Second, CEOP lowered metabolic control and stress response factors (TG, Insulin, Leptin, and Cortisol) that contribute to postpartum depression. These results suggest that in a situation where social isolation caused by the COVID-19 pandemic is common, CEOP can alleviate postpartum depression by improving the metabolic imbalances that occur frequently after childbirth.

Regarding gestational obesity, the U.S. Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) actively recommend participation in physical activities to maintain a healthy pregnancy; they also recommend at least 150 minutes of medium-intensity exercise per week for both pregnant and postpartum women^{[25, 26]}. In addition, the Institute of Medicine (2015) stipulates the standard weight for each pregnant woman according to their weight before pregnancy to prevent the gestational weight gain (GWG)^[27]. However, approximately 50% of pregnant women have a GWG exceeding the standard weight, which must be managed because the inflammation caused by gestational diabetes and the visceral fat accumulation can be fatal to maternal and fetal health^[28].

To date, there are no clear guidelines for pregnant women's exercise; however, ACOG suggests that in healthy pregnant women, participating in moderate-intensity exercise for 20–30 minutes daily lowers insulin resistance and is effective in preventing GWG^[22]. However, there is a significant lack of alternatives for treating the obesity problem that was increased by the pandemic among pregnant women. Although there are many applications for home training and YouTube content, there are few real-time online exercise programs that consider the physical and epidemiological conditions of pregnant women, most of whom are healthy. Therefore, based on the exercise intensity of ACOG, we conducted a real-time contactless exercise intervention for pregnant women under the supervision of a professional exercise leader and confirmed the following effects: The body fat amount, weight, BMI, and TC of this exercise group reduced more than those of the non-exercise group, and significant differences and interaction effects between groups and periods were observed for insulin and TG. These results are consistent with studies that show that online exercise reduces weight and blood lipids in overweight and obese pregnant women, lowering the risk of pregnancy complications^{[29, 30]}, pregnant women's real-time online Pilates participation during COVID-19 reduced their weight, BMI, and visceral fat after childbirth^[31]. In addition, considering that the metabolic syndrome caused by obesity is caused by inflammation secreted by fat tissues, the increase in HDL, LDL, and CRP in this study indicates that exercise lowers the chain reaction of body fat-abnormal lipidemia-inflammation. In addition, significant differences in muscle strength between groups suggest that continuous exercise has a positive effect on the rate of postpartum recovery^[32], and previous studies support the idea that eHealth interventions have the same effect as face-to-face exercise^{[33, 34]}.

Psychological factors in pregnant and postpartum women are highly correlated with PPD, and the COVID-19 environment has a higher risk of developing depression in young or pregnant women than in men^{[35, 36]}. Kim & Hyun (2022) suggested that online exercise is helpful for the psychological stability of motherhood^[24]. However, to date, most studies on online exercises have been conducted on women after childbirth^[37–39]. Therefore, we mediated continuous exercise during pregnancy and the postpartum period, and verified its preventive effect on PPD. The results showed that continuity exercise had intergroup differences and interaction effects on cortisol levels, PSS, and EPDS in women after childbirth, all of which were positively correlated with PPD. This indicates that continuous exercise in this study not only directly lowers EPDS but is also related to the PPD subvariables cortisol, PSS, and ODL. Previous studies have suggested that increased maternal stress has a significant impact on fetal neural development and cortisol levels, a potential biomarker of stress, are associated with exercise and cognitive development at six months of age^[40]. Our findings confirm that exercise has a positive effect in cortisol levels, reflecting psychological stress and that cortisol reduction has a direct effect on PPD. These results are consistent with studies showing that Maryam exercise has a positive effect on stress and serum cortisol levels in pregnant women^[41] and that the degree of activity (exercise frequency) in pregnant women has a negative correlation with cortisol levels^[42]. In addition, in relation to hormones, a PPD sub-variant, leptin levels tended to decrease in the continuous exercise group of this study. These results are consistent with studies showing that exercise and dietary interventions in obese pregnant women significantly reduce leptin^[43] and that long-term exercise before and during pregnancy in animal experiments has a significant difference in insulin and leptin levels^[44]. Bad habits, such as irregular postpartum sleep, late-night snacks, and binge eating, intensify depression by increasing leptin resistance and reducing serotonin^[45]. Although there was no significant change in serotonin levels in this study, positive changes in leptin and cortisol levels indicated that continuous contactless exercise via an online platform can regulate the metabolic mechanism of PPD.

Back pain is caused by physical and mechanical changes in women before and after pregnancy and has a direct effect on PPD^[46]. Most pregnant women experience back pain, but spinal rearrangement may not occur within four to five months after childbirth, or the degree of pain may worsen due to incorrect posture, sitting habits, holding the baby on one side, or overuse of smart devices^{[18, 23]}. According to a recent survey, 90% of early postpartum women (from postpartum to 21 weeks of age) who do not exercise experience abdominal muscle relaxation, which causes back pain, urinary incontinence, and pelvic girdle pain^[47]. On the other hand, pregnant women who participate in regular physical activities relieve physical fatigue, back pain, and pelvic pain and reduce the risk of sleep disorders and depression^{[48, 49]}. In this study, back pain was positively correlated with PPD, and continuous exercise directly reduced back pain. Considering that previous studies have suggested that back pain can promote pregnancy and postpartum depression^[50], home-based online training can be used as an indirect healing method. It will also be effective in reducing PPD during continuous rather than short-term exercise. Although this study did not compare short-term and long-term interventions, this aspect should be verified through further studies.

Taken together, our research supports previous studies showing that online exercise is a good alternative for maintaining healthy conditions in pregnant and postpartum women^{[51, 52]}. It is also consistent with studies showing that online exercise programs are more effective when conducted under the supervision of leaders than when exercising alone^{[53, 54]}. In particular, the presence of a leader during exercising in pregnancy may have a synergistic effect caused by an increase in the exercise effect due to interactive communication and the formation of a consensus among the subjects (similar pregnancy and childbirth periods, parenting stress).

Physical, psychological, environmental, and social factors are complex during PPD outbreaks. Therefore, successful weight loss after childbirth or reducing stress is not the only solution to PPD. In addition, pregnant women with large metabolic changes are vulnerable to all diseases; therefore, continuous observation and measures are needed until postpartum period, including during the pregnancy. However, some studies have reported that exercise does not provide any special benefits for the health of pregnant women and their offspring^{[55, 56]}. These differing results are because the exercise form or intensity setting in pregnant women is unclear ^[32], and dietary recommendations can be more important than exercise for GWG^{[49, 56]}. Therefore, future studies require an integrated intervention through a more systematic classification ( according to women's weight gain, pre-pregnancy, or quarterly group classification).

Despite the various effects observed in this study, it has several limitations. First, it was not possible to consider individual differences in the physical strength levels of pregnant women. Since pre-pregnancy fitness levels can affect GWG and PPD and are also related to the rate of recovery after childbirth, exercise interventions considering pre-pregnancy BMI and fitness levels should be applied in future studies. However, as mentioned earlier, there are no detailed guidelines for online exercises for pregnant women. Therefore, it will be our homework to prepare exercise guidelines for non-face-to-face programs and verify their safety and effectiveness. Second, the dietary recommendations for pregnant and postpartum women were not thoroughly regulated. This study was conducted in a special environment of COVID-19, and the stress experienced by the participants greatly increased. Therefore, excessive calorie restriction can harm the psychological state of pregnant women, and increased stress is likely to cause participants to drop out of the study. Therefore, we provided information on dietary recommendations on the day of the pre-examination, and after the study began, nutritional status was checked once a week by a professional nutritionist. The participants wrote a daily meal diary, and the nutritionist advised them about incorrect eating habits or food choices. However, some postpartum women's late-night snacks, high-GI foods, and salty foods are not completely regulated. In future studies, balanced diet intervention and exercise should be combined to verify the preventive effects of PPD. Third, the number of blood samples used in the analysis of some of the hormonal indicators (Leptin, Serotonin) was insufficient. This was the result of the subject's disapproval of the process of collecting additional blood, and the results of the experiment are planned to supplement the reliability of the results in future follow-up studies on the premise of a high possibility.

In conclusion, these findings suggest that the contactless online exercise interventions can mitigate postpartum depression by addressing metabolic dysregulation that frequently occurs after delivery, especially in situations of social isolation caused by the pandemic.

Ethics approval

This study was approved by the Bioethics Committee of Korea National Sports University (IRB No. 1263-202109-br-018-01) and was conducted following the related guidelines and regulations (the recommendations of the Declaration of Helsinki). All participants were provided with a detailed description of the study, and they signed a consent form before the study began. Written informed consent was obtained from all subjects.

Study design and participants

A total of 60 pregnant women at 22–26 weeks of pregnancy were included in the study, corresponding to those under 45 years of age and with a body mass index (BMI) of 25 kg/m². All participants took part in the study with the consent of their doctors and had no medical findings (not corresponding to gestational diabetes or high blood pressure, excluding twin pregnant women). Since this study aimed to verify the effectiveness of continuous exercise during pregnancy and after childbirth, participants who could participate for a total of eight months were selected. A total of 60 pregnant women were recruited, and they were randomly divided into exercise (n=30) and non-exercise groups (n=30). Thirty pregnant women in the exercise group participated in Pilates for eight weeks, and after childbirth, they were recruited again and participated in postpartum Pilates for eight weeks. The Study design is illustrated in <Figure 1>.

Contactless exercise program

The exercise group participated in a contactless exercise program consisting of Pilates for eight weeks during the first intervention period (pregnant) and participated in the second intervention 100 days after childbirth. The participants participated in the exercise in real-time using a video chat application in their respective homes and communicated directly with the leader. The exercise was conducted for a total of eight weeks, twice a week, for 50 minutes a day, and it was the same before and after the prenatal period. The exercise program consisted of warm-up, main, and cool-down exercises with a rest time of 10 s in between. Exercise intensity was set at 55-65% of the maximum heart rate according to the standards of the American Obstetrics and Gynecology Association (ACOG, 2020). The exercise intensity evaluation maintained a subjective exercise index (RPE) of 11-13 using the Borg's scale and increased exercise intensity every three weeks. The leader checked the participant’s condition every hour and recommended immediate rest if physical pain or discomfort was observed during exercise. The non-exercise group banned participation in all sports except housework and childcare and was periodically supervised during the intervention period. The online Pilates program used in this study is shown in <Table 1>.

Body Composition and blood tests

All participants stopped eating food two hours before the measurement and emptied their bladders 10 min before the test. The height of each participant was measured using an automatic kidney meter (DS-103M; Dong Shan Jenix Co., Seoul, Korea). Body composition tests measured weight (kg), body fat (kg), BMI (kg/m²), skeletal muscle mass (kg), and body fat percentage (%) using bioelectrical impedance analysis (In-Body 770, Biospace Co., Seoul, Korea). All the participants removed their metal accessories, dressed lightly, and stood with their sole touching the foot and hand electrodes. For blood sugar and blood lipid tests, all participants fasted from 9 pm on the previous day to 10 am on the day of the test. The nurse took a 5 mL blood sample from the upper arm vein. After incubating at room temperature for 30 min, the blood sample was centrifuged (3000 rpm, 10 min) to separate the serum and immediately transferred to the Green Cross Research Institute. The analyzed items included insulin, total cholesterol (TC), triglycerides (TG), low-density lipoprotein (LDL), high-density lipoprotein (HDL), CRP, insulin, cortisol, leptin, and serotonin.

Edinburgh Postnatal Depression Scale test

A postpartum depression test was performed using the Edinburgh Postpartum Depression Scale (EPDS). The EPDS is a self-report scale developed in the UK and has been modified for Korean mothers. A total of ten question items, and questions about depression, anxiety, and suicidal thoughts over the past week were asked. Each item was evaluated on a 4-point Likert scale ranging from 0 to 3, with a total score of 0 to 30. A total score of 13 points or higher was considered as risk of depression. In this study, the reliability of the EPDS (Cronbach’s alpha) was 0.83, which was analyzed using SPSS (version 22.0; IBM, Armonk, NY, USA).

Perceived Stress Scale test

The Perceptual Stress Scale (KPSS), developed by Cohen (1988) and modified by Lee (2016) in Korean, was used for the stress test. The total number of items was 10, and each item used a 5-point scale (0 = never, 1 = rarely, 2 = occasionally, 3 = frequently, 4 = Very Often) to ask about the perceived stress over the past month. Negative questions were scored in reverse, with a total score of 40. The higher the score, the more stressful it was. The PSS reliability of this study (Cronbach’s alpha) was 0.83, and SPSS 22.0 was used (IBM, Armonk, NY, USA).

Oswestry Disability Index test

The ODI (Oswestry Disability Index) questionnaire was used to measure the degree of back pain. The ODI was developed to measure the level of back pain symptoms and the degree of pain-related dysfunction, with a total of ten evaluation items consisting of pain management, personal management, walking, standing, sitting, sleep, and social life. Each question is scored from 0 to 5, and the total score is calculated by summing the scores for each item. Then, the total score is divided by 50 and multiplied by 100 to obtain the percentage value. Values in each range indicate patients with minimal, moderate, severe, paralysis, and bed-bound disabilities ( 0–20%, 21–40%, 41–60%, 61–80%, and 81–100%), respectively. To verify the effectiveness of this study, the scores are given before and after the experiment, and the total score is recorded. The reliability (Cronbach's) of the ODL used in this study was 0.84, which was processed using SPSS version 22.0.

Statistical Analyses

All data were processed using GraphPad Prism software (GraphPad Prism Inc., CA, USA). Statistical significance was determined by two-way analysis of variance (ANOVA) to test the effect of time, group, and their interaction on functional state, psychological factors, body composition, and hormones, followed by Tukey’s post hoc test for multiple comparisons. Unpaired t-test was conducted to analyze the delta (Δ) changes in the ODI, PSS, and EPDS tests. Correlation between scores were derived from the psychological state questionnaire and related biological factors. The effect sizes (Cohen’s d) between the pre- and post-test results were expressed as the mean change. Statistical values wefre presented as mean ± standard deviation (SD), and a p <.05 was considered statistically significant.

Acknowledgements

This work was supported by the National Research Foundation (NRF) grant funded by the Korean Government (MEST) (NRF-2021R1A6A3A01086399)

Author contributions

Each author has contributed significantly to this work and has read and approved the final version of the manuscript. A.-H.H. designed the experiments and interpreted the data. D.-J.H., and A.-H.H. performed all experiments and analyzed the data. D.-J.H., J.-Y.C., and A.-H.H. wrote and edited the manuscript.

Competing interests

The authors declare no competing interests.

Data availability

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

Ethical declarations - This study was approved by the Bioethics Committee of Korea National Sports University (IRB No. 1263-202109-br-018-01) and was conducted following the related guidelines and regulations (the recommendations of the Declaration of Helsinki). All participants were provided with a detailed description of the study, and they signed a consent form before the study began.

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Table 1. Contactless exercise intervention program

Modes	Contents	Time (min)	Reps, Set, and Rest	RPE
Modes	Prenatal exercise	Time (min)	Reps, Set, and Rest	RPE
Warm-up	Breathing & stretching	10		10
Main Exercise	Level 1: 1~3 week Bridge, clam, Cat cow, One -leg circles, Side kick, Spine twist, Kneeing push-up, Squat Level 2: 4~6 week Half standing roll down, Leg side up, Saw, Donkey kick, Down dog, Half-lunges, Wide-lunges, Side steps Level 3: 7~8 week Squat with mini ball, Spine twist on the ball, Shoulder press with band, Lunge-twist, kneeing down dog plank, Breathing	30	12∼15 reps × 3 set 10 sec rest between sets	11~13
Cool-down	Deep breathing & Meditation	10		10
	Prenatal exercise
Warm-up	Total body stretching	10		10
Main Exercise	Level 1: 1~3 week Roll down, Kneeing push-up, Crunch, Leg raise, Side leg circles, Squat with shoulder press Level 2: 4~6 week Lunges, Sidewalk, Hill squat, Animal walking, Side-crunch, Wide leg raise, push-up Level 3: 7~8 week Deep squat, Lunge twist, Side plank, Knee up run, Squat Jump, Oblique Crunch, Leg raise with mini ball, Saw with ball	30	12∼15 reps ×3 set. 10 sec rest between sets	11~14
Cool-down	Breathing & stretching	10		10

Table 2. Comparison of body composition and metabolic parameters in blood before and after contactless exercise. Two-way ANOVA followed by Tukey’s multiple comparison test was performed. Tables depict mean ± SD. Pairwise calculation of (Cohen's d) effect size between pre- and post-values were expressed as mean changes. p < 0.05 was considered to be statistically significant.

	Non-exercise		Effect size	Exercise		Effect size	Statistics
	Pre	Post	Cohen's d	Pre	Post	Cohen's d	Interaction effect	Time effect	Group effect
Body weight (g)	65.43 ± 6.8	63.47 ± 6.8	-0.40	66.84 ± 6.0	60.68 ± 7.1	-1.32	F (1, 116) = 2.834; p=.095	F (1, 116) = 10.57; p=.002	F (1, 116) = 0.3011; p=.584
Fat mass (g)	25.05 ± 5.5	23.54 ± 5.7	-0.38	23.93 ± 5.2	20.75 ± 5.6	-0.83	F (1, 116) = 0.6572; p=.419	F (1, 116) = 5.212; p=.024	F (1, 116) = 3.623; p=.059
Lean mass (g)	24.75 ± 6.0	24.61 ± 5.6	-0.03	29.14 ± 8.7	27.76 ± 8.1	-0.23	F (1, 116) = 0.2138; p=.645	F (1, 116) = 0.3179; p=.574	F (1, 116) = 7.823; p=.006
Fat ratio (%)	36.41 ± 4.7	34.86 ± 4.7	-0.46	34.55 ± 4.9	31.55 ± 4.9	-0.86	F (1, 116) = 0.6610; p=.418	F (1, 116) = 6.411; p=.013	F (1, 116) = 8.300; p=.005
BMI (kg/m²)	25.59 ± 2.9	24.60 ± 3.1	-0.46	25.49 ± 2.7	23.22 ± 3.3	-1.04	F (1, 116) = 1.278; p=.261	F (1, 116) = 8.173; p=.005	F (1, 116) = 1.691; p=.196
	Non-exercise		Effect size	Exercise		Effect size	Statistics
	Pre	Post	Cohen's d	Pre	Post	Cohen's d	Interaction effect	Time effect	Group effect
TG (mg/dL)	210.1 ± 56.8	157.20 ± 49.1	-1.41	199.30 ± 61.7	99.53 ± 36.3	-2.79	F (1, 116) = 5.907; p=.017	F (1, 116) = 62.68; p<.001	F (1, 116) = 12.61; p<.001
TC (mg/dL)	236.70 ± 30.2	200.07 ± 28.7	-1.75	241.63 ± 36.2	183.40 ± 33.9	-2.35	F (1, 116) = 3.214; p=.076	F (1, 116) = 62.00; p<.001	F (1, 116) = 0.9485; p=.332
HDL (mg/dL)	71.63 ± 17.9	60.97 ± 16.6	-0.87	76.00 ± 15.6	72.93 ± 19.1	-0.25	F (1, 116) = 1.385; p=.242	F (1, 116) = 4.523; p=.036	F (1, 116) = 6.398; p=.013
LDL (mg/dL)	152.13 ± 25.4	126.13 ± 22.7	-1.52	148.00 ± 25.0	111.23 ± 26.7	-2.00	F (1, 116) = 1.338; p=.250	F (1, 116) = 45.47; p<.001	F (1, 116) = 4.181; p=.043
CRP (mg/dL)	1.02 ± 0.7	0.68 ± 0.6	-0.67	0.87 ± 0.8	0.26 ± 0.3	-1.37	F (1, 116) = 1.124; p=.291	F (1, 116) = 14.32; p<.001	F (1, 116) = 5.256; p=.024

No competing interests reported.

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Contactless exercise intervention in prenatal and postnatal period during COVID-19 lowers the risk of postpartum depression

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