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A Systematic Review and Meta-Analysi Review Br J Sports Med: first published as 10.1136/bjsports-2018-099697 on 18 October 2018. Downloaded from Impact of prenatal exercise on both prenatal and postnatal anxiety and depressive symptoms: a systematic review and meta-analysis Margie H Davenport,1 Ashley P McCurdy,1 Michelle F Mottola,2 Rachel J Skow,1 Victoria L Meah,3 Veronica J Poitras,4 Alejandra Jaramillo Garcia,4 Casey E Gray,5 Nick Barrowman,6 Laurel Riske,1 Frances Sobierajski,1 Marina James,1 Taniya Nagpal,2 Andree-Anne Marchand,7 Megan Nuspl,8 Linda G Slater,9 Ruben Barakat,10 Kristi B Adamo,11 Gregory A Davies,12 Stephanie-May Ruchat13 ► Additional material is ABStract it is generally accepted that both conditions are published online only. To view Objective To examine the influence of prenatal exercise underdiagnosed and undertreated during the peri- please visit the journal online 5 6 (http:// dx. doi. org/ 10. 1136/ on depression and anxiety during pregnancy and the natal period. These conditions have immediate bjsports- 2018- 099697). postpartum period. and persisting adverse impacts on both mother and Design Systematic review with random effects meta- child. For numbered affiliations see analysis and meta-regression. For mothers, depression and/or anxiety during end of article. Data sources Online databases were searched up to 6 pregnancy strongly predicts postpartum depres- January 2017. sion and anxiety; depression and anxiety are asso- Correspondence to Dr Margie H Davenport, Study eligibility criteria Studies of all designs ciated with reduced self-care, preterm labour, low Program for Pregnancy and were included (except case studies) if they were birth weight as well as compromised caregiving and Postpartum Health, Faculty published in English, Spanish or French and contained bonding with the infant.7–9 Maternal depression of Kinesiology, Sport, and information on the Population (pregnant women without and anxiety have also been linked with delays in Recreation, University of contraindication to exercise), Intervention (subjective offspring development (cognitive, emotional and Alberta, Edmonton T6G 2E1, 10 10–13 Canada; or objective measures of frequency, intensity, duration, social development). Standard treatments for mdavenpo@ ualberta. ca volume or type of exercise), Comparator (no exercise depression and anxiety include pharmacological or different frequency, intensity, duration, volume and and psychological intervention14–16 but the long- Accepted 10 August 2018 type of exercise) and Outcome (prenatal or postnatal term impact of some medications on the fetus has depression or anxiety). not been established7 16 and psychotherapy can be Results A total of 52 studies (n=131 406) were costly and difficult to access.17 18 The consequences included. ’Moderate’ quality evidence from randomised of leaving these disorders untreated can be severe. controlled trials (RCTs) revealed that exercise-only In non-pregnant women, exercise may be as interventions, but not exercise+cointerventions, reduced effective as antidepressants and psychotherapy for http://bjsm.bmj.com/ the severity of prenatal depressive symptoms (13 RCTs, treating mild-to-moderate depression (ie, a moderate n=1076; standardised mean difference: −0.38, 95% CI effect size).19 A recent review demonstrated that 2 −0.51 to –0.25, I =10%) and the odds of prenatal light to moderate intensity aerobic exercise initi- depression by 67% (5 RCTs, n=683; OR: 0.33, 95% CI ated in the postpartum period improves mild to 2 0.21 to 0.53, I =0%) compared with no exercise. moderate depressive symptoms and increases the Prenatal exercise did not alter the odds of postpartum likelihood of resolving mild to moderate depres- depression or the severity of depressive symptoms, sion in the postpartum period compared with stan- nor anxiety or anxiety symptoms during or following dard care.20 It has not been established if prenatal on 19 October 2018 by guest. Protected copyright. pregnancy. To achieve at least a moderate effect size exercise reduces the prevalence and/or severity of in the reduction of the severity of prenatal depressive depression and anxiety during pregnancy and the symptoms, pregnant women needed to accumulate at postpartum period. least 644 MET-min/week of exercise (eg, 150 min of Current national and international guidelines moderate intensity exercise, such as brisk walking, water recommend that women without contraindica- aerobics, stationary cycling, resistance training). tions to exercise (eg, preeclampsia, incompetent Summary/Conclusions Prenatal exercise reduced the cervix, premature labour) be physically active odds and severity of prenatal depression. throughout pregnancy.21–23 This systematic review and meta-analysis forms part of a series of reviews, which will form the evidence base for the develop- © Author(s) (or their ment of the 2019 Canadian guideline for physical employer(s)) 2018. No INTRODUCTION commercial re-use. See rights In 2017, the WHO identified that depression is the activity throughout pregnancy (herein referred to as 24 and permissions. Published leading cause of disability worldwide.1 Pregnant Guideline). The purpose of this paper is to present by BMJ. and postpartum women are particularly vulnerable the results of a systematic review and meta-analysis To cite: Davenport MH, to declining mental health as a result of elevated of the relationships between prenatal exercise, and 2 McCurdy AP, Mottola MF, stress and lack of social support. Depression affects (1) depression and anxiety during pregnancy as et al. Br J Sports Med approximately 13% and anxiety affects up to 39% well as (2) any persisting effect into the postpartum 2018;52:1376–1385. of pregnant and postpartum women;3 4 however, period. Davenport MH, et al. Br J Sports Med 2018;52:1376–1385. doi:10.1136/bjsports-2018-099697 1 of 11 Review Br J Sports Med: first published as 10.1136/bjsports-2018-099697 on 18 October 2018. Downloaded from METHODS or in combination with other interventions (such as diet; termed In October 2015, the Guidelines Consensus Panel was formed to ‘exercise+cointerventions’) were considered. Studies were identify outcomes for the Guideline update. The panel included excluded if exercise was performed after the beginning of labour. researchers, methodological experts, a fitness professional, a public health representative (Middlesex-London Health Unit) CompariSON and representatives from the Society for Obstetricians and Eligible comparators were: various frequencies, intensities, dura- Gynecologists of Canada, Canadian Society for Exercise Phys- tions, volumes and types of exercise; various durations of inter- iology (CSEP), The College of Family Physicians of Canada, vention or exercise or exercise in different trimesters. Canadian Association of Midwives and Canadian Academy of Sport and Exercise Medicine, Exercise is Medicine Canada. OUTCOME During this meeting, 20 ‘critical’ and 17 ‘important’ outcomes Eligible outcomes were diagnosis of depression or anxiety (either related to prenatal exercise and maternal/fetal health were by exceeding a specific threshold via questionnaire or diagnosis selected. Maternal mental health was rated as ‘critical’ outcome. by a qualified professional) and severity of symptoms of depres- This systematic review and meta-analysis was conducted in sion or anxiety. accordance with the PRISMA guidelines and the checklist was completed.25 STUDY DESIGN Primary studies of any design were eligible, except case studies Protocol and registration (n=1). Narrative or systematic reviews and meta-analyses were Two systematic reviews examining the impact of prenatal exer- excluded. cise on fetal and maternal health outcomes were registered with PROSPERO, the international prospective register of system- Information sources atic reviews (fetal health: Registration no. CRD42016029869; A comprehensive search was created and run by a research Available from: https://www. crd. york. ac. uk/PROSPERO/ librarian (LGS) in the following databases: MEDLINE, EMBASE, display_ record. asp? ID= CRD42016029869; maternal health: PsycINFO, Cochrane Database of Systematic Reviews, Cochrane Registration no. CRD42016032376; Available from: https:// Central Register of Controlled Trials, Scopus and Web of Science www. crd. york. ac. uk/ PROSPERO/ display_ record. asp? ID= Core Collection, CINAHL Plus with Full-text, Child Develop- CRD42016032376). Because the relationships between prenatal ment & Adolescent Studies, ERIC, Sport Discus, ClinicalTrials. exercise and maternal/fetal health outcomes are examined gov and the Trip Database up to 6 January 2017 (see online in studies related to both fetal and maternal health, records supplementary file for complete search strategies). retrieved from both of these reviews were considered for inclu- sion in the present systematic review. Study selection and data extraction Titles and abstracts of all retrieved articles were independently Eligibility criteria screened by two reviewers. Abstracts that were judged to have This study was guided by the participants, interventions, compar- met the initial screening criteria by at least one reviewer were isons, outcomes and study design (PICOS) framework.25 retrieved as full-text articles. Articles were reviewed for relevant PICOS information by at least one person. If it was deemed that POPULatioN articles did not meet the inclusion criteria, they were reviewed by http://bjsm.bmj.com/ The population of interest included in this review was pregnant MHD and/or SMR prior to exclusion. If agreement
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