[Note: This article is being published in draft form for use in an active research study. Its contents may be adjusted as we receive feedback from collaborating health care professionals.]
Guidelines by the United States Department of Health and Human Services and American College of Obstetricians and Gynecologists (ACOG) recommend that in the absence of obstetric or medical complications or contraindications, women during pregnancy and in the postpartum period do at least 150 minutes of moderate aerobic activity each week.1,2 For women who engaged in vigorous exercise before pregnancy, they further advise that the continuation of these activities during and after pregnancy is safe. For women who were sedentary before pregnancy, they advise that they gradually increase in exercise until meeting the recommendations.
Physical activity is associated with minimal risk, and the benefits far outweigh any potential risks.2 The benefits of exercise during pregnancy and the postpartum period are numerous, including decreased incidence of gestational diabetes mellitus, cesarean birth and operative vaginal delivery, postpartum recovery time, and the prevention of depressive disorders in the postpartum period.
Due to the physical changes inherent in pregnancy (weight gain, increasing stress on joints, and a shift in point of gravity), ACOG advises that these changes be taken into account before advising patients to do any particular exercise routine.2 Examples of exercises that have been studied during pregnancy and postpartum and have been found to be both safe and beneficial include walking, stationary cycling, aerobic exercise, dancing, resistance training such as weightlifting or use of elastic bands, stretching exercises, and water aerobics. Activities to avoid during pregnancy include scuba diving and any contact activities with high risk of abdominal trauma or imbalance such as American football or rugby.
Guidelines are nonspecific about when women are recommended resume exercising postpartum, advising that they resume gradually as soon as medically safe depending on the mode of delivery and any complications in childbirth.2 ACOG advises that some women are able to resume exercising within days of delivery. Concerns regarding exercise affecting lactation have not been substantiated, and physical activity appears to have no effect on milk production or composition.
Warning signs to discontinue exercising while pregnant include vaginal bleeding, abdominal pain, regular painful contractions, amniotic fluid leakage, dyspnea before exertion, dizziness, headache, chest pain, muscle weakness affecting balance, calf pain, or calf swelling.2
Exercise Postpartum
The results of a randomized trial published in 2022 examined the effects of aerobic exercise on stress and fatigue management in 60 lactating, employed, 25-35-year-old mothers with an infant 6-8 months old in Egypt.3 The participants were randomized into two groups, one receiving five sessions of 30-minute aerobic training on a treadmill per week and lifestyle modification advice (including fatigue and stress reduction, healthy diet, and general new mothering advice) for six weeks, and one receiving only lifestyle advice. Stress and fatigue levels were assessed using the Perceived Stress Scale (PSS-10, scored 1-40 with higher scores indicating greater stress) and Fatigue Assessment Scale (FAS, scored 10-50 with lower scores indicating more fatigue). At baseline, PSS-10 scores were 28.9 among the intervention group and 28.5 among controls, and FAS scores were 3.9 and 4.2. At six weeks, exercise was found to significantly reduce both stress and fatigue, with PSS-10 scores of 13.9 in the intervention group vs 22.0 in the control group (p=0.001) and FAS scores of 18.4 vs 4.5 control (p=0.001). The study found that exercising as part of a daily routine can help reduce stress and fatigue in lactating employed mothers.
A 2023 longitudinal prospective cohort study investigated the impact of exercise on the severity of pelvic symptoms and abdominal separation after pregnancy.4 The study followed 504 participants and assessed pelvic symptoms, exercise behavior, pelvic floor muscle strength, and abdominal separation at three month intervals for up to a year postpartum. Participants were categorized into four groups based on their level of exercise at baseline: non-exercisers (<2 times per week, n=105), minimal low-impact exercisers (low-impact exercise 2-4 times per week, n=249), regular low-impact exercisers (low-impact exercise >5 times per week, n=117), and high-impact exercisers (high-impact exercise at least once a week in addition to low-impact exercise ≥2 times per week, n=32). Pelvic girdle pain assessed using the Pelvic Girdle Questionnaire (scored 0-100 with higher scores indicating more pain) decreased with increased exercise, with non-exercisers having an average score of 25.6, minimal exercisers scoring 20.7, regular exercisers scoring 19.7, and high-impact exercisers scoring 15.0 (p=0.02). Findings on stress urinary incontinence, vaginal heaviness, pelvic floor muscle strength, and abdominal separation were not significant. The authors noted that while they did not analyze the specific benefits of high-impact exercise over other types of exercise, they felt the study adequately demonstrated the safety of these exercises for women postpartum.
Pelvic Strengthening Exercises
A 2013 meta-analysis of 14 randomized control trials (n=6,454) examined the effect of Kegel exercises on urinary incontinence postpartum.5 At six months postpartum, 22.6% of women performing Kegel exercises experienced self-reported urinary incontinence compared to 28.0% of controls (Odds Ratio [OR] 0.75, p<0.001).
A 2024 randomized control trial investigated the impact of warm acupuncture therapy combined with Kegel exercises on postpartum pelvic floor dysfunction.6 A total of 70 primiparous women with postpartum pelvic floor muscle (PFM) injury were randomized to receive warm acupuncture and Kegel exercise (n=35) or placebo (n=35) three times a week for four weeks. Pelvic floor strength as assessed by urethral rotation angle (URA), retrovesical angle (RVA), and bladder neck descent (BND) was significantly improved in the intervention group compared to placebo (URA 12.72° improvement vs 5.35° placebo, p=0.041; RVA 18.79° improvement vs 12.55°, p=0.013; BND 3.23 mm improvement vs 1.6 mm, p=0.031). Incontinence assessed using the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF, scored 0-21 with higher scores indicating more severe symptoms) decreased significantly in the intervention arm (3.32 decrease vs 0.95, p=0.016), as did pelvic girdle pain assessed using the Pelvic Floor Dysfunction Inventory-20 (PFDI-20, scored 0-40 with higher scores indicating more severe symptoms, 8.66 decrease vs 3.65, p=0.047).
Cardiovascular Health
A 2024 prospective study (n=412,413) investigated the sex-specific associations between physical activity and cardiovascular mortality.7 The study analyzed the Centers for Disease Control (CDC) National Center for Health Statistics (55% female, age 44±17 years) survey data from 1997-2019 on regularity of physical activity, sex, cardiovascular mortality, and all-cause mortality. Over 4,911,178 person-years of follow-up, all-cause mortality was 39,935 (8.1 per 1,000 person-years) and cardiovascular mortality was 11,670 (2.4 per 1,000 person-years). Regular physical activity (defined as ≥150 minutes of moderate physical activity or ≥75 minutes of vigorous physical activity) was associated with 24% lower risk of all-cause mortality in women, equating to a drop from 8.1 to 6.2 deaths per 1,000 person-years (Hazard Ratio [HR] 0.76, 95% Confidence Interval [CI] [0.73-0.80], p<0.001) and 15% lower risk in men, or a drop from 8.1 to 6.9 deaths per 1,000 person-years (HR 0.85, 95% CI [0.82-0.89], p<0.001). Sex-specific findings were similar for cardiovascular death and consistent for both aerobic exercise as well as muscle strengthening exercise. Men had the most benefit from 300 minutes of moderate to vigorous physical activity per week, whereas women achieved a similar benefit at 140 minutes, but similarly had the most benefit from 300 minutes. The study found that women derived greater gains than men in all-cause and cardiovascular mortality risk reduction from equivalent doses of physical activity.
Mental Health
Several randomized trials have shown that exercise reduces depressive symptoms, depression, and anxiety. For example, a meta-analysis published in 2018 included 17 randomized controlled trials that together studied 1,428 participants.8 Standardized mean differences overall significantly favored fewer depressive symptoms in intervention participants. Mean incidence of depressive symptoms ranged from 3-18.08% in experimental arms and 0.81-12.76% in control arms with an overall standard mean difference of -0.64 (p<0.001).
A 2012 randomized control trial (n=679) examined the effect of education on improved diet and physical activity in low-income postpartum women who were eligible for the United States Department of Agriculture Special Supplemental Nutrition Program from Women and Children (WIC).9 Over a mean follow-up period of 13.3 months, women who received diet and exercise education had significantly fewer depressive symptoms compared to controls. Using the Center for Epidemiological Studies Depression Scale (CES-D, scored 0-60 with higher scores indicating worse symptoms) to assess depression, those in the intervention arm on average had scored 2 points lower than controls.
A 2010 randomized control trial (n=161) compared the effect of a personalized exercise program and parenting education versus only parenting education on postpartum depression.10 After eight weeks, those receiving a personalized exercise program had significantly lower depressive symptoms as assessed by both the Positive Affect Balance Scale (PABS, scored 0-15 with higher scores indicating fewer depressive symptoms; scores of 11.82 intervention vs 10.47 control, p=0.007) and the Edinburgh Postnatal Depression Scale (EPNDS, scored 0-40 with higher scores indicating more depressive symptoms; scores 5.47 vs 6.75, p<0.0001).
A 2020 randomized control feasibility study explored the efficacy of online yoga classes in reducing symptoms of post-traumatic stress disorder (PTSD) in women who experienced stillbirth (n=90).11 Women who had experienced a stillbirth within the past 24 months with clinically confirmed PTSD were randomized to participate in either 150 minutes of yoga per week (moderate dose), 60 minutes of yoga per week (low dose), or 60 minutes of stretching (control) over 12 weeks. There was a nonsignificant difference between PTSD symptoms assessed using the Impact of Events Scale (IES-R, scored from 0-88 with higher scores indicating higher symptom burden; decrease of 25.61 for moderate, 18.63 for low, and 10.08 for controls). However, there was a significant dose-dependent effect on depression assessed using the Patient Health Questionnaire-9 (PHQ-9, scored 0-27 with higher scores indicating greater severity; decrease of 2.96 for moderate, 6.21 for low, and 0.59 for controls, p=0.036) and Perinatal Grief Scale (PGS, scored 33-165 with higher scores indicating greater grief, decrease of 19.00 for moderate, 17.21 for low, and 0.34 for controls, p=0.009). The study concluded that by leveraging innovative approaches to exercise delivery, such as online platforms, this study offers insight into novel avenues for addressing psychological challenges during the postpartum period.
Although not specific to postpartum women, studies have also shown that exercise reduces general stress and anxiety as well. A 1989 randomized control trial of 80 college students examined the acute effects of exercise on anxiety assessed using the Profile of Mood States survey (scored 20-80 with higher scores indicating higher levels of anxiety).12 Participants were randomly assigned to either do 20 minutes of moderate aerobic exercise on a stationary bike followed by 20 minutes of rest or to only have 20 minutes of rest. Exercise significantly reduced anxiety scores by 2.2 vs 0.2 for controls (p=0.006).
In conclusion, various studies indicate that exercise can have a significant positive impact on women’s health after giving birth. United States Department of Health and Human Services guidelines recommend that women appeal to healthcare providers for personalized exercise plans to address patient-specific challenges of the postpartum period to improve their overall health and well-being.
References
- Piercy KL, Troiano RP, Ballard RM, et al. The Physical Activity Guidelines for Americans. Jama. Nov 20 2018;320(19):2020-2028. doi:10.1001/jama.2018.14854
- Physical Activity and Exercise During Pregnancy and the Postpartum Period: ACOG Committee Opinion, Number 804. Obstet Gynecol. Apr 2020;135(4):e178-e188. doi:10.1097/aog.0000000000003772
- Shehata MA, Basyouny SE, Atef H, Hussien HE, Botla AM. The SAFE study: Stress and fatigue control by exercise: Acute and long-term effects of aerobic exercise in lactating employed mothers. Work. 2024;77(2):641-649. doi:10.3233/wor-220677
- Vesting S, Gutke A, Olsén MF, Rembeck G, Larsson MEH. The Impact of Exercising on Pelvic Symptom Severity, Pelvic Floor Muscle Strength, and Diastasis Recti Abdominis after Pregnancy: A Longitudinal Prospective Cohort Study. Phys Ther. Dec 18 2023;doi:10.1093/ptj/pzad171
- Park SH, Kang CB, Jang SY, Kim BY. [Effect of Kegel exercise to prevent urinary and fecal incontinence in antenatal and postnatal women: systematic review]. J Korean Acad Nurs. Jun 2013;43(3):420-30. doi:10.4040/jkan.2013.43.3.420
- Dai J, Jin Z, Zhang X, Lian F, Tu J. Efficacy of Warm Acupuncture Therapy Combined with Kegel Exercise on Postpartum Pelvic Floor Dysfunction in Women. Int Urogynecol J. Jan 18 2024;doi:10.1007/s00192-023-05698-9
- Ji H, Gulati M, Huang TY, et al. Sex Differences in Association of Physical Activity With All-Cause and Cardiovascular Mortality. J Am Coll Cardiol. Feb 27 2024;83(8):783-793. doi:10.1016/j.jacc.2023.12.019
- Carter T, Bastounis A, Guo B, Jane Morrell C. The effectiveness of exercise-based interventions for preventing or treating postpartum depression: a systematic review and meta-analysis. Arch Womens Ment Health. Feb 2019;22(1):37-53. doi:10.1007/s00737-018-0869-3
- Surkan PJ, Gottlieb BR, McCormick MC, Hunt A, Peterson KE. Impact of a health promotion intervention on maternal depressive symptoms at 15 months postpartum. Matern Child Health J. Jan 2012;16(1):139-48. doi:10.1007/s10995-010-0729-x
- Norman E, Sherburn M, Osborne RH, Galea MP. An exercise and education program improves well-being of new mothers: a randomized controlled trial. Phys Ther. Mar 2010;90(3):348-55. doi:10.2522/ptj.20090139
- Huberty J, Sullivan M, Green J, et al. Online yoga to reduce post traumatic stress in women who have experienced stillbirth: a randomized control feasibility trial. BMC Complement Med Ther. Jun 5 2020;20(1):173. doi:10.1186/s12906-020-02926-3
- Roth DL. Acute emotional and psychophysiological effects of aerobic exercise. Psychophysiology. Sep 1989;26(5):593-602. doi:10.1111/j.1469-8986.1989.tb00716.x
