Postpartum Depression: Hormones and Healing

Introduction

Postpartum depression is a major depressive condition in which the women develop depression after 4-6 weeks of childbirth (Stewart and Vigod, 2016). The sudden changes in hormones after the childbirth is mainly related with rise of postpartum depression among new mothers but the actual link between the hormonal change and depression is currently not clear (Silverman et al. 2017). As asserted by Emerson et al. (2018), symptoms of postpartum depression include difficulty sleeping, excessive fatigue, lower appetite, decreased libido and others. This is because the new mothers are unable to understand the way to care for the child which makes them depressed and develop fear of incapability to support effective development of the child. As argued by Guintivano et al. (2018), lack of effective management of postpartum depression leads to create hindrance towards effective bonding and maternal role to be executed by the new mothers. This is because depressed new mothers are unable to focus on executing their responsibilities of caring the child such as breastfeeding, nursing, maintaining hygiene and others for the child which is essential to support enhanced growth and development of the child in the initial years. In the study by Komori et al. (2018), it is mentioned that antidepressants are effective to treat postpartum depression (PPD). However, it is seen that new mothers in their postpartum period avoid taking anti-depressants due to the side-effects of the medication (Schoretsanitis et al. 2019). There are trails of psychological therapies made to overcome PPD and they are found to provided positive results in coping depression but the availability of such therapies are often found to be limited (Carter et al. 2019). In contrast, the non-aerobic and aerobic exercises are considered to have minimal side-effect present in managing PPD for new mothers. They are also considered to be cost-effective and self-management treatment available for the new mothers in making them overcomes PPD (Vargas-Terrones et al. 2019). As criticised by Campolong et al. (2018), women with PPD when asked to execute increased amount of task to manage their symptoms develop difficulty to make the changes. This, in turn, leads them to feel inadequate in taking their own care. However, executing physical exercise as the single intervention would be appropriate for mothers with PPD to manage their symptoms.

In the study of Pritchett et al. (2017), physical exercise such as pram walking is considered to be effective for new mothers in controlling depression. This is because walking leads the individuals under depression to produce increased amount of stress-bursting endorphins which are able to alleviate the signs of depression. As commented by Innes and Selfe (2020), yoga during postpartum period leads mothers to develop increased physical efficiency by overcoming mental weakness. This is because yoga leads the new mothers in the postpartum period become motivated to develop self-efficacy and enhanced self-esteem to overcome mental depression regarding their condition. As commented by Pao et al. (2019), social support during the postpartum period leads the mothers feel ease in managing their responsibility of care regarding the newborn. Thus, the study is being developed to understand the extent to which social support, yoga and physical exercise are able to lower symptoms of PPD among mothers. In this purpose, a systematic review of existing articles related to the study topic is be made and findings are to be presented to mention the effect of the determined intervention in managing or preventing PPD.

Rationale of the Topic

The postpartum depression is often considered to remain unreported by the mothers to the healthcare practitioners and the patients avoid seeking help for the condition. This is because often new mothers are unable to detect the signs and symptoms of depression perceived after the initial weeks of childbirth, in turn, making them neglect their mental health condition as well as avoid to seek assistance to overcome the issue (Guintivano et al. 2018). In the UK, 1 in every 10 women is found to suffering from PPD who are in the first year after giving childbirth (NHS, 2018). This indicates presence of PPD is quite common among the mothers of the newborn. The presence of PPD among women has become an issue as it is interfering with their ability to care for themselves as well as the child. This is because presence of PPD among mothers of the newborn is found to interfere with their capability in making mother-child interaction which is essential in the initial years of birth for the baby for effective physical and mental growth (Yator et al. 2016). As commented by Coker et al. (2017), PPD leads mothers to develop risky behaviour of intending to execute self-harm. This is because depression makes the mother perceive they are not following their effective duty as the mothers and develop intension of self-harm to punish them. The PPD leads the mother remain physical and emotionally weak along with makes them develop sleep deprivation, inappropriate cognitive functioning and others. The presence of PPD has currently become an issue because of the internalised stigma and stereotype regarding the disorder. This is evident as mothers showing hindered mental capability in caring for their newborn are mentioned to be bad mothers in society (Bodnar-Deren et al. 2017). As commented by Schoretsanitis et al. (2019), use of anti-depressants in managing PPD among mothers in the initial years of childbirth leads them to cross the medication to be present in the breast milk. This creates concern and avoidance among the mothers in using medication to manage the depressed condition as it creates negative impact on their child. Thus, this study is developed to understand the effect of social support, yoga and physical exercise which creates minimum side-effect on the health of the mothers and their babies in preventing and managing PPD.

Hypothesis

The social support therapy, yoga and physical exercise are effective in lowering symptoms as well as managing and preventing postpartum depression.

Aim

The study aims to identify the effects of social support therapy, yoga and physical exercise on managing and preventing postpartum depression.

Objectives

To identify the concept of postpartum depression

To analyse the impact of social support therapy, yoga and physical exercise on managing and preventing postpartum depression

To recommend strategies to be implemented in providing social support therapy, yoga and physical exercise on managing and preventing postpartum depression

Methodology

Research Design

In this study, the systematic review research design is to be implemented. The systematic review is referred to the review in which the evidence on the basis of the formulated question by the use of systematic and explicit methods is collected by identifying and critically appraising primary research (Munn et al. 2018). The process of systematic review includes gathering team of researcher, formulating question through PICO framework, planning the search strategy, screening of data, managing data, synthesising evidence and developing conclusion (Boland et al. 2017). The following steps are to be followed in developing systematic review of the data to be presented in the study. As commented by Yli-Huumo et al. (2016), benefit of systematic review is that it lowers chances of creating bias in results. This is because the data collected from the existing studies are formulated by the previous researchers by following appropriate protocols and reliable methods. The systematic review allows summarisation of data from multiple studies. This, in turn, benefits the researcher to gather wider information regarding any study topic to deliver in-depth information (Boland et al. 2017). Therefore, a systematic review is to be used in this study for avoiding biased information through primary studies and allowing scientifically approved data to be used in enriched development of the study.

Search Strategy and Keywords

In this study, the electronic search strategy is to be used for identifying the impact of social support therapy, yoga and physical exercise on managing and preventing postpartum depression (PPD). The electronic search is beneficial as it allows access to multiple databases to gather wide amount of data from various researches regarding the topic to present it in enriched manner. Moreover, electronic databases allow less time consumption in identifying potential research articles regarding the study topic (Campanella et al. 2016). This is because through the use of keywords effective searches are made to identify required articles relevant to the topic. The search platforms to be used for the study include Goggle Scholar, CINHAL, MEDLINE, PubMed and others. The selected databases allow providing the most current articles and relevant journals regarding medical and clinical topics. The use of well-developed search terms assists the researchers in retrieving potentially relevant articles regarding the study topic, in turn, ensuring comprehensive gathering of data (Allen‐Duck et al. 2017). The search terms to be used in this study include “Postpartum Depression”, “physical exercise”, “yoga”, “exercise impacts PPD”, “yoga after pregnancy” and others. The mentioned key terms are to be customised during the search based on the database to develop suitable results. The Boolean operators “AND” and “OR” to be made to link between the keywords in formulating an enriched search to gather relevant information regarding the topic.

Research Question

The development of an effective research question is important as it allows connecting present research with previously accepted knowledge in the form of scientific assumption. Moreover, research questions act as guidance to the researcher regarding the way the study is to be presented (Palaskar, 2017). The PICO Tool is to be used for formulating the research question in this study. This is because the framework allows identifying essential concepts to be gathered from existing studies for answering the research question (Eriksen and Frandsen, 2018). The PICO framework stands for problem, intervention, comparison and outcome. The problem is key clinical health problem to be focussed in the study and in this research, the presence of postpartum depression in mothers is the key problem. The intervention is actions taken to cope with the identified medical problem which in this study is social support therapy, yoga and physical exercise. In this study, no other interventions are included to compare them with the chosen actions. In this study, the outcome is the management and prevention of postpartum depression among women. Thus, the research question is: What are the effects of social support therapy, yoga and physical exercise on managing and preventing postpartum depression?

Inclusion and Exclusion criteria

The criteria that are relevant and essential to be present in the study for gathering relevant information regarding the study topic are known as inclusion criteria. The criteria which are not to be included in the study as hinder the enriched execution of the research are known as exclusion criteria (AlHaisoni et al. 2019). In this study, the inclusion criteria are articles written in English language, published on and after 2013, present in full-text format, academic, primary research articles, related to impact of physical exercise, yoga and social support for postpartum depression. The exclusion criteria are articles written not in English, partially available, published before 2013, secondary articles, articles informing impact of exercise, yoga and social support in managing general depression and non-academic articles. The articles written only in English are to be included in the study and rest are excluded as the researcher performing the study only have understanding regarding the English language. Thus, considering the articles based on specific language would allow the researcher in appropriately reading and reviewing the information to be present in effective format in the study. The articles that are fully accessed are to be involved in the study as it helps the researcher to present detailed information about the cause and effect of results identified from the study. The articles published on and after 2013 are considered to be included in the study as they contain most current information that is backed-up by updated research information avoid to create error in data presentation that is invalid. The primary articles are to be used in gathering information because they allows development of confidence in the researcher in understanding and knowing information in an untarnished and appropriate manner. It avoids misinterpretation of information as the evidence is collected by analysing the existing direct information provided by participants in the existing studies (Olin et al. 2016). The secondary articles such as meta-analysis, systematic review and others are avoided to be used in the study as it always does not provide effective focus on specific information and the information presented can be faulty as they can be presented with biased knowledge from researchers (Hahn-Holbrook et al. 2018). The academic sources are to be used and others are to be excluded as they provide relevant and scientifically approved evidence that is collected and presented by the researcher through effective experiment and observation of participants. The articles specific to impact of exercise, yoga and social support for postpartum depression is to be included and those focussed on general depression are to be avoided as it would allow relevant data regarding the topic to be gathered for systematic review.

Study selection

The PRISMA tool is referred to evidence-based minimum set of factors essential for framing the systematic review (Ukatu et al. 2018). (Refer to Appendix 1)

Quality Assessment

The critical appraisal is referred to the systematic process used to identify the enriched feature and information in a research article along with the limitation present in it for presenting valid, trustworthy and relevant findings in the study. In this purpose, the Caldwell critical framework is to be used. This is because it provides opportunity to present systematic and consistent results regarding the study (Surabattula et al. 2019).

Ethical Consideration

The ethical considerations are essential to be abided in the study as it helps the researchers to perform the research morally and legally without fear of facing illegal concerns (Holm‐Larsen et al. 2019). In this purpose, to maintain ethical consideration in the study, the researchers are going to effective reference the authors for each information gathered from previous studies to avoid illegal representation of data. The researchers to maintain confidentially are going to avoid sharing any personal details of participants from previous studies. Moreover, the researchers are going to include studies that are been approved by the ethical committee of the University to avoid the presentation of any unethical information.

Critiquing the Literature

The study by Stevens and Wade (2019) informed that nearly half of the 11.5% of the women who are diagnosed with postpartum depression (PPD) after initial few months of delivery remain untreated. In this purpose, the researcher implemented Move and Mingle project within which yoga along with social support therapy was weekly provided to women with PPD for continuously six weeks. The participants selected in the project were 5 women who have given birth within last six months and are diagnosed with PPD but in the end, only 4 were found to complete the program and provide results to assess the condition of their health through the use of Edinburg Postnatal Depression Score (EPDS) Scale. As asserted by Boddy (2016), small sample size affects the reliability and increases the variability of results. This often creates biases in the study leading to raise errors and lowers the efficiency of the study to prove the determined hypothesis. Thus, by selecting sample size in the study, the researcher has created inability to determine the larger effects of yoga and social support therapy on women with PPD and well as supported to create biases in the study. However, limiting the women with PPD who have given birth within last six months was appropriate for the study as it led to avoid inclusion of any unwanted participants. The study used pre-test and post-test quasi-experimental design to allocate the participants. This was an effective approach as it led to compare the variability of the results before and after intervention as well as allows to allocate relevant participants who are appropriate for the study (Top and Karaçam, 2016). The Edinburg Postnatal Depression Score (EPDS) Scale contains a set of 10 questions which helps to determine whether a parent has symptoms of anxiety and depression during pregnancy and year following birth of the baby (Di Florio et al. 2017). Thus, the use of the EPDS Scale was effective approach in determining to what extent the mentioned intervention of yoga and social support therapy acted to resolve symptoms of PPD in women. The EPDS score was collected from the participants before (mean score=13) and after (mean score= 5.75) the intervention and on the comparison, an average improvement of 7.25 points is seen in case of the participants. The first, second, third and fourth participants expressed pre-program EPDS score of 14, 11,14, 13 and post-program EPDS score of 2, 6,5 and 10 indicating a total change of 12, 5, 9 and 3 in score (Stevens and Wade, 2019). This indicates that yoga along with social support therapy is effective to allow women with PPD to cope with their psychological issues of depression to great extent due to which they expressed improvement in mentioned score for EPDS scale. In similar to the study by Stevens and Wade (2019), the study of Ko et al. (2015) executed a 10–week exercise intervention that includes yoga and physical exercise to understand its impact on lowering depression and fatigue in women. In this study, the intervention was found to be executed for longer time compared to the previous study which was for 6-weeks only. The long-term care intervention for patients is important as it leads to support the patients have increased time in accessing care services for enhancing their health (Mundorf et al. 2018). In similar to the previous study, the EPDS Scale was also used by the researcher to determine the difference in PPD pre and post-intervention in this study. This was an effective approach as EPDS Scale acts as sensitive device that provides specific ability to effectively screen and analyse level of depression in women in postnatal stage (Novotney and Maurer, 2017). In this study, 15 participants who have given childbirth in the last 7-12 weeks have developed PPD are selected. The postpartum period is mainly mentioned to initiate after six weeks of childbirth (Ko et al. 2015). Since the participants were selected after 7 weeks of giving birth, thus it indicates appropriate selection of the sample by following the duration of the postpartum period. In this study, similar to the previous study, to understand the variability of results regarding PPD the pretest post-test quasi-experimental design is used. This creates the advantage of making an effective analysis of the potential impact of the intervention (Hiremath et al. 2016).

In contrast, the number of participation though being small is more than the previous study. This in indicates that it could provide less variable results and create less bias compared to the previous study. The intervention made in the 10-weeks program for women includes coaching them to execute yoga, low-intensity aerobic exercise, Pilates and elastic-band exercise. In this study, the mean pre-test PPD score of women was 10.40 and the post-test PPD score was 7.80 indicating a total decrease of 2.73 points for PPD after the intervention (Ko et al. 2015). In comparison to the previous study, it can be considered that the impact of the intervention was poor as the average improvement score was 7.25 which is 3.02 points more than the current impact score. Thus, comparing the two studies it can de determined that yoga supported with social support therapy is more effective than combined with Pilates exercise. In similarity to the previous studies, the study by Forsyth et al. (2017) also tried to identify the effectiveness of physical exercise as intervention in managing postpartum depression. The study used randomised control trial (RCT) in executing the study. The advantage of using RCT is that it eliminates development of biased findings for the treatment as well as resolve confounding issues related with the study (Duncan et al. 2017). The participants included in the study are 22 women who are at six weeks after childbirth and shows EPDS score of more than 12 indicating the selected participations are at risk of PPD. In the study, women are randomly allocated to the intervention and control group. As argued by DeMaris and Mahoney (2017), lack of control group in a study leads the researchers unable to determine the extent of impact of the intervention. This is because the researchers without the control group are unable to compare and assess baseline data with collected data from intervention. Thus, the presence of control group was effective for the study as it allowed to make researcher ensure the extent to which the intervention works in lowering symptoms of PPD in women. In the previous studies by Stevens and Wade (2019) and Ko et al. (2015), no control group was seen to be used which may have led the researcher in the studies unable to make effective compare baseline data with intervention data without bias. All the participants in the study are allocated to engage in 150 minutes of physical exercise each week for 3 months. The data regarding the impact of intervention of physical exercise for PPD management in the study is gathered by interviewing the participants previous and post three months after intervention. The results mentioned that women with PPD on receiving exercise session mentioned that it allows them to feel confident along with expressed developing better mental health and resilience to overcome PPD (Forsyth et al. 2017). The participants mentioned that pram walking, home-based exercise, group exercise and self-initiated exercise are effective intervention for reducing symp0toms of PPD. In another context, the women reported that exercise session provides them opportunity to socialise in turn helping them to overcome boredom and mental pressure which often leads to their PPD condition. Moreover, it created opportunity for them to feel motivated in overcoming depression through actively involving in work and social activities (Forsyth et al. 2017). This indicates that physical exercises are effective for overcoming PPD as most of the women provided positive review for the intervention in helping the cope the mental health condition after giving childbirth. Moreover, this study helps to explain the reason behind reduction of PPD score in women as seen in the previous studies by Stevens and Wade (2019) and Ko et al. (2015). In the study of Corrigan et al. (2015), the impact of social support on managing postpartum depression is discussed. It is different from the previous study of Stevens and Wade (2019) where the combination of yoga and social support therapy is discussed to determine its impact on PPD. This is effective as the study would allow solely determine effectiveness of social support in managing PPD. Thus, the studies create a limitation of identifying which of the activities are more effective in managing PPD compared to one another among new mothers. The current study has taken up survey approach in gathering data and used descriptive research design in formulating the study. The advantage of performing survey is that it allows the researcher to gather wide amount of information directly from the population ensuring collection of accurate first-hand information in drawing potential conclusion (Moniz et al. 2017).

In this study, a total of 61 participants are included who are mothers with 18 years of age and over and has given birth in the past 8 months. A social support questionnaire was provided to the participants and their depression is assessed by using the EPDS scale. This was used to develop two groups which are one with mothers that are facing PPD and the other group of mothers that are not depressed. The EPDS scale indicated that there are 13 mothers out of 61 patients who are suffering from PPD (Corrigan et al. 2015). A Pearson Correlation is used to assess the score for social support questionnaire and EPDS among mothers with PPD. The statistical data expressed significant negative correlation indicating that individuals in the study with increased social support tend to have lower PPD level (r = −.39, p = .002) (Corrigan et al. 2015). Thus, the finding from the study reveals that social support is effective in managing PPD among new mothers. In comparison to the previous study by Forsyth et al. (2017), the study by Shakeel et al. (2018) has implemented population-based prospective cohort study design to gather information on the impact of physical activity for postpartum depression (PPD). The RCT is determined to provide rigour investigational details regarding any intervention and mentions the cause behind its use. However, in cohort studies, the researchers mainly gather data through observation which makes the incapable to develop understanding of the true cause of the impact of any medical intervention on patients (Ti and Curtis, 2019). Thus, using cohort design, the researcher in the study may lead to develop bias which is not prevalent in the previous study. In the study, 643 pregnant women who expressed more than 10 points on the EPDS scale are selected. The advantage of using sample size is that it provides accurate mean values as well as allows identifying outliners which are able to skew data in case of smaller sample (Aoyagi and Tsuchiya, 2019). In the previous three studies, sample size was taken whereas in this study large sample is present indicating probability to provide highly significant data. The women with PPD in this study were included in more than 150 minutes of vigorous physical activity for each week during pregnancy. In the study, through bivariate logical regression, it was seen that women who actively involved in physical exercise during pregnancy expressed lower risk of PPD compared to the control. Moreover, it was seen that longer amount of physical activity was inversely proportional to manage PPD. This is evident as out of the total women who performed more than 150 minutes of physical exercise each week nearly 25.4% expressed no presence of PPD compared to 8.6% who report presence of mild symptoms of PPD. However, those that performed physical exercise for 1-74 min each week it was seen that 25% expressed no presence of PPD whereas 17.3% experienced presence of symptoms of PPD (Shakeel et al. 2018). Thus, it can be determined that PPD is reduced with longer physical exercise and when it is provided during pregnancy, the women expressed higher chances of not developing PPD in the postpartum period. In support of the previous studies, the study by Okyay and Ucar (2018) has also focussed on the impact of physical activity on the depression level and quality of life during the postpartum period. This study used cross-sectional study design to gather information which is effective as it allowed gathering results in quicker way. In this study, the sample included women in the period of six weeks to six months after childbirth. In comparison to Stevens and Wade (2019), Ko et al. (2015), Forsyth et al. (2017) and Shakeel et al. (2018), it is seen that this study took initiative to understand impact of physical exercise on extended postpartum depression by including participants even from six months after childbirth whereas in the previous studies at the most participants who are at 12 weeks after childbirth are chosen. Thus, the results from the study are going to assist in understanding whether or not physical exercise is effective in managing late postpartum depression that is extended to six months.

In the study, 347 women are chosen who are suffering from PPD and they are provided physical exercise intervention. The use of large sample size avoids creating variability issue in the study. The data from the participants are collected by executing face-to-face interview. This helped to gather in-depth information about the impact of physical exercise in coping PPD. The results from the study inform that mean scores of general health, physical role, mental health and social functioning in women with PPD on involving in physical exercise was found to be higher compared to those women with PPD who involved in less extensive physical exercise irrespective of the duration of the postpartum period. Moreover, psychological efficiency among women with PPD was found to be higher who are involved in high physical exercise compared to others (Okyay and Ucar, 2018). Thus, the results are similar to the study by Shakeel et al. (2018) also mentions that extensive physical exercise in the postpartum period are effective to enhance mental role psychological efficiency of the women indicating lower expression of symptoms of PPD in which people express low mood and reduced mental role. In the existing studies, the overall impact of physical activity on managing PPD symptoms is discussed. However, in the study of Aguilar-Cordero et al. (2019), it is seen that they are focussing on to determine the specific physical exercise that could be effective in managing and preventing PPD. This is evident as the study has focussed on to determine the effect of water-based physical exercise during pregnancy in managing PPD symptoms. Moreover, in comparison to the previous studies expect Shakeel et al. (2018), this study focussed to determine the impact of physical exercise being introduced during pregnancy in preventing or managing the risk of PPD in women. Thus, the study highlights, if proactive physical exercise during pregnancy could be effective in managing PPD during the postpartum period apart from aquatic physical exercise to be effective to lower PPD. In similar to the studies of Forsyth et al. (2017) and Shakeel et al. (2018), this study also used RCT as the research design to gather information. In the study, women who are in 12 weeks of gestation are selected and among them, 65 women in the exercise group and 64 women in the control group were selected. In the study, aquatic physical exercises are provided in 1-hour session for 3 days a week to the participants and then the risk of PPD was considered among them by using the EPDS scale. The EPDS score mentions that 38 women out of 64 in the control group and only 14 women out of 65 women in the intervention group are found to be at risk of developing PPD in the postpartum period. Moreover, the average EPDS score in the intervention group was 6.41 indicating no risk of PPD compared to EPDS score of 10.17 in control group indicating mild risk of PPD (Aguilar-Cordero et al. 2019). Thus, the results indicate that aquatic physical exercise acts proactively during pregnancy to save women have reduced risk of suffering from PPD after given birth. The existing studies such as Stevens and Wade (2019), Ko et al. (2015), Forsyth et al. (2017), Shakeel et al. (2018), Okyay and Ucar (2018) and Aguilar-Cordero et al. (2019) mainly discussed the effect of physical exercise on managing PPD that are provided weekly to the women. However, the current study Coll et al. (2019) informs the efficacy of regular exercise during pregnancy in preventing postpartum depression. Thus, it would lead to understand the duration to be maintained for physical exercise to be effective in preventing PPD. In similar to studies of Forsyth et al. (2017) and Shakeel et al. (2018) and Aguilar-Cordero et al. (2019), the researcher in this study also used RCT as study design making it to deliver effective comparative results from the determine intervention. In this study, pregnant women who are at 16-20 weeks of gestation with no complication to exercise are included in the study in 1:2 ratio to the intervention and control group. In the study, nearly 639 participants are selected that is one of the largest sample size used out of the other studies being discussed. The results mentioned no significant presence of men difference in PPD scores between the control and intervention group. Moreover, no variation in the rate of PPD is experienced in the study between control and intervention group (Coll et al. 2019). Thus, this indicates that moderate-intensity exercise in regular manner during pregnancy has significant effect to reduce PPD in women. However, it was seen that noncompliance to perform exercise was significantly related to raise PPD changes among women. The study mentioned that intervention for a short period that is 12 weeks was one of the limitation faced in gathering information. Another limitation was noncompliance in participation irrespective of the favourable environment due to which many potential participants could be included in the study to gather an in-depth understanding of information.

In comparison to the studies of Stevens and Wade (2019) and Ko et al. (2015) where effects of yoga combined with physical exercise and social support therapy on PPD are discussed, the current study by Buttner et al. (2015) focuses to identify impact of yoga as only intervention in preventing and managing PPD. In this purpose, the RCT study design is being used for gathering data instead of pretest and post-test quasi-experimental design was used in the previous two similar studies. The use of RCT is more effective than quasi-experimental design as it allows random selection of participants which helps the researcher to gather sample which represents the population as a whole (Lin et al. 2018). The study recruited 57 women in their postpartum period and has an EPDS score of more than 12 indicating risk of PPD as score more than 8 in the EPDS scale is considered to indicate risk of PPD. The yoga intervention provided to the participants was seen to last for 8 weeks and consist 16 classes in which they are taught regarding the way to perform yoga to overcome PPD. The results mentioned that individuals of the intervention group expressed steep linear decline in symptoms of PPD in 8 weeks compared to the control group. Nearly 78% of the women in the intervention group, expressed positive change in their psychological state on involving with yoga in the postpartum period indicating yoga reduce symptoms of PPD. The treatment group mentioned changes in level of depression in postpartum period during treatment (t (52) = -3.26, p = .002) and post-treatment (t (52) = - 4.27, p < .001) (Aguilar-Cordero et al. 2019). This informs that yoga as a single physical activity is also effective to ensure decline in depression among women in the postpartum period. In comparison to the previous studies, the study by Lewis et al. (2014), focussed on to determine the impact of physical exercise intervention in managing PPD among mothers along with comparison to the impact of wellness/support control for the mothers. In this purpose, randomised control trial study design is used. The wellness/'support condition is referred to as the situation in which new mothers are provided social support along with involved in physical activity to manage PPD (Lewis et al. 2014). This is advantageous as it allows drawing effective comparison between the two intervention as well as avoid biases in the study to be developing, in turn, ensuring effective validity for the study (Lewis et al. 2014). In executing the study, the 130 women who are less than eight weeks of the postpartum period with history of depression are randomly chosen. The Structured Clinical Interview for DSM-IV Axis 1 Disorders (SCID-1) is chosen to select the women from the gathered participants those are suffering from PPD. The SCID-1 provided information about the level of depression or other mental health issues being faced by the individuals (Kepple et al. 2016). This is unlike the EPDS scale which is specially designed to identify depression level in new mothers in the postpartum period. The PHQ-9 tool is used for determining the severity of depression and the response of individuals towards any treatment (Moraes et al. 2017). In his study, the PHQ-9 is used to determine the impact of physical exercise and wellness condition at six months for controlling PPD among new mothers. The results mentioned that fewer depressive symptoms were faced by individuals who are involved in physical activity as seen by PHQ-9 compared to involvement in the wellness/support condition. Moreover, increase physical activity among mothers in the postpartum period indicated less depressive symptoms among the study participants (p<0.05). The probability (p)-value less than 0.05 indicates that the result is statistically significant (Zaidi et al. 2017). This indicates that physical exercise is effective in managing PPD among women compared to use of wellness program.

Conclusion and Recommendations

The systemic review mentioned that postpartum depression (PPD) is a major health issue being faced by women. The PPD is the depressed health condition experienced by women after 46 weeks of the birth of their child. The use of social support, yoga and physical exercise is effective for the management and prevention of PPD. This is because social support helps to provide assistance to the mothers after childbirth in managing the care of the child. Moreover, yoga and physical exercise boost and motivate mothers with PPD to develop positive thinking in overcoming depression. The study is developed to understand the extent of effect of yoga, social support therapy and physical exercise in managing and preventing symptoms of postpartum depression. A total of 10 articles are analysed and critically reviewed to gather information for the study. The critiquing of the data informed that yoga and social support are effective to lower symptoms of PPD. This is because it allows the mothers to socialise, share their emotion, develop greater self-esteem and others. The physical exercise also has greater contribution towards lower symptoms of PPD in women. However, no results are present to compare which of the existing intervention that are yoga or social support or physical exercise in more effective in managing and preventing PPD in better way. The critiquing of the studies also informs that there are no significant differences in prevention or reduction of PPD symptoms on the basis of change in the hours or weeks of physical activity. The recommendations developed on the basis of the information collected is that the intervention such as social support therapy, yoga and physical exercise to manage and reduce symptoms of PPD are to be initiated from during the pregnancy years of the women. This is to make the women at risk of PPD to develop knowledge regarding the actions to be executed to control their emotion in a positive manner during the postpartum period. The use of group exercise, pram walking and self-initiated physical activity is to be promoted for managing symptoms of PPD among individuals. The interventions are recommended to be provided after effective health analysis of the mothers. This is to avoid hindrance of inappropriate damage to the body of new mothers from inappropriate physical exercise. In lowering symptoms of PPD, physical exercise is recommended to be essential intervention provided to the new mother apart from yoga and social support. This is because in majority of the studies it is highlighted that exercise led the new mothers to remain physical and mentally active during the postpartum depression and they also expressed reduced symptoms of PPD. The health professionals are recommended to provide appropriate education and training to the new mothers regarding the nature of physical exercise to be performed or yoga poses suitable for them to manage PPD. The physical exercise and yoga intervention are recommended to be made more than 8-10 weeks as it is the normal duration in which effective management of PPD is seen in all the existing studies among the women.

References

Aguilar-Cordero, M.J., Sánchez-García, J.C., Rodriguez-Blanque, R., Sánchez-López, A.M. and Mur-Villar, N., 2019. Moderate physical activity in an aquatic environment during pregnancy (SWEP study) and its influence in preventing postpartum depression. Journal of the American Psychiatric nurses association, 25(2), pp.112-121.

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