Effectiveness of nonpharmacological interventions for reducing postpartum fatigue: A systematic review and meta- analysis

Protocol and registration

The protocol has been registered in the International Prospective Register of Systematic Reviews (PROSPERO); registration number CRD42021234869.

Study design

This systematic review and meta-analysis has been reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement (PRISMA). The PRISMA checklist can be seen in Additional file 1.

Search strategy

The focus of the review was to examine nonpharmacological interventions for fatigue reduction in postpartum women. Seven electronic databases, including the Cochrane Library, PubMed, Embase, Web of Science, PsycINFO, CINAHL and ProQuest, were searched for articles published from inception until February 2021 without language or time restrictions. An additional search of OpenGrey was conducted for grey literature. A combination of Medical Subject Heading, Emtree terms and free terms [e.g., (postnatal OR postpartum OR delivery OR childbirth OR birth OR parturition OR labour OR pregnancy) AND (fatigue OR mental fatigue OR lassitude OR exhaust*) AND (randomized controlled trial OR controlled clinical trial OR cohort OR clinical trial) was used. The final search strategies applied are shown in Additional file 2. Moreover, a manual search of reference lists was performed to thoroughly identify relevant studies that were missed. Two authors (XXX and XXX) performed the search process independently.

Eligibility/exclusion criteria for selecting studies

The inclusion criteria of this review were as follows: (1) Study design: Clinical trials adopting randomized controlled trials (RCTs), quasi-experimental, before-and-after or prospective cohort study designs; (2) Participants: women aged 18 years or over who had a healthy pregnancy; and (3) Intervention: nonpharmacological interventions conducted during the women’s postpartum period with the primary or secondary aim of decreasing fatigue symptoms. The intervention setting, frequency, timing and duration were not limited; (4) Comparison: usual care, placebo, waitlist or no interventions; and (5) Outcomes: the primary efficacy outcome was postpartum fatigue estimated as the rate or mean severity of fatigue. The second efficacy outcome was psychological variables, such as depression, anxiety or stress. The exclusion criteria were as follows: (1) duplicated publications (only the one with the most participants was included); (2) analyses of interventions based on postpartum fatigue in some special conditions, such as postpartum haemorrhage; and (3) studies without sufficient data to be extracted.

After removing duplicates, two authors (XXX and XXX) independently screened the studies according to the inclusion criteria in 2 steps: 1) title and abstract screening and 2) full-text screening. A third author (XX) was consulted to reach a consensus when there was any uncertainty about the inclusion of an article.

Data extraction

A standardized data extraction sheet was used to extract important information from the included studies. The extracted data included first author, publication year, country, study design, population, sample size (trial/control), intervention details (e.g., type, frequency and duration), control, evaluation time points, assessment tools and outcomes. Two authors (XXX and XXX) independently extracted the data, and any inconsistencies were resolved by a third author (XX).

Risk of bias summary

For RCTs, the Cochrane risk-of-bias tool was used for the quality assessment[15]. Studies were assessed based on seven criteria (random sequence generation, allocation concealment, blinding of participants and researchers, blinding of outcome assessor, incomplete outcomes data, selective reporting and other bias). Bias was evaluated as a judgement (high or low or unclear), and then each included study was rated as having a high, moderate or low risk of bias. The Risk of Bias in Nonrandomized Studies of Interventions was used to assess the risk of bias of non-RCTs[16]. Seven domains are evaluated in this tool (confounding, selection of participants into the study, classification of intervention, deviation from the intended interventions, missing data, measurements of outcomes and selection of the reported results). Two authors (XXX and XXX) assessed the risk of bias and evidence quality separately. Disagreements were discussed with a third researcher (XX) to reach a consistent conclusion.

Data analysis

We performed a meta-analysis utilizing Review Manager 5.3. For continuous outcomes, we calculated mean differences (MDs) and 95% confidence intervals (CIs) if the outcomes were measured using the same tool. We used standardized mean differences (SMDs) and 95% CIs to combine studies when the same outcome was measured by adopting different tools[17]. For the SMD, ≤ 0.20, = 0.50, and ≥ 0.80 are designated as small, moderate and large effect sizes, respectively[18]. The heterogeneity among the analysed trials was examined by standard chi-square and I-square statistics. If the P value was > 0.1 or I² < 50%, it indicated that there was no observed heterogeneity, and the researchers employed a fixed-effects model to combine the study results. If not, a random-effects model analysis was used[19].

The study characteristics are summarized in Table 1. Studies were published between 2003 ~ 2020. The 17 included articles were conducted in different countries: China (n = 5), Iran (n = 4), the USA (n = 2), Canada (n = 2), Turkey (n = 2), Australia (n = 1) and the UK (n = 1). A total of 2142 participants were included in this systematic review. The sample size ranged from 27 to 356 participants in each trial. Eleven of the 17 included studies employed a randomized controlled trial design.

Four types of interventions were undertaken: exercise [12, 20–23](n = 5), psychoeducational intervention[13, 24–29] (n = 7), physical therapy[10, 11, 30] (n = 3) and drinking tea [31, 32](n = 2). The intervention duration ranged from 1 day to 3 months. All included studies described the baseline assessments, with the scores for the intervention and control groups comparable at baseline. Additionally, the studies reported assessment scores immediately after the intervention and follow-up assessment scores at 1 month postintervention[31, 32], 6 weeks[24, 25, 28] and 9 weeks postintervention[24], 2 months postintervention[20], 3 months postintervention[21, 23, 25, 28] and 6 months[23] postintervention. These trials adopted the MFI-20, MFSC, PFS, VAS-F, FAS and FSC to evaluate the level of postpartum fatigue; the EDPS, DASS-21, CES-D, VAS for distress; and the PANAS and PSS were used to assess psychological variables such as depression, anxiety and stress.

Risk of bias of the evidence

The quality of the study designs was low to moderate overall. Several methodological limitations were observed in the critical appraisal. Quality assessments of the 11 included studies using an RCT design, with a risk of bias graph and risk of bias summary, are described in Fig. 2 and Fig. 3. All of the studies reported using randomization; however, two articles did not provide detailed information about the randomization method. Six studies reported sufficient details about allocation concealment. Blinding of the participants and researchers who delivered the interventions was not feasible because the interventions were easy to identify. Therefore, all of the studies are at a high risk of performance bias. Regarding detection bias, only four studies provided sufficient explanations. Except for one study, all RCT studies gave clear information about the incomplete outcome data. No reporting bias was found in the included RCTs.

The results of the quality appraisal of the six nonrandomized studies are displayed in Table 2. Bias due to confounding factors, selection of participants into the study and classification of interventions were low for all included nonrandomized studies. Three articles were at moderate risk of bias due to deviations from the intended intervention. All of the studies were reasonably reported and addressed missing data. In regard to bias in the measurement of outcomes, considering that the interventions were not blinded to the participants, all studies were judged as at moderate risk of bias. Bias in selection of the reported results was not observed.

Meta-analysis results

For the purposes of meta-analysis, postpartum interventions were grouped into four broad categories: exercise, psychoeducational interventions, physical therapy and drinking tea. Only one trial[27] reported the postpartum fatigue rate. Three trials[21, 23, 24] without sufficient original data for meta-analysis were thus not included. Ultimately, thirteen studies that reported the mean fatigue scores and standard deviations were included in the meta-analysis. For the secondary outcomes, since more than two studies reported depression, a statistical combination was performed regarding this psychological outcome.

Effectiveness of exercise

Figure 4 shows the effect sizes of the exercise intervention in terms of fatigue and depression. For the primary outcome, three trials showed a postassessment of fatigue. The heterogeneity was I² = 95% (P < 0.0001), so a random-effects model was applied. The pooled SMD was − 1.74 (95% CI=-2.61 to -0.88, Z = 3.94, P < 0.0001), demonstrating that the exercise intervention had a better effect on decreasing fatigue symptoms. For the secondary outcome, depression data were presented in two trials. No significant effects on reducing depression were indicated. Significant heterogeneity was not detected (I² = 46%, P = 0.17), so a fixed-effect model was used. The pooled SMD was − 0.05 (95% CI=-0.33 to 0.24, Z = 0.31, P = 0.75).

Effectiveness of physical therapy

Three trials showed the effectiveness of physical therapy on posttreatment fatigue severity (Fig. 6). Significant improvements were observed in the participants who received physical therapy in comparison with the participants in the control groups. There was substantial evidence of high heterogeneity (I² = 74%, P = 0.02), so a random-effect model was applied. The pooled SMD was − 0.50 (95% CI=-0.96 to -0.03, Z = 2.09, P = 0.04).

Effectiveness of drinking tea

The effectiveness of drinking tea on fatigue and depression at postintervention and at the 2-week follow-up were presented in two trials (Fig. 7). At postintervention, significant differences were noted between the intervention and control groups in regard to fatigue and depression. No significant heterogeneity was found in terms of fatigue and depression (I² = 0%, P = 0.44; I² = 0%, P = 0.74). Therefore, a fixed-effects model was used. The pooled MD was − 3.12 (95% CI=-5.44 to -0.80, Z = 2.64, P = 0.008) and − 2.89 (95% CI=-4.30 to -1.49, Z = 4.04, P < 0.0001).

At the 2-week follow-up, the results suggested that there were no significant differences between the intervention and control groups in regard to fatigue. There was no evidence of significant heterogeneity (I² = 0%, P = 0.59). The pooled MD was − 1.38 (95% CI=-3.58 to 0.81, Z = 1.24, P = 0.22). The results showed that tea consumption had significant effects on depression at the 2-week follow-up. We used a fixed-effects model because the heterogeneity was I² = 0% (P = 0.77). The pooled MD was − 2.05 (95% CI=-3.47 to -0.62, Z = 2.82, P = 0.005).

Main findings

This systematic review identified a total of seventeen published clinical trials examining nonpharmacological interventions (including exercise, psychoeducational interventions, physical therapy and drinking tea) on postpartum fatigue in postnatal women. Thirteen studies involving 1686 participants were included in the meta-analysis to examine the respective effectiveness of each type of intervention.

The findings of the meta-analysis suggest that exercise intervention significantly reduces symptoms of postpartum fatigue (SMD= -1.74, 95% CI=-2.61 to -0.88, Z = 3.94, P < 0.0001). This is consistent with the findings of previous studies[33, 34], which clarified the necessities and benefits of physical exercise for the overall health of postpartum women. A meta-analysis[35] indicated that postpartum exercise was beneficial for decreasing postpartum fatigue (SMD = 0.36). The benefits of exercise on fatigue are worth affirming. However, postpartum women are still at high risk for physical inactivity and rarely understand how to engage in postpartum exercise[33]. The American College of Obstetricians and Gynaecologists (ACOG) suggested that physical activity, including performing muscle-toning exercises, could be restarted 6 weeks after childbirth if the delivery was uncomplicated[36]. Daily 20 ~ 30 min of regular moderate-to-intense exercise is recommended[37]. A previous study reported that supervised postpartum exercise lasting more than eight weeks is suggested for reducing postpartum fatigue[14]. Therefore, clinical staff should give sufficient explanations and evidence-based instructions for postnatal exercises to help reduce women’s postpartum fatigue and facilitate their postpartum rehabilitation.

For depression, the results showed that there were no significant differences between the two groups (SMD=-0.05, 95% CI=-0.33 to 0.24, Z = 0.31, P = 0.75). This is inconsistent with the findings of a previous meta-analysis[38], which reported that exercise reduced symptoms of depression (SMD=-0.81, 95% CI=-1.53 to -0.10) of mothers who had been diagnosed with depression. The insignificant results may be explained by the fact that the two studies[12, 22] in our review did not include participants with obvious depressed symptoms at baseline. Therefore, a significant reduction in depression was difficult to observe after the exercise intervention. It is worth noting that in Yang et al.[12]’s study, women reported feelings of mood relaxation and pressure relief after the intervention, which indicated that exercise may have potential efficacy for women’s mental health. More research conducting exercise interventions among puerperae who have severe symptoms of psychological problems is needed to confirm the true effect of exercise on mothers’ psychological well-being.

Five studies performing psychoeducational interventions showed no obvious differences in postpartum fatigue and depression between the two groups at either the postintervention or 8-week follow-up. Although psychoeducational interventions usually involve various aspects associated with postnatal health, including fatigue, sleep, infection, nutrition, breastfeeding and so on, this type of intervention was mostly delivered via home visits, leaflet/booklets and home calls. It is difficult to guarantee the good compliance of participants due to a lack of sufficient supervision and guidance. Therefore, it may be difficult to perform psychoeducational interventions effectively. With the development of rapid electronic technology, people’s requests for health services have also facilitated instant communication and promoted efficiency in the transmission of information[39]. A previous study reported that web-based interventions had better effects on improving postnatal depression than home-based postnatal psychoeducational interventions[40] and suggested that web-based interventions should be introduced to mothers for better postnatal care. Hence, psychoeducational interventions could be combined with internet technology[41] or smartphones[42] in the future to improve the participation of women, observe the compliance of the participants and better manage the intervention implementation.

The findings from our meta-analysis of three studies[10, 11, 30] suggested that physical therapy was an effective treatment in relieving postpartum fatigue (SMD= -0.50, 95% CI=-0.96 to -0.03, Z = 2.09, P = 0.04). The intervention frequency of the included physical therapies ranged from 1 ~ 3 sessions. Each session lasted 10 ~ 30 minutes. These interventions were completed in 1 day. Physical therapies have the advantages of a short intervention time and good controllability. Warm showers, as a comfort measure, are closely associated with increased relaxation and tension reduction[43]. It is a safe and effective measure for healthy, labouring women who are experiencing physical and psychological issues[43]. The benefits of lavender oil on postpartum fatigue were reported in another RCT conducted among pregnant women[44]. Participants in either the lavender and footbath or lavender alone group showed that fatigue was improved significantly at 6 weeks postpartum. Although the efficacy of mother-infant skin-to-skin on fatigue was not observed in Funda et al.’s study, a recently published meta-analysis demonstrated that mother-infant skin-to-skin was a cost-effective, simple and feasible approach for postpartum depression[45]. Considering that physical therapies are relatively safe and effective, physical therapies such as footbaths[44], reflexology[46], warm showers[30] and lavender oil[11], which show effects on fatigue reduction and mental health improvement, could be used in combination to enhance the intervention efficacy. Among the three included studies, only Vaziri et al.’s study examined the efficacy of lavender oil aroma for psychological outcomes, including distress and mood, and positive effects were observed. More research is needed to explore its effectiveness for mental health.

In terms of drinking tea, the results showed that there were significant differences in postpartum fatigue between the two groups at postintervention (MD= -3.12, 95% CI=-5.44 to -0.80, Z = 2.64, P = 0.008), but no significant differences were found at the 2-week follow-up. The positive effects of drinking tea on relieving depression were obvious at the postintervention and 2-week follow-up. Postnatal women were required to smell (appreciate) the aroma before drinking the tea. Aromatherapy has been used for pain and anxiety relief, relaxation, and creating a pleasant feeling in mothers[47–49], which could help to relieve fatigue and depressive emotions. Women in the intervention group reported the benefits of drinking chamomile tea to be facilitating emotional stability and relaxation and having an aromatic fragrance, which could calm restlessness, facilitate the postnatal paternity relationship, and alleviate postpartum fatigue[50]. However, the positive effects did not last long after the intervention. Thus, multiple daily consumption of tea may be recommended to assess its lasting effect in consideration of its convenience.

Strengths and limitations

To the best of our knowledge, this is the first systematic review and meta-analysis on nonpharmacological interventions for reducing postpartum fatigue. This review was rigorous and based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statements as well as a prospective registered protocol. Another strength was that randomized controlled trials and controlled clinical trials were included in this review, which provides good standards for evidence-based research.

There were some limitations of this systematic review. First, a limitation of the review was that non-English electronic databases were not searched, which may cause language bias[51]. Second, the number of included studies for each type of intervention was small. The heterogeneity in the statistical combinations of exercise, psychoeducational intervention and physical therapy was significant. These factors may have an impact on the reliability of the pooled results. Third, a limitation lies in the risk of bias within the included studies. The potential biases may have influenced the reported effect estimates; therefore, caution is required when interpreting the findings of our study.