Sage Journals: Discover world-class research

Abstract

Background:

Exercise may be a potentially helpful strategy to improve mood during the perinatal period. However, little is known about the exercise behaviors and preferences of perinatal women seeking psychiatric care. This study was designed to shed light on the acceptability of exercise-based interventions for this population, and to examine the proportion of perinatal psychiatric patients who report engaging in regular exercise.

Materials and Methods:

Three hundred perinatal women (31% pregnant, 69% postpartum) seeking psychiatric care completed a survey assessing self-reported exercise behaviors, interest in participating in a perinatal exercise program, and perceived benefits of exercise. Respondents self-reported their presenting psychiatric symptoms and any comorbid health conditions.

Results:

Fewer than 25% of women surveyed reported any recent exercise, and far less (<9%) reported activity levels consistent with current exercise recommendations. However, 87% reported interest in participating in an exercise program and viewed numerous potential benefits (improved health and energy, sense of accomplishment, better sleep, reduced stress, and less anxiety and depression). More than 65% of women reported significant medical comorbidities; these women were equally interested in exercise programs.

Conclusion:

In this preliminary study, we found that pregnant and postpartum women seeking psychiatric care reported very low levels of exercise, yet women's interest in participating in a tailored exercise program was high. Findings underscore the potential value of an exercise program for distressed perinatal women. Implementing a tailored exercise program within the context of an existing perinatal care setting could promote access and bode well for initiation and adherence.

Introduction

Depression and anxiety during the perinatal period are associated with high levels of maternal distress and functional impairment, as well as with poor medical outcomes.¹ For example, pregnant women with elevated depression require antenatal medical hospitalization more often than non-depressed women,² and they have a higher likelihood of delivering preterm and low birthweight infants.³ Women with antenatal depression are also more likely to experience comorbid health problems such as obesity,⁴ pre-eclampsia,⁵ gestational diabetes,⁶ and prenatal hypertension⁷—problems that can persist beyond the perinatal period.^8,9 A large literature has also detailed adverse outcomes associated with perinatal anxiety, including risk for preterm birth¹⁰ and higher rates of behavioral problems in school age children.¹¹

In spite of recent advances in screening and detection of perinatal depression and anxiety, rates of engagement in standard forms of mental health treatment remain low.¹² Even when treatment is available, affected women might not seek mental health care due to concerns about the adverse effects of perinatal medication use, stigma related to seeking mental health treatment during the childbearing period, or logistical barriers.¹³ In some areas, a shortage of perinatal mental health specialists contributes to the challenge of meeting the needs of pregnant and postpartum women experiencing psychiatric conditions.¹⁴ Further, although some women do engage in psychiatric treatment during pregnancy or the postpartum period, it is not uncommon for women to express an interest in avoiding medications and treating symptoms with non-pharmacologic strategies, including psychotherapy and complementary health practices (yoga, exercise, nutritional supplements).¹⁵ In addition, some women who engage in standard mental health treatment (e.g., antidepressants) still seek out other therapies¹⁶ or complementary health practices¹⁷ as adjunctive strategies to improve mood.

Exercise and lifestyle physical activity interventions are potentially promising strategies to improve maternal mental health as well as physical health. Among non-perinatal patients, these interventions have been shown to be effective in improving depression¹⁸ and anxiety.¹⁹ However, prior research addressing the mental health benefits of exercise has typically not included pregnant and postpartum women, a population that requires a tailored exercise approach.²⁰ Further, although a small number of studies have examined exercise beliefs and preferences among pregnant women, very little work has specifically examined the exercise behaviors and preferences among perinatal women with psychiatric conditions. This group is important to study, as they are likely to be most in need of a more tailored physical activity program, given the difficulty of initiating and maintaining new exercise behaviors when experiencing acute mental health symptoms.²¹ Thus, research examining the exercise habits of perinatal women with psychiatric conditions, as well as their preferences for exercise, is an important first step in determining the viability and acceptability of an exercise intervention for this population. Ultimately, tailored interventions that address the specific preferences for exercise among this patient population may lead to better exercise adherence.

To begin to examine these questions, we conducted an exploratory survey study designed to examine the self-reported exercise habits and preferences among pregnant and postpartum women seeking psychiatric treatment. We sought to determine: (1) the proportion of perinatal psychiatric patients who report regular exercise, and the average amount of weekly exercise reported among physically active women; (2) the extent to which women endorse interest in engaging in an exercise program tailored for pregnant and postpartum women; and (3) the perceived benefits of engaging in this type of program.

Materials and Methods

This project was reviewed and approved by the Women & Infants' Hospital Institutional Review Board before initiating data collection. Three hundred perinatal women who were either pregnant (n = 93; 31%) or up to 1 year postpartum (n = 207; 69%) and seeking psychiatric treatment completed an anonymous survey designed for this study. To promote the feasibility of administration in the clinic setting where the research was conducted, the survey was kept very brief (one page). Survey items assessed women's self-reported exercise habits during the past 3 months, including average number of days of exercise per week, and average number of minutes spent exercising during a typical bout of exercise. In addition, women were asked whether or not they were interested in participating in an exercise program designed for perinatal women, if available to them. Respondents were also asked to endorse any potential benefits that might be experienced if they took part in an exercise program, selecting from a list of 10 choices (i.e., improved health, managing weight, lowering stress, better sleep, lower depression, lower anxiety, increased happiness, feelings of accomplishment, increased energy, decreasing pregnancy discomforts).

Finally, although women's psychiatric and medical diagnoses were not assessed as part of this research, respondents were asked to self-report the primary mental health symptoms for which they were currently seeking care (i.e., depression, anxiety, other mental health condition) and to note whether they were experiencing one of four comorbid health problems (i.e., diabetes, overweight/obesity, hypertension, high cholesterol) or whether they had another chronic medical condition or were currently a smoker. In all, the survey included 25 items, and it was optional for clinic patients to complete when they presented for their initial appointment.

The research study was separate from patient clinical care; researchers were not involved in the clinical treatment of the survey respondents, and completed surveys were not added to the patient's clinical record. Completed surveys were returned to an anonymous collection bin and were not associated with patient names. Data were collected during 2 years of survey administration. Once compiled, data were entered into SPSS^® 22.0 (IBM Corporation, Armonk, NY) for Windows for analysis; descriptive statistics (means, frequencies, chi-square) analyses were conducted.

Results

Description of clinic setting and sample

All participants were registered patients at a university-affiliated facility that provides specialized outpatient and partial hospital psychiatric treatment for pregnant and postpartum women in an urban U.S. setting. The survey was designed for brevity, and it did not collect demographic details from each respondent. However, the nature of the clinical services provided²² and details regarding the clinic's patient demographics^23,24 have been described in detail in prior reports. Most recent demographic descriptions of patients served at the facility indicate that in terms of racial/ethnic background, slightly more than half (54%) are non-Latina White women, 22% are Hispanic/Latina, and 13% are Black/African American, with the remaining women identifying as members of other racial/ethnic minority groups, or choosing to not report racial/ethnic background. Less than half of the patients (44%) are married or in a committed relationship. The dominant psychiatric diagnosis for which patients seek care is major depression, typically representing 75%–87% of the patients seen; other conditions, such as panic disorder, generalized anxiety disorder, posttraumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), bipolar disorder, and adjustment disorder, are routinely treated as well.

In the current survey, women were asked to report the reason(s) that they were seeking psychiatric care, and they could select more than one presenting symptom or condition if necessary. Consistent with the overall clinic population, the most common psychiatric symptom for which participants sought treatment was depression (86%), followed by anxiety (49%) and symptoms of bipolar disorder (5%); to a lesser extent, women stated that they were seeking care for other concerns such as PTSD, sleep disturbance, OCD, and panic attacks. In terms of self-reported medical problems, the majority of survey respondents (more than 65%) reported having one or more comorbid physical health issues. More than half of the sample (58%) reported being overweight or obese, 7% reported having high blood pressure, 3% reported elevated cholesterol, and 2% reported diabetes. In addition, 13% of the pregnant women and 19% of postpartum women in the sample reported that they were current cigarette smokers.

Physical activity patterns

Women were asked to self-report their exercise habits over the past 3 months. As shown in Table 1, results indicate that overall, fewer than one-fourth of perinatal women in our sample exercised regularly (24%), with slightly more pregnant women reporting that they had engaged in some type of regular exercise in the past 3 months (31%), in comparison to 21% of postpartum women reporting regular exercise during that period (χ²(1) = 3.94, p < 05). We also examined the amount of exercise, in terms of number of minutes, that women self-reported. Though a small subset of women reported very regular exercise, the vast majority reported exercising fewer than 150 minutes per week, therefore not meeting the current physical activity recommendation for healthy adults including perinatal women.²⁵ More specifically, 8.6% of pregnant women and 7.6% of postpartum women reported exercising at least 150 minutes per week. Thus, our data suggest that more than 91% of perinatal women seeking psychiatric care do not meet established physical activity recommendations.

Table 1.

Physical Activity Behavior Self-Reported by Perinatal Women Seeking Psychiatric Care

	Pregnant women	Postpartum women	Total sample
Engaged in regular exercise during the past 3 months, N (%)	29 (31.2%)	43 (20.5%)	71 (23.7%)
Engaged in exercise for 150 or more minutes per week, N (%)	8 (8.6%)	16 (7.6%)	24 (8.0%)
Average no. of minutes of exercise per week, mean (SD)	42.7 (84.3)	30.3 (76.3)	34.1 (79.2)

Acceptability of perinatal exercise program

Although self-reported exercise levels were low, the majority of respondents (87%) did express interest in engaging in exercise during pregnancy or the postpartum period, if given an opportunity. Our survey specifically asked about interest in a walking program tailored for pregnant or postpartum women, given that this type of intervention is both potentially efficacious and simple to implement, not requiring special equipment or gym membership. We also examined whether or not specific subgroups of women might be more interested in participating in a perinatal walking program. We found that interest was greater among women who were sedentary as compared with those women who were already physically active (χ²(1) = 15.6, p < 0.001). No difference in degree of interest was found between pregnant and postpartum women (χ²(1) = 0.62, p = 0.43). As previously noted, nearly two-thirds of the sample reported some type of comorbid physical health condition; we found that women with medical comorbidities reported a similarly high level of interest in a tailored perinatal exercise program (87%) compared with those women without medical comorbidities (88%).

Perceived benefits of a perinatal exercise program

Women who expressed interest in a tailored perinatal exercise program endorsed a number of potential benefits of participation (Table 2). The most common perceived benefits of a perinatal walking program included improving physical health (endorsed by 83% of women), reducing stress (77%), managing weight (77%), increasing one's energy level (68%), fostering a sense of accomplishment (64%), decreasing anxiety (61%), increasing feelings of happiness (59%), improving sleep (58%), and decreasing depression symptoms (56%).

Table 2.

Perceived Benefits of Participating in a Physical Activity Program for Perinatal Women

Perceived benefit	% Endorsing
My physical health would improve	75.4
It would help me manage my weight	69.9
I would manage stress better	69.9
I would have more energy	61.8
It would give me a feeling of accomplishment	58.6
I would feel less anxious	55.0
I would feel happier	51.5
I would sleep better	51.1
I would feel less depressed	49.2

Discussion

This study represents one of the first investigations to examine the exercise behaviors and preferences among pregnant and postpartum women seeking psychiatric care. We found the level of self-reported exercise among women in our sample to be very low, with only 7.3% of postpartum women and 7.7% of pregnant women meeting current physical activity guidelines. Given that epidemiologic research indicates that ∼15% of pregnant women in the United States meet physical activity guidelines²⁶—a rate much lower than the general U.S. adult population²⁷—our findings suggest that perinatal women in psychiatric care are even less active than their counterparts without psychiatric conditions. Further, given that exercise behavior is often overestimated when it is based on self-report versus objective measurement,²⁸ it is possible that the actual level of physical activity in this population is even lower. Consistent with prior research addressing comorbidities experienced by psychiatric patients, we found that many of the women in our sample were facing comorbid health concerns, such as obesity or diabetes, with more than 60% of women reporting some type of current medical condition. The high proportion of health problems among expectant and new mothers seeking psychiatric care underscores the value of a physical activity intervention that could potentially improve physical health status and functioning.

Although self-reported exercise behaviors suggested that women in our sample engaged in low levels of exercise overall, the majority of respondents did express interest in engaging in a tailored exercise program (i.e., walking), if available. An encouraging finding was that interest in participating in such a program was higher among those women who were not already physically active on a regular basis, suggesting that more sedentary perinatal women may benefit significantly from a structured program to help initiate and maintain regular exercise behavior. As noted by some experts, lack of knowledge regarding safety parameters for exercise during the perinatal period may lead some women to refrain from being active, even if they are interested.²⁹ Moreover, some women may experience pressure to remain relatively sedentary by well-meaning friends and family members who are not aware of the current exercise recommendations for perinatal women, which are more encouraging of exercise than those from prior generations.³⁰ In situations where either the woman or a family member is concerned about safety of exercise, a program that offers specific safety guidelines and instruction may help allay concerns, making increased physical activity seem more viable. Symptoms or discomforts associated with pregnancy or recovery from childbirth may represent another common barrier to exercise that some women may experience, potentially reducing the likelihood of adherence to an exercise program. A structured, supportive program may help women overcome the challenge of staying active when coping with fatigue or other physical discomforts.

In addition to the challenges noted earlier, which may be experienced by any perinatal woman, it is important to recognize unique challenges that may be encountered by women experiencing significant psychiatric symptoms. Clinical levels of depression can substantially decrease energy and motivation, and also prompt social withdrawal. Heightened anxiety can similarly lead to lower levels of exercise, as the physiological effects of exercise can increase anxiety symptoms in some individuals.³¹ In light of these issues, a structured activity program would likely be particularly useful to promote and support lasting change in physical activity levels. Most women have increased interactions with health care providers during pregnancy and the postpartum period. As such, implementing an exercise program within the context of an existing prenatal or postpartum care setting could increase access and bode well for initiation and adherence. A tailored walking program embedded in a health care setting, that helps define specific goals for each individual while also addressing barriers to care, could provide the structure needed to help women adhere to an exercise program. Providers who work with prenatal women can play a key role in helping to evaluate the safety of exercise during the perinatal period, and by providing encouragement during the course of routine visits, if increased physical activity is a goal. To date, only a small number of clinical trials have examined the extent to which exercise can improve maternal mood during the perinatal period,³² with the majority of studies with depressed populations focusing on postpartum women.¹⁷ More high-quality, controlled trials are needed to assess the safety and efficacy of exercise in improving mood and functioning among women with psychiatric conditions during the perinatal period.

Limitations

Results from this brief self-report survey shed initial light onto the exercise habits and preferences of perinatal women seeking psychiatric care. This study was preliminary in nature, with its major limitation being reliance on patient self-report to assess physical activity and health status, through the use of a brief survey that was designed for the study. Although some aspects of this research are not hindered by self-report (i.e., assessment of an individual's exercise preferences and perceived benefits of exercise), other variables are more limited by the use of self-report. Specifically, to more accurately measure the actual level of activity among psychiatric treatment-seeking women, future research should employ objective assessment strategies to assess physical activity (i.e., actigraphy), and structured assessments or chart review to assess medical and psychiatric conditions. In addition, a larger sample of women would allow for examination of exercise behaviors, and acceptability and perceived benefits of exercise, among women at different stages of pregnancy or at different lengths of time since giving birth. Finally, because we collected data from clinical sites located in one urban region of the United States, we cannot assume that our findings regarding exercise practices and preferences can be generalized across other geographic regions or cultural groups.

Conclusions

Although preliminary, findings from this investigation suggest that most perinatal women who are seeking psychiatric care do not engage in recommended levels of exercise; in addition, our findings suggest that many perinatal women are open to participating in an exercise program, if tailored to meet their specific needs. Even though regular exercise for healthy pregnant and postpartum women is endorsed in the Physical Activity Guidelines for Americans,³³ and is encouraged by the American College of Obstetricians and Gynecologists,²⁵ research suggests that a few healthy perinatal women actually meet those guidelines.²⁶ This is in spite of increasing evidence for a variety of potential benefits of perinatal exercise, such as improved mood, reduction of anxiety, improved maternal functioning, decreased pregnancy discomforts, improved cardiovascular fitness, as well as a possibly lower risk for gestational diabetes and improved weight management.^34,35 Our findings extend the existing literature by revealing that pregnant and postpartum women seeking psychiatric care—who could greatly benefit from regular exercise—have markedly lower physical activity levels than their counterparts who are not experiencing psychiatric symptoms. These findings underscore the importance of developing and testing tailored exercise programs for this population. More research is needed to examine the efficacy of tailored perinatal exercise programs in improving maternal mental and physical health, as well as the most optimal implementation strategies of such programs within health care settings.

In spite of evidence regarding the very low physical activity levels among this population, the current findings are encouraging as they suggest that many treatment-seeking perinatal women are interested in finding safe ways to increase their physical activity. Further, they view that increased activity levels could bring about a number of tangible benefits, such as positive changes in their mental and physical health. Thus, this preliminary study provides evidence for the potential acceptability of tailored physical activity programs among distressed perinatal women. Focused research is now needed to develop and evaluate tailored exercise programs for perinatal women, including specific strategies for making programs viable for psychiatrically distressed women, who may experience greater physical health comorbidities and other challenges that make it difficult to change activity behavior.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Cite this article as: Battle CL, Scott BLD, Fritzson AE, Howard M, Abrantes AM (2020) Acceptability and perceived benefits of exercise among pregnant and postpartum women seeking psychiatric care, Women's Health Report 1:1, 212–217, DOI: 10.1089/whr.2020.0039.

Abbreviations Used

References

Stein

, Pearson

, Goodman

, et al. Effects of perinatal mental disorders on the fetus and child. Lancet, 2014; 384:1800–1819.

Huang

, Sung

, Chen

, et al. Obstetric outcomes in pregnant women with and without depression: Population-based comparison. Sci Rep, 2017; 7:13937.

Grigoriadis

, VonderPorten

, Mamisashvili

, et al. The impact of maternal depression during pregnancy on perinatal outcomes: A systematic review and meta-analysis. J Clin Psychiatry, 2013; 74:e321–e341.

Molyneaux

, Poston

, Ashurst-Williams

, Howard

. Pre-pregnancy obesity and mental disorders during pregnancy and postpartum: A systematic review and meta-analysis. Pregnancy Hypertens, 2014; 4:236.

Delahaije

, Dirksen

, Peeters

, Smits

. Anxiety and depression following preeclampsia or HELLP syndrome: A systematic review. Acta Obstet Gynecol Scand, 2013; 92:746–761.

Katon

, Russo

, Gavin

, Melville

, Katon

. Diabetes and depression in pregnancy: Is there an association?. J Women's Health, 2011; 20:983–989.

Mautner

, Greimel

, Trutnovsky

, Daghofer

, Egger

, Lang

. Quality of life outcomes in pregnancy and postpartum complicated by hypertensive disorders, gestational diabetes, and preterm birth. J Psychosom Obstet Gynecol, 2009; 30:231–237.

Kim

, Newton

, Knopp

. Gestational diabetes and the incidence of type 2 diabetes. Diabetes Care, 2002; 25:1862–1868.

Pauli

, Repke

. Preeclampsia: Short-term and long-term implications. Obstet Gynecol Clin North Am, 2015; 42:299–313.

10.

Ding

, Wu

, Xu

, et al. Maternal anxiety during pregnancy and adverse birth outcomes: A systematic review and meta-analysis of prospective cohort studies. J Affect Disord, 2014; 159:103–110.

11.

Rees

, Channon

, Waters

. The impact of maternal prenatal and postnatal anxiety on children's emotional problems: A systematic review. Eur Child Adolesc Psychiatry, 2019; 28:257–280.

12.

Cox

, Sowa

, Meltzer-Brody

, Gaynes

. The perinatal depression treatment cascade: Baby steps toward improving outcomes. J Clin Psychiatry, 2016; 77:1189–1200.

13.

Fonseca

, Gorayeb

, Canavarro

. Womens help-seeking behaviours for depressive symptoms during the perinatal period: Socio-demographic and clinical correlates and perceived barriers to seeking professional help. Midwifery, 2015; 31:1177–1185.

14.

Osborne

, Hermann

, Burt

, et al. Reproductive psychiatry: The gap between clinical need and education. Am J Psychiatry, 2015; 172:946–948.

15.

Battle

, Salisbury

, Schofield

, Oritz-Hernandez

. Perinatal antidepressant use: Understanding women's preferences and concerns. J Psychiatr Pract, 2013; 19:443–453.

16.

Ahmadpanah

, Nazaribadie

, Aghaei

, et al. Influence of adjuvant detached mindfulness and stress management training compared to pharmacologic treatment in primiparae with postpartum depression. Arch Womens Ment Health, 2018; 21:65–73.

17.

Reza

, Deligiannidis

, Eustis

, Battle

. Complementary health practices for treating perinatal depression. Obstet Gynecol Clin North Am, 2018; 45:441–454.

18.

Cooney

, Dwan

, Greig

, et al. Exercise for depression. Cochrane Database Syst Rev. 2013:CD004366.

19.

Jayakody

, Gunadasa

, Hosker

. Exercise for anxiety disorders: Systematic review. Br J Sports Med, 2014; 48:187–196.

20.

Battle

, Abrantes

, Schofield

, Kraines

. Physical activity as an intervention for antenatal depression: Rationale for developing tailored exercise programs for pregnant women with depression. J Midwifery Womens Health, 2015; 60:479–482.

21.

Forsyth

, Boath

, Henshaw

, Brown

. Exercise as an adjunct treatment for postpartum depression for women living in an inner city—A pilot study. Health Care Women Int, 2017; 38:635–639.

22.

Battle

, Howard

. A mother-baby psychiatric day hospital: History, rationale, and why perinatal mental health is important for obstetric medicine. Obstet Med, 2014; 7:66–70.

23.

Battle

, Zlotnick

, Miller

, Pearlstein

, Howard

. Clinical characteristics of perinatal psychiatric patients: A chart review study. J Nerv Ment Dis, 2006; 194:369–377.

24.

Schofield

, Battle

, Howard

, Ortiz-Hernandez

. Symptoms of the anxiety disorders in a perinatal psychiatric sample: A chart review. J Nerv Ment Dis, 2014; 202:154–160.

25.

ACOG Committee Opinion No. 650: Physical activity and exercise during pregnancy and the postpartum period. Obstet Gynecol, 2015; 126:e135–e142.

26.

Evenson

, Savitz

, Huston

. Leisure-time physical activity among pregnant women in the US. Paediatr Perinat Epidemiol, 2004; 18:400–407.

27.

Katzmarzyk

, Lee

, Martin

, Blair

. Epidemiology of physical activity and exercise training in the United States. Prog Cardiovasc Dis, 2017; 60:3–10.

28.

Troiano

, Berrigan

, Dodd

, Masse

, Tilert

, McDowell

. Physical activity in the United States measured by accelerometer. Med Sci Sports Exerc, 2008; 40:181–188.

29.

Evenson

, Bradley

. Beliefs about exercise and physical activity among pregnant women. Patient Educ Couns, 2010; 79:124–129.

30.

Artal

, O'Toole

. Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period. Br J Sports Med, 2003; 37:6–12; discussion 12.

31.

Aylett

, Small

, Bower

. Exercise in the treatment of clinical anxiety in general practice—A systematic review and meta-analysis. BMC Health Serv Res, 2018; 18:559.

32.

Davenport

, McCurdy

, Mottola

, et al. Impact of prenatal exercise on both prenatal and postnatal anxiety and depressive symptoms: A systematic review and meta-analysis. Br J Sports Med, 2018; 52:1376–1385.

33.

Piercy

, Troiano

, Ballard

, et al. The physical activity guidelines for Americans. JAMA, 2018; 320:2020–2028.

34.

Prather

, Spitznagle

, Hunt

. Benefits of exercise during pregnancy. PM R, 2012; 4:845–850.

35.

Nascimento

, Surita

, Cecatti

. Physical exercise during pregnancy: A systematic review. Curr Opin Obstet Gynecol, 2012; 24:387–394.

Acceptability and Perceived Benefits of Exercise Among Pregnant and Postpartum Women Seeking Psychiatric Care

Abstract

Background:

Materials and Methods:

Results:

Conclusion:

Introduction

Materials and Methods

Results

Description of clinic setting and sample

Physical activity patterns

Acceptability of perinatal exercise program

Perceived benefits of a perinatal exercise program

Discussion

Limitations

Conclusions

Footnotes

Author Disclosure Statement

Funding Information

Abbreviations Used

References