Elsevier

Midwifery

Volume 26, Issue 3, June 2010, Pages 367-375
Midwifery

How women manage fatigue after childbirth

https://doi.org/10.1016/j.midw.2008.07.004Get rights and content

Abstract

Objective

to explore the strategies used by women to manage fatigue in the first six months following childbirth.

Design

a qualitative study using an exploratory descriptive design. Data were collected using open-ended questions contained in surveys posted to participants six, 12 and 24 weeks after birth.

Setting

Canberra, Australian Capital Territory, Australia.

Participants

59 well women, 27 primipara and 32 multipara, aged 20–40 years, who gave birth in the Australian Capital Territory.

Findings

three themes emerged from the analysis:‘Looking after me’ or self-care practices; ‘Managing the load’ or balancing the work to be done with the aim of managing the woman's fatigue; and ‘How it worked’, describing how useful the strategies had been in managing fatigue. From six weeks to six months, the women used self-care strategies (sleep/rest, relaxing, conserving energy) more often than strategies designed to manage the load (getting help, planning, lowering expectations). Most multiparas (24/32) conserved energy to manage fatigue, in contrast to primiparas (13/27). Women experiencing high fatigue conserved energy more often than women who were experiencing less fatigue. No differences in strategy choice were found between women who experienced a vaginal birth and those who had experienced a caesarean birth, or between those women who scored ⩾13 on the Edinburgh Postnatal Depression Scale (EPDS) as opposed to those who scored <13. Overall, women rated their chosen strategies as very useful or useful. Womens’ comments also indicated that getting help from partners and family was sometimes difficult, reducing the usefulness of this strategy.

Implications for practice

preparing women and their partners to manage postnatal fatigue more effectively is essential. Midwives should encourage women to identify sources of help and what particular help that individual could provide. Scenarios should be used in parenting classes to encourage women and their partners to negotiate issues surrounding the sharing of responsibilities after birth. After birth, ongoing assessment of fatigue and the strategies used to manage it is essential beyond the first six weeks.

Introduction

For two decades, women from Western industrialised nations have ranked fatigue among their top five concerns after birth (Troy, 2003). Experienced as a negative and unpleasant symptom, it is one of the most common symptoms reported by women following childbirth (Gjerdinger et al., 1993; Bick and MacArthur, 1995; Killien, 1995; Brown and Lumley, 1998; Thompson et al., 2000, Thompson et al., 2002; McGovern et al., 2006, McGovern et al., 2007; Rychnovsky, 2007). Postnatal fatigue is defined as an overwhelming sense of exhaustion that is accompanied by a decreased capacity for physical and mental work at the individual's usual level (Milligan et al., 1997; NANDA, 2005–2006).

Beginning in the 1980s, the following research studies have contributed significantly to our understanding of the nature of postnatal fatigue and its effects on women, infants and families. Not only is postnatal fatigue a common health problem, but researchers highlight that it is progressive, rather than self-resolving, and continues past the traditional six-week period when women are considered to have recovered physically from giving birth (Bick and MacArthur, 1995; Parks et al., 1999). Ongoing postnatal fatigue has been associated with the development of maternal depression (Affonso et al., 1990; Bozoky and Corwin, 2002; Corwin et al., 2005), lower infant developmental performance (Parks et al., 1999), and delayed return of maternal functional status and early cessation of breast feeding (Tulman et al., 1990; Milligan et al., 1996; Parks et al., 1999; McVeigh, 2000). Few studies have described or tested interventions that reduce fatigue for childbearing women. This study aims to describe the strategies used by women within the first six months after childbirth, and outlines how useful women found such approaches.

Several factors have been identified by researchers as contributing to or increasing levels of fatigue in women. Factors consistently associated with higher fatigue levels included: being a primipara (Milligan, 1989; MacArthur, 1999), experiencing a longer labour, caesarean birth, increased postpartum blood loss (Milligan, 1989; MacArthur et al., 1991), more depressive symptoms, perceiving the infant to be more difficult (Milligan, 1989; Wambach, 1998), less sleep (Elek et al., 1997) and less social support (Gottlieb and Mendelson, 1995).

Combinations of factors also intensify fatigue. Milligan (1989) found that, together, having a difficult infant, breast feeding, and experiencing more depressive symptoms were significant predictors of women's fatigue six weeks after birth. Additionally, the factors involved change over time. Birth-related factors (length of labour, assisted vaginal or caesarean birth) resulted in higher levels of fatigue two weeks after birth (Milligan, 1989; Troy, 1999). Having a more difficult infant (Milligan, 1989; Wambach, 1998), less sleep or more disturbed sleep (Wambach, 1998; Elek et al., 2002), and the presence of more depressive symptoms (Milligan, 1989; Wambach, 1998) were the major contributors to fatigue two to three months after birth.

In healthy postnatal women, where serious physical and mental causes of fatigue have been excluded, management of fatigue is best decided by the individual. The severity of fatigue may influence what strategies individuals choose to manage fatigue, and how useful they perceive the strategies to be. Additionally, as fatigue intensity changes over time, the strategies used to manage it may also change. Midwives and maternal–child health nurses give anticipatory advice on how to manage fatigue; however, these strategies generally reflect a common sense approach. A better understanding of the strategies women use, and the usefulness of those strategies, may lead to better advice.

In judging usefulness, it is imperative that the perspective of the individuals concerned is sought. Maushart (1997), and other feminist writers, have criticised what they consider to be the takeover of women's knowledge of birth and mothering by professional experts. Knowledge of management strategies developed from women, for women, could provide support for the approaches currently recommended by midwives, other health professionals and women's support groups such as La Leche and other not-for-profit groups. This knowledge may also suggest additional strategies.

Few studies address the management of fatigue; however, some authors suggest that each woman should be assessed for the presence and causes of fatigue. Strategies to relieve the fatigue can then be chosen (Gardner and Campbell, 1991; Parks et al., 1999; Bick et al., 2002). Sleeping, resting, relaxing, decreasing energy consumption, and enlisting the help of family to decrease workloads are some of the strategies suggested in the literature (Bick et al., 2002; Troy and Dalgas-Pelish, 1995, Troy and Dalgas-Pelish, 2003).

Only two fatigue-reduction strategies have been specifically tested in postnatal women. Lying on the side to breast feed whilst in hospital (as opposed to sitting upright) was associated with less fatigue (p<0.05) in women who gave birth vaginally (n=14) (Milligan et al., 1996). Troy and Dalgas-Pelish (2003) found the use of a tiredness management guide was associated with less morning fatigue (p<0.01) in primiparas who had given birth vaginally (n=68) two to four weeks after birth. These intervention studies present a beginning in testing strategies for the self-care management of fatigue. Further evidence of the effectiveness of the strategies over longer periods of time with samples more representative of the general population of postnatal women is warranted.

Given the high incidence of fatigue in women after birth, its impact on quality of life, and the lack of evidence-based interventions for managing the problem, there is a clear need to develop a better understanding of how childbearing women manage fatigue. The purpose of this research was to explore the strategies used by women to manage fatigue in the first six months following childbirth. The following research questions were explored: (1) How do women manage fatigue? (2) Are there differences/similarities in the strategies chosen by women with different characteristics (parity, type of birth, levels of fatigue and less/more depressive symptoms) (3) How do the strategies change over time? (4) From the woman's perspective, how useful are the strategies they choose?

Section snippets

Methods

A qualitative descriptive design was used. Qualitative descriptive studies draw on the principles of naturalistic inquiry that aim to explore phenomena in their natural state, with no a priori commitment to one or another philosophical view (Lincoln and Guba, 1985; Sandelowski, 2000). Qualitative descriptive studies are the method of choice when the purpose is to know the ‘who’, ‘what’ and ‘where’ of events (Sandelowski, 2000).

Participant profile

Fifty-nine women were chosen for inclusion in this phase of the study. The women's ages ranged from 20 to 44 years (M=30.49, SD=4.86). The majority were married or in a de facto relationship (98%) and were born in Australia (76%). Twenty-four per cent of women (n=14) were born in another country, including New Zealand, Europe, Africa, Asia and the Americas. The ACT has a low number of indigenous birthing women and, despite active recruiting, no woman who identified herself as indigenous

Implications for practice

These findings can assist midwives and antenatal educators to better understand how they might help women and their partners to prepare for and manage postnatal fatigue. Just as educators attempt to equip women and their partners with the skills to deal with the pain of labour, so can we attempt to equip them with skills to deal with fatigue. The content of such educational sessions could use the fatigue management strategies and exemplars identified in this study as a starting point for the

Conclusions

Fatigue was a significant problem for these Australian women, and the experience of fatigue had a greater impact than had been anticipated. The strategies women used (sleep, asking for help with tasks) were general and could be applied to any situation in which an individual was fatigued. Women rated their chosen strategies as very useful or useful, although getting help from partners and family was sometimes difficult. Further research is required on how women decide on specific strategies in

Acknowledgements

This study was funded by a PhD scholarship from the University of Western Sydney where the first author was a PhD candidate. We acknowledge the contribution of Dr Carol McVeigh to this study, and thank the midwives who assisted with the recruitment and the women who shared their stories.

References (46)

  • D. Affonso et al.

    A standardized interview that differentiates pregnancy and postpartum symptoms from perinatal clinical depression

    Birth

    (1990)
  • K. Armstrong et al.

    The effectiveness of a pram-walking exercise programme in reducing depressive symptomatology for postnatal women

    Journal of Nursing Practice

    (2004)
  • D. Bick et al.

    The extent, severity and effect of health problems after childbirth

    British Journal of Midwifery

    (1995)
  • D. Bick et al.

    Postnatal Care: Evidence and Guidelines for Management

    (2002)
  • P. Boyce et al.

    The Edinburgh postnatal depression scale: validation for an Australian sample

    Australian and New Zealand Journal of Psychiatry

    (1993)
  • I. Bozoky et al.

    Fatigue as a predictor of postpartum depression

    Journal of Obstetric, Gynecologic, and Neonatal Nursing

    (2002)
  • S. Brown et al.

    Maternal health after childbirth: results of an Australian based population survey

    British Journal of Obstetrics and Gynaecology

    (1998)
  • P. Choi et al.

    Supermum, superwife, supereverthing: performing feminity in the transition to motherhood

    Journal of Reproductive and Infant Psychology

    (2005)
  • I. Coyne

    Sampling in qualitative research. Purposeful and theoretical sampling: merging or clear boundaries?

    Journal of Advanced Nursing

    (1997)
  • S. Elek et al.

    Expectant parents’ experience with fatigue and sleep during pregnancy

    Birth

    (1997)
  • S. Elek et al.

    Couples’ experiences with fatigue during the transition to parenthood

    Journal of Family Nursing

    (2002)
  • D. Gardner et al.

    Assessing postpartum fatigue

    American Journal of Maternal/Child Nursing

    (1991)
  • D. Gjerdinger et al.

    Changes in women's physical health during the first postpartum year

    Archives of Family Medicine

    (1993)
  • Cited by (40)

    • Comparison of subjective sleep and fatigue in breast- and bottle-feeding mothers

      2017, Midwifery
      Citation Excerpt :

      It has been well documented that mothers experience sleep changes and increased levels of fatigue after childbirth (Dørheim et al., 2009, Rychnovsky and Hunter, 2009; Taylor and Johnson, 2010).

    • Depressive symptoms and changes in physiological and social factors 1 week to 4 months postpartum in Japan

      2015, Journal of Affective Disorders
      Citation Excerpt :

      Thus, it is necessary to make an assessment of the change in PPW׳s physiological and mental condition over time. Many countries, including Japan, have introduced a system to deal with PPD (Taylor and Johnson, 2010; Norhayati et al., 2014). These systems include questionnaires for screening high-risk PPD subjects in the prenatal and postnatal periods, education about PPD, and provisions for support care after discharge (Alipour et al., 2012; Liberto, 2012).

    • Psychometric evaluation of a Chinese version of the Lee Fatigue Scale-Short Form in women during pregnancy and postpartum

      2014, International Journal of Nursing Studies
      Citation Excerpt :

      Outcomes include, but are not limited to, increased psychological symptoms during pregnancy, increased risks for cesarean deliveries, and a new onset of postpartum depressive symptoms (Chien and Ko, 2004; Dennis and Ross, 2005; Reeves et al., 1991). Rather than self-limiting (Corwin and Arbour, 2007; Taylor and Johnson, 2010), fatigue can persist throughout pregnancy and continue up to 18 months after delivery (Elek et al., 1997; Lee and Zaffke, 1999; Parks et al., 1999). Prolonged and unresolved fatigue interferes with maternal capacity for infant-care activities and has been associated with poor maternal mental and physical health, delayed infant development, and more symptoms of infection in both mothers and infants (Groer et al., 2005; Parks et al., 1999; Pugh and Milligan, 1993).

    • The Efficacy of an Intervention for the Management of Postpartum Fatigue

      2014, JOGNN - Journal of Obstetric, Gynecologic, and Neonatal Nursing
    View all citing articles on Scopus
    View full text