Effect of different physical activity interventions on perinatal depression: A systematic review and network meta-analysis

doi:10.21203/rs.3.rs-3719640/v1

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Research Article

Effect of different physical activity interventions on perinatal depression: A systematic review and network meta-analysis

https://doi.org/10.21203/rs.3.rs-3719640/v1

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published 30 Jul, 2024

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Background

Perinatal depression can have profound impacts on both families and society. Exercise therapy is gradually becoming a widely used adjunct treatment for perinatal depression. Some studies have already focused on the relationship between physical activity and perinatal depression (PND). However, there is currently a lack of systematic and comprehensive evidence to address the crucial question of making optimal choices among different forms of physical activity. This study aims to compare and rank different physical activity intervention strategies and identify the most effective one for perinatal depression.

Methods

Four databases, namely PubMed, Cochrane Library, Embase, and Web of Science, were searched for randomized controlled trials assessing the impact of physical activity interventions on perinatal depression. The search covered the period from the inception of the databases until June 2023. Two researchers independently conducted literature screening, data extraction, and quality assessment. Network meta-analysis was performed using Stata 15.1.

Results

A total of 45 studies were included in the analysis. The results indicate that relaxation therapy has the most effective outcome in reducing perinatal depression (SUCRA = 96.6%). Following that is mind-body exercise (SUCRA = 73.8%). Traditional aerobics and aquatic sports were also effective interventions (SUCRA = 70.1% and 67.6%, respectively).

Conclusion

Our study suggests that integrated mental and physical (MAP) training such as relaxation therapy and mind-body exercise show better performance in reducing perinatal depression. Additionally, while exercise has proven to be effective, the challenge lies in finding ways to encourage people to maintain a consistent exercise routine.

Trial registration

Registration and protocol CRD 42023469537.

Trial registration

This study has been registered on PROSPERO (CRD 42023469537).

physical activity

women

perinatal depression

network meta-analysis.

Perinatal Depression (PND), defined as depression occurring during pregnancy (prenatal depression) or after childbirth (postpartum depression), is a common mental disorder with a prevalence exceeding 10% [1–3]. Risk factors for PND may include a history of depression, lower socioeconomic status, poor physical health, anxiety about pregnancy, and reduced social support, while better living conditions and higher levels of education are possible protective factors [4, 5]. Research suggests that the prevalence of perinatal depression is higher among women in low and middle-income countries compared to women in high-income countries [6], and first-time mothers may have a higher risk of postpartum depression compared to multiparous women [7]. Perinatal depression not only has a negative impact on the mother’s quality of life, intimate relationships, childbirth outcomes, and the likelihood of breastfeeding but also has long-term effects on the social, emotional, cognitive, language, motor, and adaptive behavior development of children [5, 8, 9]. However, social stigma, difficulty in recognizing depression, limited understanding of treatment options, and a lack of access to treatment are major barriers to addressing perinatal depression [10].

Both pharmacological and non-pharmacological treatments can alleviate symptoms of perinatal depression in women [11]. However, due to concerns about potential adverse effects of medications on the health of the fetus and infant, some women tend to prefer non-pharmacological treatments [12]. Non-pharmacological treatments primarily include psychological interventions, physical therapies, exercise therapy, music therapy, acupuncture, and more [13]. Psychological intervention is the first-line treatment for mild to moderate perinatal depression, and its therapeutic effects can last for at least 6–12 months[14]. Cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) are effective psychological interventions for perinatal depression [15].

It’s worth noting that exercise therapy, due to its low cost and ease of implementation, has gradually become a widely used adjunctive treatment for postpartum depression [16]. Exercise during pregnancy and postpartum may have benefits for both maternal and fetal health: it can reduce the risk of conditions such as preeclampsia, gestational hypertension, gestational diabetes, excessive weight gain during pregnancy, and complications during childbirth. It also improves the psychological well-being of pregnant and postpartum women, lowers the incidence and severity of perinatal depression, reduces complications in newborns, has no adverse effects on birth weight, and does not increase the risk of stillbirth [17–21]. The American College of Obstetricians and Gynecologists (ACOG) considers exercise to be generally safe for perinatal women and recommends that women engage in moderate-intensity exercise for 20–30 minutes most days of the week, as it may play a significant role in preventing postpartum depression [22].

Previous research has indicated a positive correlation between aerobic exercise and the alleviation of perinatal depression symptoms. Group exercise, participant-choice exercise, and combined interventions involving exercise have all shown potential effectiveness as interventions [16, 23]. Prenatal yoga has been shown to improve current mood and reduce symptoms of both prenatal and postpartum depression [24–26]. Women who engage in moderate physical activity in aquatic environments have a lower risk of developing postpartum depression compared to sedentary women. Prolonged sedentary behavior during pregnancy has been closely associated with positive screening for postpartum depression, particularly in overweight and obese pregnant women [27]. A meta-analysis and systematic review have suggested that interventions such as exercise, yoga, meditation, tai chi, or qigong can improve symptoms of depression. Among these, exercise is most beneficial for treatment-resistant depression, unipolar depression, and post-traumatic stress disorder, while mindfulness-based meditation can have lasting effects on depression for up to six months or longer [28].

Previous meta-analyses have often focused on the association between physical activity and perinatal depression, but there has been a lack of high-quality evidence to support decisions regarding the optimal choice among various physical activity interventions. To address this gap and provide more precise and safe treatment options for women with perinatal depression, this study conducted a network meta-analysis and systematic review based on high-quality randomized controlled trials (RCTs). The aim was to compare and rank different physical activity interventions and determine the best physical activity intervention for perinatal depression. This research seeks to offer more accurate guidance for the treatment of perinatal depression in women.

2.1 Protocol and registration

We followed the requirements of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines for literature inclusion, data organization, statistical analysis, and results reporting. This study has also been registered on PROSPERO (CRD 42023469537).

2.2 Data sources and search strategy

We conducted a comprehensive search for relevant literature on the association between physical activity and perinatal depression in four electronic databases: PubMed, Cochrane Library, Embase, and Web of Science. The search period extended from the inception of the databases up to June 20, 2023. Following the PICOS (Population, Intervention, Comparison, Outcome, Study Design) principles, the search terms included “Exercise” or “Exercises” or “Physical Activity” or “Physical Activities” or “Motor Activity” or “Sport” or “Aerobics” or “Training” or “Trainings” or “Jogging” or “Walking” or “Ambulation” or “Yoga” or “Swimming” or “Dancing” or “Cycling” or “Resistance” or “Pilates” or “Stretching” and “Postpartum Depression” or “Postnatal Depression” or “Postnatal Dysphoria” or “Postpartum Dysphoria” or “Puerperal depression” or “Antepartum depression” or “Antenatal depression” or “Perinatal depression” or “Prenatal depression” or “Depression during pregnancy” or “Postpartum psychosis.” For specific search strategies, please refer to Supplementary Appendix A.

2.3 Study selection

After conducting the literature search using the aforementioned search strategy, two authors (YS and DL) independently conducted the literature screening process. Initial screening was performed by reviewing the titles and abstracts of the retrieved articles to identify potentially relevant studies. Subsequently, the articles with higher relevance were selected for full-text retrieval and examination. Ultimately, the literature meeting the criteria was included in the statistical analysis. In cases of disagreement, group discussions were held among team members to reach a consensus.

2.4 Inclusion and exclusion criteria

This systematic review, based on the PICOS framework, established criteria for the selection, inclusion, and exclusion of literature.

Inclusion criteria for literature were as follows:

(1) Study subjects were perinatal women, including those during pregnancy and within one year postpartum [5].

(2) Interventions involved various types of exercise or physical activity.

(3) Studies reported data on depression indicators in perinatal women before and after the intervention.

(4) Experimental study designs were limited to randomized controlled trials (RCTs).

(5) Original data were provided.

(6) The studies were written in English.

Exclusion criteria for literature were as follows:

(1) Study participants were not perinatal women.

(2) The intervention did not include physical activity.

(3) There was no reporting on depression-related outcomes.

(4) The study types included qualitative research, reviews, theses, conference papers.

(5) Non-interventional study designs, including cross-sectional studies, case-control studies, and cohort studies.

(6) Original data were not provided.

(7) The studies were written in a language other than English.

2.5 Data extraction

The data from the included trials were independently extracted by two authors (YS and DL). Any discrepancies that arose during this process were resolved through group discussions. The following information was extracted from each study:

(1) Descriptive information, such as author(s), year, and country.

(2) Participant characteristics, including age range, gender, and sample size.

(3) Intervention details, including time, frequency, and duration.

(4) Outcome measurements, specifically related to perinatal depression.

When interventions or outcomes were unclear but presented graphically, the Engauge Digitizer software was used to extract data. For studies with multiple follow-up assessments, data were only extracted immediately after the intervention. In cases where standard deviations were not provided, they were calculated from the confidence intervals (95%) of the mean within the intervention or control group.

2.6 Quality assessment

We employed the Cochrane Risk of Bias assessment tool within the Review Manager 5.4 software to assess the quality of the studies using seven criteria: (1) Random sequence generation; (2) Allocation concealment; (3) Blinding of participants and personnel; (4) Blinding of outcome assessment; (5) Incomplete outcome data; (6) Selective reporting; (7) Other sources of bias.

2.7 Statistical analysis

We calculated the Standardized Mean Difference (SMD) with a 95% confidence interval (CI) for continuous outcomes. The statistical heterogeneity level was assessed using the p-value from the chi-square test and the I² index from the heterogeneity test, and the appropriate effect model was chosen accordingly. When the level of heterogeneity was low (p ≥ 0.1 and I² ≤ 50%), a fixed-effects model was used to analyze the data. Otherwise, a random-effects model was employed (p < 0.1 or I² > 50%) [29]. Following the recommendations of PRISMA NMA, we used a Bayesian framework and the Markov chain Monte Carlo simulation in Stata 15.1 software to aggregate and analyze NMA data [30, 31]. Node-splitting analysis was used to quantify and explain the consistency between indirect and direct comparisons. If the p-value was greater than 0.05, it was considered consistent through the consistency test.

We conducted a network meta-analysis using a Bayesian model. Data preprocessing was performed using the network package, and evidence network plots were generated. In the evidence network plot, each point represents an intervention, and the size of the point corresponds to the sample size included in the respective intervention study. Lines connecting two points represent direct comparisons between two interventions, and the thickness of the line segment indicates the number of studies included in the comparison, with thicker lines indicating more included studies. To rank the effects of different types of exercise, we calculated the Surface Under the Cumulative Ranking Curve (SUCRA) and presented the probability ranking in a table. SUCRA is expressed as a percentage, where a higher proportion indicates a better effect of the intervention. Furthermore, to assess publication bias and the effect of smaller sample studies, we generated funnel plots and checked for symmetry using symmetry tests.

3.1. Trial selection

To ensure the accuracy of the literature retrieval and screening process, two researchers (YS and DL) with expertise in the fields of perinatal depression and exercise science independently screened titles, abstracts, and full-text articles after the literature search was completed. The inter-rater reliability (Cohen’s kappa) between these two screening stages was calculated, including the screening stages for titles and abstracts, as well as the full-text screening stage. The consistency levels were categorized as follows: fair consistency (0.40–0.59), good consistency (0.60–0.74), and excellent consistency (> 0.75) [32].

After conducting comprehensive searches on the four electronic databases, a total of 7,912 articles were initially identified. Following the removal of duplicate studies (n = 1,494), 6,418 relevant articles remained. Subsequently, through title and abstract screening, 6,295 articles were excluded, leaving 102 articles eligible for full-text review. During this stage, the inter-rater reliability between the two assessors was classified as “good” (Cohen’s kappa = 0.73). After a full-text review, 57 articles were further excluded. Among these, 11 were not randomized controlled trials, 17 did not involve exercise interventions, 26 had unavailable data, and 3 lacked full-text access. Finally, 45 studies were used for quantitative synthesis (Fig. 1). During this stage, the inter-rater reliability between the two assessors was classified as “excellent” (Cohen’s kappa = 0.81).

3.2. Trial characteristics

Table 1 presents the characteristics of the 45 included studies. All studies were published between 2003 and 2022. The United States had the highest number of publications, with a total of 11 papers. The sample size in the intervention groups ranged from 8 to 396 individuals, totaling 2,832 perinatal women. The control group sample sizes ranged from 7 to 382 individuals, totaling 2,804 perinatal women. The average age of women included in the experimental and control groups was less than 40 years.

Table 1

Summary table of included reviews.
Study	Country	N (IG; CG)	Age (IG; CG)	Intervention (IG)			Intervention (CG)			Perinatal period	Outcomes
Study	Country	N (IG; CG)	Age (IG; CG)	Intervention content	Intervention time, frequency, period	Type	Intervention content	Intervention time, frequency, period	Type	Perinatal period	Outcomes
Aguilar-Cordero et al., 2019	Spain	65; 64	34.52 ± 4.50; 33.67 ± 5.37	Exercise in an aquatic environment	60 min, 3 weekly, 18 weeks	Aquatic sport	Recommendations and consultations	NR	Usual care	Prenatal	EPDS
Armstrong et al., 2003	Australia	10; 10	NR; NR	Pram-walking + social support	30–40 min, 3 weekly, 12 weeks	Walking	NI	NI	NI	Postpartum	EPDS
Armstrong et al., 2004	Australia	9; 10	≤ 29 7, ≥ 30 12	Pram-walking	40 min, 2 weekly, 12 weeks	Walking	Non-structured sessions	90 min, 1 weekly, 12 weeks	Social support	Postpartum	EPDS
Bose, 2015	India	26; 28	NR; NR	Exercise (heating and cycling)	40–60 min, 4 weekly, 4 weeks	Traditional aerobics	Patient handout	NR	Health education	Prenatal	PHQ-9
Buttner et al., 2015	USA	27; 29	29.81 ± 5.17; 32.45 ± 4.78	Yoga	150 min, 1 weekly, 8 weeks	Mind-body exercise	NI	NI	NI	Postpartum	HDRS
Coll et al., 2019	Brazil	187; 382	27.2 ± 5.5; 27.3 ± 5.5	Exercise (aerobic activities, strength training, etc.)	60 min, 3 weekly, 16 weeks	Combination exercise	Usual care	NR	Usual care	Prenatal	EPDS
Daley et al., 2008	UK	16; 15	21–30 20, 31–40 17, > 40 1	Exercise (pram-walking, etc.) + exercise consultations	30 min, 5 weekly, 12 weeks	Traditional aerobics	Usual care	NR	Usual care	Postpartum	EPDS
Daley et al., 2015	UK	43; 42	31.7 ± 5.3; 29.3 ± 5.7	Exercise (walking, jogging, etc.) + exercise consultations	30 min 3–5 weekly, 6 months	Traditional aerobics	Usual care	NR	Usual care	Postpartum	EPDS
Daley et al., 2018	UK	189; 194	27.7 ± 6.2	Walking + exercise consultations + behavioural support	30 min, 6–7 weekly, 8 weeks	Walking	Behavioural support	20 min, 6 weekly, 4 weeks	Usual care	Prenatal	EPDS
Davis et al., 2015	USA	20; 19	29.74 ± 5.40; 30.57 ± 4.46	Yoga	75 min, 1 weekly, 8 weeks	Mind-body exercise	Usual care	NR	Usual care	Prenatal	EPDS
Duchette et al., 2021	USA	10; 9	27.1 ± 2.88; 30.1 ± 4.10	Yoga	75 min, 1 weekly, 10 weeks	Mind-body exercise	Do not participate in yoga	NR	NI	Prenatal	EPDS
El-Rafie et al., 2016	Egypt	50; 50	26.7 ± 2.3; 28.4 ± 2.6	Aerobic exercise (step aerobics, bicycling, or walking)	60 min, 3 weekly, 12 weeks	Traditional aerobics	Usual care	NR	Usual care	Prenatal	CES-D
Field et al., 2013(a)	USA	37; 38	24.4 ± 4.7; 26.0 ± 5.6	Tai chi/yoga	20 min, 1 weekly, 12 weeks	Mind-body exercise	NI	NI	NI	Prenatal	CES-D
Field et al., 2013(b)	USA	40; 39	24.4 ± 4.7; 24.5 ± 5.02	Yoga	20 min, 1 weekly, 12 weeks	Mind-body exercise	Leaderless group sessions	Consistent with IG	Social support	Prenatal	EPDS
Forsyth et al., 2017	UK	11; 11	25.0 ± 5.1; 27.0 ± 5.5	Pram-walking + exercise consultations	150 min, 1 weekly, 12 weeks	Walking	Usual care	NR	Usual care	Postpartum	EPDS
Gallagher et al., 2020	USA	48; 31	30.44 ± 6.17; 27.65 ± 7.46	Yoga	30 min, 2 weekly, average of 7.46 (3–16) instructor-led sessions	Mind-body exercise	Usual care	NR	Usual care	Prenatal	HADS
Garnæs et al., 2019	Norway	38; 36	31.3 ± 3.8; 31.4 ± 4.7	Treadmill walking + resistance training	50–60 min, 4 weekly, from gestational week 12–18 to delivery	Combination exercise	Usual care	NR	Usual care	Prenatal	PGWBI
Gustafsson et al., 2016	Norway	396; 365	30.5 ± 4.4; 30.4 ± 4.3	Aerobic and strength training	45–60 min, 3 weekly, 12 weeks	Combination exercise	Usual care	NR	Usual care	Prenatal	PGWBI
Haruna et al., 2013	Japan	48; 47	33.8 ± 3.6; 33.7 ± 4.0	Aerobic exercise (bounce on an exercise ball)	90 min, 4 weekly, 4 weeks	Traditional aerobics	NR	NR	NI	Postpartum	EPDS
Heh et al., 2008	China	33; 30	NR; NR	Stretching exercise	60 min, 3 weekly, 3 months	Traditional aerobics	Usual care	NR	Usual care	Postpartum	EPDS
Huang et al., 2011	China	61; 64	32.13 ± 4.50, 30.67 ± 3.70; 31.91 ± 4.85	Individualised dietary and physical activity education plan	30–40 min, 1 bimonthly, from gestational week 16 to six months postpartum (IG 1), from 24–48 hours after birth to six months postpartum (IG 2)	Traditional aerobics	Obstetric educational programme	1 trimonthly	Health education	Postpartum	BDI
Keller et al., 2014	USA	39; 54	28.3 ± 5.59; 28.3 ± 5.59	Group walking ± 4 different types of support	1 weekly, 12 weeks	Walking	Health information	1 monthly	Health education	Postpartum	EPDS
Kim et al., 2018	Korea	23; 22	32.22 ± 2.58; 31.50 ± 4.48	Structured bed exercise (isometric exercise)	30 min, 1 daily, 4 days	Strength training	NR	NR	NI	Prenatal	EPDS
Kim et al., 2022	Korea	8; 8	39.71 ± 2.01; 38.14 ± 1.39	Pilates	50 min, 2 weekly, 8 weeks	Mind-body exercise	Do not participate in any exercise	NR	NI	Prenatal	EPDS
Kiyak et al., 2021	Turkey	71; 70	30.70 ± 6.44; 30.70 ± 6.37	Progressive muscle relaxation exercises ± laughter therapy	40 min, 3–4 times, from the first day of ovarian stimulation protocol to the day of oocyte retrieval	Relaxation therapy	Usual care	NR	Usual care	Prenatal	BDI
Lewis et al., 2014	USA	61; 63	31.69 ± 5.27; 31.39 ± 4.63	Exercise (walk, bike, weights, etc.) + exercise consultations	30 min, 5 weekly, 6 months	Combination exercise	Wellness/support contact	NR	Health education	Postpartum	EPDS
Mitchell et al., 2012	USA	12; 12	26.6(18–37)	Yoga	20 min, 2 weekly, 12 weeks	Mind-body exercise	Parenting education	Consistent with IG	Health education	Prenatal	CES-D
Mohammadi et al., 2015	Iran	38; 36 36; 36	25.2 ± 4.7, 25.5 ± 4.6; 25.3 ± 5.2	Stretching and breathing practices ± exercise education	20–30 min, 3 weekly, from gestational week 26–32 to delivery (IG 1), from gestational week 26–32 to 2 months postpartum (IG 2)	Traditional aerobics	Antenatal and postnatal ordinary education	40 min	Health education	Postpartum	EPDS
Nasiri et al., 2018	Iran	26; 28	24.82 ± 4.15; 25.75 ± 4.72	Progressive muscle relaxation exercises ± guided imagery	7 weekly, 6 weeks	Relaxation therapy	Usual care	1 weekly, 6 weeks	Usual care	Postpartum	BDI
Navas et al., 2021	Spain	139; 132	31.1 ± 4.1; 31.5 ± 4.2	Aerobic water exercise	45 min, 3 weekly, 5 months	Aquatic sport	Usual care	NR	Usual care	Postpartum	EPDS
Newham et al., 2014	UK	29; 22	31 ± 5; 31 ± 7	Yoga	8 weeks	Mind-body exercise	Usual care	NR	Usual care	Prenatal	EPDS
Norman et al., 2010	Australia	62; 73	29.3 ± 4.0; 30.1 ± 5.3	Group exercise (involving cardiovascular and strength components) ± health education	60 min, 1 weekly, 8 weeks	Combination exercise	Written educational material	1 weekly, 8 weeks	Health education	Postpartum	EPDS
O’Connor et al., 2018	USA	44; 45	28 ± 5; 29 ± 4	Resistance exercise	17 min, 2 weekly, 12 weeks	Strength training	NI	NR	NI	Prenatal	POMS
Özkan et al., 2020	Turkey	34; 31	28.90 ± 4.83	Exercise	30 min, 5 weekly, 4 weeks	Traditional aerobics	Usual care	NR	Usual care	Postpartum	EPDS
Perales et al., 2014	Spain	90; 77	31.08 ± 3.39; 31.66 ± 3.86	Exercise (walking, aerobic dance, muscle exercises, etc.)	55–60 min, 3 weekly, from gestational week 9–12 to 39–40	Combination exercise	Usual care	NR	Usual care	Prenatal	CES-D
Robledo-Colonia et al., 2012	Colombia	37; 37	21 ± 3	Aerobic exercise	60 min, 3 weekly, 3 months	Traditional aerobics	Usual care	1 weekly, 12 weeks	Usual care	Prenatal	CES-D
Rong et al., 2021	China	32; 32	29.00 ± 2.81; 28.16 ± 2.78	Yoga	60 min, 3 weekly, 12 weeks	Mind-body exercise	Usual care	Consistent with IG	Usual care	Prenatal	EPDS
Satyapriya et al., 2013	India	51; 45	26.41 ± 3.01; 24.96 ± 2.58	Integrated yoga	60–120 min, 3–7 weekly, 16 weeks	Mind-body exercise	Stretching exercises	Consistent with IG	Traditional aerobics	Prenatal	HADS
Shahzadi et al., 2022	Pakistan	20; 20	30.65 ± 5.92; 31.30 ± 4.43	Relaxation Therapy	Three sets of 15 repetitions, 2 weekly, 6 weeks	Relaxation therapy	Conventional pharmacotherapy treatment	NR	Pharmacotherapy	Prenatal	EPDS
SONGØYGARD et al., 2012	Norway	379; 340	30.59 ± 4.3; 30.57 ± 4.2	Aerobic and strengthening exercises	45–60 min, 3 weekly, 12 weeks	Combination exercise	Usual care	NR	Usual care	Postpartum	EPDS
Teychenne et al., 2021	Australia	32; 30	33.6 ± 3.7; 33.0 ± 3.7	Treadmill walking or cycling ± social support	12 weeks	Traditional aerobics	NI	NI	NI	Postpartum	EPDS
Uebelacker et al., 2016	USA	11; 7	28.0 ± 5.9; 28.9 ± 6.0	Yoga	75 min, 1 weekly, 9 weeks	Mind-body exercise	Perinatal health education	Consistent with IG	Health education	Prenatal	EPDS
Vargas-Terrones et al., 2021	Spain	36; 25	32.5 ± 3.3; 32.6 ± 4.7	Exercise (aerobic activities, muscle strengthening exercises, etc.)	60 min, 3 weekly, from gestational week 12–16 to 38–40	Combination exercise	Usual care	NR	Usual care	Prenatal	CES-D
Wilczyńska et al., 2022	Poland	34; 20	31 ± 4; 32 ± 4	HIIT	60 min, 3 weekly, 8 weeks	Combination exercise	Health education	150 min, 1 weekly, 8 weeks	Health education	Prenatal	BDI
Yang et al., 2018	China	60; 62	31.89 ± 4.03; 32.45 ± 4.12	Aerobic gymnastic exercise	15 min, 3 weekly, 3 months	Traditional aerobics	Usual care	NR	Usual care	Postpartum	EPDS
IG, intervention group; CG, control group; NR, no report; NI, no intervention; EPDS, Edinburgh Postnatal Depression Scale; CES-D, Center for Epidemiological Studies Depression Scale; BDI, Beck Depression Inventory; HADS, Hospital Anxiety and Depression Scale; PGWBI, Psychological General Well-Being Index; POMS, Profile of Mood States; HDRS, Hamilton Depression Rating Scale; PHQ-9, Physical health questionnaire-9; HIIT, High-intensity interval training.

To investigate whether different types of physical activity have varying effects on perinatal women's depression, we classified them into seven types based on common features of physical activity and previous related research [33, 34]. This classification was determined through team discussions and expert consultations. The seven types include aquatic sport (2 studies) [27, 35], combination exercise (9 studies) [36–44], mind-body exercise (12 studies) [25, 26, 45–54], relaxation therapy (3 studies) [55–57], strength training (2 studies) [58, 59], traditional aerobics (12 studies) [23, 60–70], and walking (5 studies) [71–75].

Non-physical activity interventions included no intervention, health education, pharmacotherapy, social support, and usual care. Measurement tools commonly used for perinatal depression included the Edinburgh Postnatal Depression Scale (EPDS), Center for Epidemiological Studies Depression Scale (CES-D), Beck Depression Inventory (BDI), Hospital Anxiety and Depression Scale (HADS), Psychological General Well-Being Index (PGWBI), Profile of Mood States (POMS), Hamilton Depression Rating Scale (HDRS), and Physical health questionnaire-9 (PHQ-9), among others.

3.3. Risk of bias

Out of the 45 included studies, 32 studies were considered to have a low risk of bias in random sequence generation, while 13 studies did not specify the methods of random sequence generation, leading to an unclear risk assessment. In terms of allocation concealment, 29 studies were deemed to have a low risk of bias, 15 studies were assessed as having an unclear risk due to the lack of specific details regarding allocation concealment methods, and 1 study was found to have a high risk of bias in allocation concealment. Because implementing physical activity interventions under double-blind conditions is challenging, both researcher and participant blinding had a high risk of bias. Regarding outcome assessment blinding, 21 studies employed blinded assessors, indicating a low risk, while 24 studies did not clearly specify the outcome assessment methods, resulting in an uncertain risk assessment.

41 studies had consistent or mostly consistent participant numbers between baseline and post-intervention assessments and reported complete outcome data, indicating a low risk of bias. In contrast, 3 studies had an uncertain risk of bias due to some differences in participant numbers between post-intervention and baseline assessments, and 1 study had a high risk of bias due to incomplete outcome data reporting. Risk of selective reporting bias was considered low in 27 studies, while it was deemed uncertain in 12 studies, primarily due to the lack of pre-registered protocols or detailed explanations of participant dropouts. Six studies were regarded as having a high risk of selective reporting bias. It was unclear whether there were other forms of bias in all included studies. Details of the bias assessment for the included studies are presented in Fig. 2.

3.4. Network meta-analysis

Figure 3 represents the Network Meta-Analysis diagram. It is evident that the three interventions with the largest sample sizes in the experimental group are traditional aerobics, mind-body exercise, and combination exercise. In the control group, the three interventions with the largest sample sizes are usual care, health education, and no intervention. The most frequently studied comparisons involve traditional aerobics versus usual care, combination exercise versus usual care, and traditional aerobics versus health education.

As shown in Table 2, the statistical significant results of the network meta-analysis are as follows: Relaxation therapy [MD=-4.02, 95% CI=(-7.53, -0.51)] was more effective than combination exercise. Compared to health education, relaxation therapy [MD=-4.60, 95% CI=(-8.20, -1.00)] and traditional aerobics [MD=-1.62, 95% CI=(-3.16, -0.08)] were more effective. Relaxation therapy [MD=-4.91, 95% CI=(-9.75, -0.07)] was more effective than strength training.

Table 2 League table on interventions.

Relaxation therapy	Mind-body exercise	Traditional aerobics	Aquatic sport	Pharmacotherapy	Walking	Combination exercise	Health education	Strength training	Usual care	No intervention	Social support
Relaxation therapy	2.74 (-0.84,6.33)	2.98 (-0.48,6.44)	2.91 (-1.22,7.03)	2.70 (-1.09,6.49)	3.39 (-0.58,7.37)	4.02 (0.51,7.53)	4.60 (1.00,8.20)	4.91 (0.07,9.75)	5.08 (1.88,8.28)	5.67 (1.83,9.50)	7.25 (2.18,12.32)
-2.74 (-6.33,0.84)	Mind-body exercise	0.24 (-1.48,1.96)	0.17 (-2.90,3.23)	-0.04 (-5.26,5.18)	0.65 (-2.00,3.31)	1.28 (-0.79,3.35)	1.86 (-0.15,3.87)	2.17 (-1.34,5.67)	2.34 (0.73,3.95)	2.93 (1.04,4.82)	4.51 (0.75,8.27)
-2.98 (-6.44,0.48)	-0.24 (-1.96,1.48)	Traditional aerobics	-0.07 (-2.99,2.84)	-0.28 (-5.41,4.85)	0.41 (-2.10,2.93)	1.04 (-0.72,2.80)	1.62 (0.08,3.16)	1.93 (-1.64,5.50)	2.10 (0.79,3.41)	2.69 (0.67,4.71)	4.27 (0.28,8.26)
-2.91 (-7.03,1.22)	-0.17 (-3.23,2.90)	0.07 (-2.84,2.99)	Aquatic sport	-0.21 (-5.81,5.40)	0.49 (-3.03,4.00)	1.11 (-1.87,4.09)	1.69 (-1.39,4.78)	2.00 (-2.46,6.47)	2.17 (-0.43,4.78)	2.76 (-0.59,6.11)	4.34 (-0.37,9.06)
-2.70 (-6.49,1.09)	0.04 (-5.18,5.26)	0.28 (-4.85,5.41)	0.21 (-5.40,5.81)	Pharmacotherapy	0.69 (-4.80,6.19)	1.32 (-3.85,6.49)	1.90 (-3.33,7.13)	2.21 (-3.94,8.36)	2.38 (-2.58,7.35)	2.97 (-2.43,8.36)	4.55 (-1.78,10.88)
-3.39 (-7.37,0.58)	-0.65 (-3.31,2.00)	-0.41 (-2.93,2.10)	-0.49 (-4.00,3.03)	-0.69 (-6.19,4.80)	Walking	0.63 (-2.00,3.26)	1.21 (-1.31,3.73)	1.52 (-2.61,5.64)	1.69 (-0.68,4.05)	2.27 (-0.61,5.16)	3.86 (-0.25,7.96)
-4.02 (-7.53,-0.51)	-1.28 (-3.35,0.79)	-1.04 (-2.80,0.72)	-1.11 (-4.09,1.87)	-1.32 (-6.49,3.85)	-0.63 (-3.26,2.00)	Combination exercise	0.58 (-1.14,2.30)	0.89 (-2.95,4.73)	1.06 (-0.39,2.51)	1.65 (-0.81,4.11)	3.23 (-0.91,7.36)
-4.60 (-8.20,-1.00)	-1.86 (-3.87,0.15)	-1.62 (-3.16,-0.08)	-1.69 (-4.78,1.39)	-1.90 (-7.13,3.33)	-1.21 (-3.73,1.31)	-0.58 (-2.30,1.14)	Health education	0.31 (-3.47,4.09)	0.48 (-1.18,2.14)	1.07 (-1.29,3.43)	2.65 (-1.44,6.74)
-4.91 (-9.75,-0.07)	-2.17 (-5.67,1.34)	-1.93 (-5.50,1.64)	-2.00 (-6.47,2.46)	-2.21 (-8.36,3.94)	-1.52 (-5.64,2.61)	-0.89 (-4.73,2.95)	-0.31 (-4.09,3.47)	Strength training	0.17 (-3.45,3.80)	0.76 (-2.19,3.71)	2.34 (-2.72,7.41)
-5.08 (-8.28,-1.88)	-2.34 (-3.95,-0.73)	-2.10 (-3.41,-0.79)	-2.17 (-4.78,0.43)	-2.38 (-7.35,2.58)	-1.69 (-4.05,0.68)	-1.06 (-2.51,0.39)	-0.48 (-2.14,1.18)	-0.17 (-3.80,3.45)	Usual care	0.59 (-1.53,2.70)	2.17 (-1.76,6.10)
-5.67 (-9.50,-1.83)	-2.93 (-4.82,-1.04)	-2.69 (-4.71,-0.67)	-2.76 (-6.11,0.59)	-2.97 (-8.36,2.43)	-2.27 (-5.16,0.61)	-1.65 (-4.11,0.81)	-1.07 (-3.43,1.29)	-0.76 (-3.71,2.19)	-0.59 (-2.70,1.53)	No intervention	1.58 (-2.53,5.70)
-7.25 (-12.32,-2.18)	-4.51 (-8.27,-0.75)	-4.27 (-8.26,-0.28)	-4.34 (-9.06,0.37)	-4.55 (-10.88,1.78)	-3.86 (-7.96,0.25)	-3.23 (-7.36,0.91)	-2.65 (-6.74,1.44)	-2.34 (-7.41,2.72)	-2.17 (-6.10,1.76)	-1.58 (-5.70,2.53)	Social support

The bold values represent the signify statistical significance.

When compared to usual care, relaxation therapy [MD=-5.08, 95% CI=(-8.28, -1.88)], mind-body exercise [MD=-2.34, 95% CI=(-3.95, -0.73)], and traditional aerobics [MD=-2.10, 95% CI=(-3.41, -0.79)] were more effective. Compared to no intervention, relaxation therapy [MD=-5.67, 95% CI=(-9.50, -1.83)], mind-body exercise [MD=-2.93, 95% CI=(-4.82, -1.04)], and traditional aerobics [MD=-2.69, 95% CI=(-4.71, -0.67)] were more effective. When compared to social support, relaxation therapy [MD=-7.25, 95% CI=(-12.32, -2.18)], mind-body exercise [MD=-4.51, 95% CI=(-8.27, -0.75)], and traditional aerobics [MD=-4.27, 95% CI=(-8.26, -0.28)] were more effective.

In terms of the probability of different interventions affecting depression as indicated by SUCRA, relaxation therapy ranked first (SUCRA = 96.6%), followed by mind-body exercise (SUCRA = 73.8%). Subsequently, traditional aerobics and aquatic sport ranked next (SUCRA = 70.1% and 67.6%, respectively). The specific results are presented in Fig. 4.

3.5. Publication bias

As shown in Fig. 5, we used a funnel plot to assess publication bias. The distribution of studies in the funnel plot appears to be roughly symmetrical, and there are no obvious signs of publication bias upon visual inspection.

This study aimed to compare the effects of different physical activity interventions on perinatal depression in women. The research indicates that the top four intervention measures for reducing perinatal depression, in order, are relaxation therapy, mind-body exercise, traditional aerobics, and aquatic sports. Detailed results can be found in Table 3.

Table 3

Ranking of SUCRA probabilities.
Intervention	Sucra	Rank
Relaxation therapy	96.6	1
Mind-body exercise	73.8	2
Traditional aerobics	70.1	3
Aquatic sport	67.6	4
Pharmacotherapy	64.4	5
Walking	60.4	6
Combination exercise	48.1	7
Health education	34.9	8
Strength training	33.9	9
Usual care	24.5	10
No intervention	17.6	11
Social support	8.3	12

Characteristics of depression include an increased preoccupation with negative information, difficulty in disengaging from negative information, and cognitive control deficits when processing negative information [76]. A recent study has shown that both physical activity and mental engagement can help maintain brain health, slowing down disease progression, and that intellectual engagement may be the most effective remedy for individuals with cognitive issues [77]. Mental and physical (MAP) training is an innovative clinical intervention that combines mental training through meditation with physical training through aerobic exercise [78]. The relaxation therapy and mind-body exercise in this study both fall under the integrated MAP training category. The results of this study suggest that, compared to traditional aerobics, integrated MAP training may offer more effective treatment for perinatal depression. On one hand, physical training can enhance muscle strength and flexibility, alleviate physiological discomfort such as back pain and fatigue [79]. On the other hand, mental training can also promote hormone secretion in the endocrine and nervous systems, alleviate stress and negative emotions, and improve self-efficacy [53].

Some studies also provide supporting evidence: the combination of aerobic exercise and meditation can promote neurogenesis in the hippocampus and maintain the vitality of neurons, reduce rumination, improve defects in cognitive control processes, and reduce depressive symptoms [78]. Buddhist walking meditation can improve functional health and vascular reactivity, reduce depression, and appear to offer greater overall improvement compared to traditional walking exercise [80]. Combining mindfulness with physical activity seems to have a more beneficial impact on sleep quality and emotional regulation in individuals with severe depression compared to mindfulness or physical activity alone, making it a valuable treatment strategy [81].

Relaxation therapy may be the most effective intervention for perinatal depression. Previous research has demonstrated that relaxation training, such as progressive muscle relaxation, can help individuals reduce stress, enhance psychological and physiological relaxation, thereby improving overall health [82]. Progressive muscle relaxation is a deep muscle relaxation technique based on the principle that muscle tension is a physiological response to stimulating thoughts [83]. It can inhibit the activity of the sympathetic nervous system, promote relaxation of the body and mind, improve sleep quality, and reduce post-Cesarean section pain intensity [84, 85]. Additionally, muscle relaxation training helps stimulate the secretion of endorphins, enhancing immune function and happiness, potentially reducing depression and anxiety in pregnant women [86–88].

Mind-body exercise may be the intervention that ranks second only to relaxation therapy. It is a gentle and slow form of exercise represented by practices like Tai Chi, Qigong, and yoga, emphasizing the coordination of meditation, physical exercise, and breathing [89, 90]. Mind-body therapies are often used in the treatment of depression to help alleviate its severity [91]. Yoga is one of the most commonly used mind-body interventions, which may alleviate physical and psychological discomfort, potentially reducing the risk of perinatal depression by increasing Brain-Derived Neurotrophic Factor (BDNF) and lowering serum cortisol levels [92–95]. Yoga can also improve psychological and physical health by promoting social connections and enhancing self-efficacy [26]. A Chinese Chan-based mind-body intervention has also been shown to potentially reduce the intake of antidepressant medication and improve depressive symptoms, including attention difficulties, gastrointestinal health issues, and overall sleep quality [96].

Traditional aerobics and aquatic sports may also be relatively effective physical activity interventions. Aerobic exercise may reduce depressive symptoms through biological mechanisms such as promoting the secretion of endorphins, serotonin, and norepinephrine [39]. Aquatic aerobic exercise is a low-impact activity with advantages such as a lower risk of miscarriage, reduced swelling, increased diuresis, decreased arterial pressure, and less back pain compared to weight-bearing exercise on land [97]. Water-based exercise programs can reduce fatigue and improve various aspects of emotional states, including tension, depression, anger, and mental fatigue, as well as enhance leg and abdominal muscle endurance [98].

In 2020, the WHO guidelines on physical activity and sedentary behavior recommended that all pregnant women and postpartum women without contraindications engage in at least 150 minutes of moderate-intensity aerobic exercise per week, along with muscle strength training and gentle stretching activities during pregnancy and postpartum, while reducing sedentary behavior [20]. A study suggested that exercise not only serves as a treatment for depression but also plays a positive role in preventing its onset. This study found a dose-response relationship between physical activity and the incidence of depression, indicating that even activity levels below the recommended guidelines can yield significant mental health benefits [99]. However, a recent study comparing the effects of antidepressant medication and running exercise on anxiety, depression, and overall health indicated that both therapies offer similar mental health benefits, but running exercise performs better in improving physical health. Although exercise therapy is a good option and might even be a better one, the challenge lies in increasing exercise adherence and motivating individuals to consistently engage in physical activity [100].

In summary, different physical activity interventions have varying degrees of impact on perinatal depression in women. Based on the results of this study, we recommend that women consider engaging in integrated mental and physical (MAP) training as a form of exercise, with the hope of more effectively preventing or treating perinatal depression. Additionally, healthcare providers can incorporate physical activity interventions into standard care provided to perinatal women in both community and hospital settings, taking into account women’s preferences and healthcare policies. It is crucial to recognize that promoting changes in physical activity behavior requires adequate supervision and encouragement to enhance the adherence of perinatal women to healthy routines. Furthermore, community and hospital staff can maintain regular communication with pregnant and postpartum women based on their records, offering support to alleviate adverse emotional experiences during the perinatal period.

This study has several strengths. Firstly, it is the first network meta-analysis on the impact of physical activity on perinatal depression, providing a scientific reference for the selection of appropriate physical activity interventions for perinatal women. Secondly, the inclusion of a substantial number of studies enhances the accuracy of the research findings. Thirdly, our study only included randomized controlled trials and excluded observational and cross-sectional studies, which increases the reliability of the results. However, there are also some limitations to our network meta-analysis. For instance, individual differences among perinatal women with depression may lead to heterogeneous effects of physical activity interventions, and different dosages of physical activity may influence the effectiveness of these interventions.

Future research could consider the following aspects. First, personalized physical activity interventions based on the individual characteristics of perinatal women with depression could be explored. For example, factors such as whether they are advanced maternal age (35 years or older), have a history of previous depression, experience depression during pregnancy or postpartum, or the severity of their depression (mild, moderate, or severe) could be taken into account when selecting targeted physical activity interventions. Tailoring interventions to the age, history of depression, timing of depression, and severity of depression among perinatal women can enhance the effectiveness of physical activity interventions. Second, investigating the optimal dosage of physical activity interventions for perinatal depression, including intervention frequency, duration, and intensity, would contribute to improving the precision of physical activity interventions.

This study discusses the impact of different types of physical activity on perinatal depression. The research indicates that integrated mental and physical (MAP) training, such as relaxation therapy and mind-body exercise, performs better in reducing perinatal depression. However, individual characteristics among perinatal women with depression vary. Therefore, before implementing physical activity interventions, it is essential to conduct a comprehensive individual assessment of perinatal women with depression to ensure the selection of the optimal type of physical activity and intervention dosage. Additionally, while exercise has proven to be effective, the challenge lies in finding ways to encourage people to maintain a consistent exercise routine.

Abbreviations	Definition
PND	Perinatal depression
MAP	Mental and physical training
CBT	Cognitive-behavioral therapy
IPT	Interpersonal therapy
ACOG	American College of Obstetricians and Gynecologists
RCTs	Randomized controlled trials
PRISMA	Preferred Reporting Items for Systematic Reviews and Meta-Analyses
NMA	Network meta-analysis
PICOS	Population, Intervention, Comparison, Outcome, Study Design principles
SMD	Standardized Mean Difference
CI	Confidence interval
SUCRA	Surface Under the Cumulative Ranking Curve
EPDS	Edinburgh Postnatal Depression Scale
CES-D	Center for Epidemiological Studies Depression Scale
BDI	Beck Depression Inventory
HADS	Hospital Anxiety and Depression Scale
PGWBI	Psychological General Well-Being Index
POMS	Profile of Mood States
HDRS	Hamilton Depression Rating Scale
PHQ-9	Physical health questionnaire-9
WHO	World Health Organization
IG	Intervention group
CG	Control group
NR	No report
NI	No intervention
HIIT	High-intensity interval training

Trial registration: Registration and protocol CRD 42023469537.

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Availability of data and materials

All datasets generated for this study are included in the article/supplementary material.

Competing interests

The authors declare that they have no competing interests.

Funding

No funding

Authors' contributions

All authors contributed to the study conception and design. YS and DL conceived and designed the study. YS, DL, CML and JLW collected the data. YS, JLW and DL analysed and interpreted the data. YS, DL and JLW drafted the manuscript. YS, CML and DL revised the manuscript. All authors have read and agreed to the published version of the manuscript.

Acknowledgements

None

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No competing interests reported.

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Effect of different physical activity interventions on perinatal depression: A systematic review and network meta-analysis

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Journal Publication

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Abstract

Background

Methods

Results

Conclusion

Trial registration

Trial registration

Figures

1 Introduction

2 Methods

2.1 Protocol and registration

2.2 Data sources and search strategy

2.3 Study selection

2.4 Inclusion and exclusion criteria

2.5 Data extraction

2.6 Quality assessment

2.7 Statistical analysis

3 Results

3.1. Trial selection

3.2. Trial characteristics

3.3. Risk of bias

3.4. Network meta-analysis

3.5. Publication bias

4. Discussion

5. Strengths and limitations

6. Conclusion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Journal Publication

Version 1