Midwifery 29 (2013) 526–534

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Midwifery
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The role of anxiety and other factors in predicting postnatal fatigue:

From birth to 6 months
Jan Taylor, RM PhD (Associate Professor)a,n, Maree Johnson, RN, PhD (Research Professor)b
a
Disciplines of Nursing & Midwifery, Faculty of Health, University of Canberra, Canberra 2601, Australia
b
School of Nursing and Midwifery, University of Western Sydney, Australia

a r t ic le i n fo a bs tr a c t

Article history: Objective: to explore the role of anxiety and other factors in predicting postnatal fatigue from birth to
Received 15 July 2011 6 months.
Received in revised form Design: a prospective longitudinal correlational survey design.
9 April 2012
Setting: Canberra, Australian Capital Territory, Australia.
Accepted 20 April 2012
Participants: 504 well women, 233 primipara and 271 multipara, aged 20–40 years who gave birth
during the study period.
Keywords: Measurement: the Postpartum Fatigue Scale, the State-Trait Anxiety Inventory, the Edinburgh Postnatal
Women Depression Scale, and the Support Behavior Inventory were used to measure the relationship between
Postnatal
the predictive factors and the intensity of fatigue at the various time points.
Fatigue
Findings: an explanatory model of fatigue development was applied to all participants, and then to
Anxiety
primiparas and multiparas, explaining 27–44% of the variance in fatigue from 1 to 24 weeks in the total
sample (p 4 .001). State anxiety was a consistently strong predictor of fatigue intensity across time
and group.
Key conclusions and implications for practice: the contribution that state anxiety made to the develop-
ment of fatigue in this group of low risk women highlights the importance of assessing symptoms of
anxiety in all childbearing women. Focusing on depressive symptoms limits the extent to which anxiety
symptoms, which occur in parallel with depressive symptoms, are addressed. Anxiety is a normal
response to the changes in roles and responsibilities that occur following birth. However the belief that
all new mothers worry excessively and that anxiety is not as harmful as depression may have
influenced the way midwives and maternal child health nurses view postnatal anxiety. Assessment of
anxiety, and use of interventions such as cognitive and behavioural strategies and self-care practices,
can be used to assist women to reduce anxiety levels.
& 2012 Elsevier Ltd. All rights reserved.

Introduction lower infant developmental performance (Parks et al., 1999),

For over two decades women from Western industrialised
nations have ranked fatigue among their top five concerns after
birth (Troy, 2003; Taylor and Johnson, 2010; Kurth et al., 2011).
Not only is postnatal fatigue a common health problem, but also
is progressive, rather than self-resolving, and can continue past
the traditional 6 week period when women are considered to
have recovered physically from giving birth (Bick and MacArthur,
1995; Parks et al., 1999; Thompson et al., 2002). Few studies have
explored the factors affecting postnatal fatigue beyond 12 weeks
after birth, despite evidence of the persistence of fatigue beyond
this time. Ongoing postnatal fatigue has been associated with
n
Corresponding author.
E-mail address: jan.taylor@canberra.edu.au (J. Taylor).
delayed return of maternal functional status, early cessation of
breast feeding (Tulman et al., 1990; Milligan et al., 1996; Parks
et al., 1999; McVeigh, 2000) and the development of maternal
depression (Affonso et al., 1990; Bozoky and Corwin, 2002;
Rychnovsky and Beck, 2006).
Women have heightened vulnerability to mood disorders
during pregnancy and the first postnatal year (Buist and Bilszta,
2006; Buist et al., 2007) with the most common problems being
anxiety and depression (Homer et al., 2002; Austin et al., 2010).
The relationship between fatigue and depressive symptoms has
been explored extensively in previous studies, but little research
has examined the relationship between fatigue and anxiety.
While acknowledging the complexity of factors that influence
postnatal fatigue, the primary purpose of this study is to explore
the relationship between maternal anxiety levels and increased
postnatal fatigue.

0266-6138/$ - see front matter & 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.midw.2012.04.011
527 J. Taylor,
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Background
Previous fatigue studies
Demographic, physical, psychological and situational factors
interact to influence fatigue. Factors consistently associated with
higher fatigue levels in previous studies include age (Gardner, 1991;
MacArthur, 1999) being a primipara (Milligan, 1989; MacArthur,
1999), experiencing a longer labour, a caesarean birth, and 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 predic-
tors of women’s fatigue six weeks after birth. In addition, the
factors involved change over time. Birth related factors (length of
labour, assisted vaginal or caesarean birth) resulted in higher levels
of fatigue 2 weeks after birth (Milligan, 1989; Troy and Dalgas-
Pelish, 1997) while 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 2–3 months after birth.
Despite acknowledgement that most women experience some
level of anxiety during pregnancy and the postnatal period (Homer
et al., 2002), the relationship between anxiety and fatigue in the
childbearing period has received less attention than depression and
fatigue, although evidence exists to support the association. The
strength of the relationship between fatigue, state anxiety and
depression during pregnancy increased over time with anxiety more
strongly related to fatigue than depression in 11 women in the third
trimester of pregnancy (Milligan and Kitzman, 1992). Rauchfuss and
Maier (2011) found pregnancy-related fears and general anxiety
were significant predictors of pre-term birth in 589 women giving
birth in Germany. Fisher et al. (2002) demonstrated the presence of
three different groups (fatigued only, fatigued and anxious, and
probably depressed) in 109 women admitted to a mother–baby unit
(F(2,97) Z 22.6; p 4 .001) while Rychnovsky (2007) identified mater-
nal anxiety as a predictor of higher levels of fatigue six weeks after
birth in 109 women serving in the armed forces. These findings
support a relationship between fatigue and anxiety in the postnatal
period that warrants further research.
The aim of this research was to examine the relationship between
demographic, physical, psychological and situational factors and the
intensity of women’s fatigue across the first 6 months after birth. In
particular, we sought to explore the relationship between maternal
anxiety and postnatal fatigue as well as model the development of
fatigue over the first 6 months after birth. Previous research has
modelled fatigue in the early postnatal period (birth to 3 months),
however, studies have shown (Bick and MacArthur, 1995; Brown and
Lumley, 1998; Thompson et al., 2000b; Rychnovsky, 2007) that
fatigue is still a major health problem for women 6 months after
birth. Understanding how the contributing factors change between
the early and the later postnatal period is essential to the develop-
ment of subsequent effective interventions.
Methods
Design
A prospective descriptive longitudinal correlational survey
design was used to examine intensity of fatigue in women across
the first 6 months after birth (1, 6, 12 and 24 weeks).
29 (2013)
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Sampling
The target population was women giving birth in the Australia
Capital Territory during the study period. A convenience sample
of women who gave birth in all sites providing maternity services
in the Australian Capital Territory (two public tertiary hospitals,
one private hospital maternity unit and one birth centre) during
the 7 month period and who met the following criteria were
eligible to be included in the study: 18 years or older, with a
medically uncomplicated pregnancy, having given birth at term
( Z 37 weeks gestation), to a healthy infant. Women who had
experienced a pregnancy complicated by the following factors
were excluded: cardiac disease, Type 1 diabetes mellitus, gesta-
tional diabetes requiring insulin, pre-eclampsia or eclampsia
requiring treatment. We also excluded women who had a history
of illnesses known to be associated with fatigue (Chronic Fatigue
Syndrome, hypothyroidism), who had been previously diagnosed
with a major psychiatric disorder (depression), a sleep disorder
requiring treatment, or who gave birth to a low birth weight baby
( o 2.5 kgs) at term ( Z 37 weeks). The information on medical risk
factors was obtained from the clients’ records by the primary
researcher. Although women from diverse cultural backgrounds
were actively sought as participants, only those able to speak,
read and write English were recruited.
Recruitment and data collection
Between the second and fourth day following birth women
who met the selection criteria were approached and provided
with written information about the project. The primary
researcher returned the following day and women who consented
were given the first questionnaire. When completed, the ques-
tionnaire was mailed to or collected by the chief investigator.
Subsequent questionnaires included a stamped self-addressed
envelope and were mailed to participants when their infant
approached 6 weeks, three and 6 months of age.
Survey and measures
Questionnaires were developed using measures with estab-
lished reliability and validity.
The survey included a number of socio-demographic variables
and physiologic factors known to affect depression or fatigue:
maternal age, level of education (completed year 10, completed
year 12, completed tertiary), hours in labour, type of birth, more
than one method of pharmacological pain relief during labour
(nitrous oxide þ narcotic analgesic þ epidural anaesthesia), blood
loss Z 500 mls after birth, previous births, breast feeding (breast
milk only), continuing level of pain (0 10), perceived difficult
infant, and amount of maternal night time sleep in increments
of hours.
The survey also included a series of valid and reliable psycho-
metric scales at each time point.
The Postpartum Fatigue Scale (PFS) (Milligan et al., 1997)
measured intensity of fatigue. The instrument consisted of 10
items measured on a four point Likert scale (1 ¼ not at all to 4 ¼ all
the time) and indicated the extent to which the particular
symptom had been experienced during the past week. Possible
scores range from 10 to 40 with higher scores reflecting higher
levels of fatigue. Cronbach’s a for the scale ranged from .88 at 1
week, 6 and 12 weeks to .89 at 24 weeks.
The Edinburgh Postnatal Depression Scale (EPDS) indicated the
probable presence of depressive symptoms. The EPDS has been
validated for use in Australia (Boyce et al., 1993) and is routinely
used as a screening tool for PND in Australian primary care
settings (Buist et al., 2007). EPDS scores alone do not represent
528 J. Taylor,
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a diagnosis of depression, however a score of 13 or above on the
EPDS is indicative of probable depression (Matthey et al., 2006).
The Spielberger State-Trait Anxiety Inventory (STAI) assessed
state and trait anxiety in the participants. The STAI consists of
separate self-report scales (each with 20 items) that measure the
two concepts of state and trait anxiety. Participants rate how they
generally feel (trait) or how they feel at this moment (state) on a
four point Likert scale. The STAI has been validated and used
extensively in general populations and during the postnatal
period (McMahon et al., 2001; Homer et al., 2002). In this study
internal consistency of the STAI scales ranged from .92 to .94
(state) and .91 to .94 (trait) across all time points. Test–retest
reliability for the trait scale was moderate at .69 to .71.
Social support was measured by the short version of the
Support Behavior Inventory (SBI) developed for use with pregnant
women (Brown, 1986). The short version of the SBI consisted of
11 items asking participants to indicate their degree of satisfac-
tion with a variety of supportive behaviours provided by partner/
spouse and also by others (friends and other family members).
Separate scales were used for each group (partner and others) and
participants responded on a six point semantic differential scale
with 1, representing very dissatisfied, and 6, representing very
satisfied with the particular support behaviour. For each of the
two scales, possible scores range from 11 to 66 with higher scores
indicating higher perceptions of support.
The shortened SBI was chosen for the study because it was
developed for use during pregnancy and the postnatal period, was
easy to administer and score and provided an opportunity to
measure partner/spouse support separate from support provided
by others.
Ethical considerations
Written consent was obtained from all participants at the
point of recruitment.
Ethical approval to conduct the study was granted by the
Human Research Ethics Committees of ACT Health, Calvary
Healthcare ACT and the University of Western Sydney, Australia.
In addition, due the nature of the study, telephone contact was
made with women who scored 10 or above on the EPDS and
information on counselling and support services was made
available to them.
Data analysis
Data were analysed using the Statistical Package for Social
Sciences (SPSS) v15. Descriptive statistics appropriate to the level
of measurement were generated for all study variables. Relation-
ships among variables were examined by computing Pearson
correlation coefficients. To examine how much variance in the
intensity of fatigue was explained for each set of statistically
significant contributors (demographic, physical, situational &
psychological) at each time point (birth, 6 weeks, 3 months and
6 months), three steps of statistical analysis were performed:
(1) examination of multicollinearity, (2) computation of variance
inflation factors (VIFs), and (3) hierarchical multiple regression.
The significance level for entry into the models was set at r .05.
Findings
Sample
Two thousand five hundred and ninety-eight (2598) women
gave birth in three midwifery units and one Birthing Centre in the
ACT during the 7 months of recruitment. A total of 138 women
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were identified from medical records as not meeting the inclusion
criteria, 21 of these due to insufficient English to complete the
questionnaires. Fifteen hundred and thirty-three (1533) women,
or 61% of the eligible births, were approached and given informa-
tion about the study. One hundred and fifty nine women were
given information but left hospital prior to the 2nd contact, and a
further 501 women declined to participate, 26 because they were
participating in another research project. Eight hundred and
seventy-three women (873/1374; 63%) agreed to participate,
signed the consent and were given the first questionnaire. Of
these, 615 women (615/873; 70%) completed and returned the
first questionnaire and 545 women (545/873; 63%) returned all
four questionnaires. Forty-four women did not complete one or
more questionnaires within the requested timeframe (7 days 7 3
days, 6 weeks 7 1 week, 12 weeks 7 2 weeks, 24 weeks 7 2
weeks) and were therefore not included, leaving a total of 504
complete data sets for the analysis (Fig. 1).
A power analysis for multiple regression based on a medium
effect size (f ¼ .15), a of .05 and power of .80 with ten independent
variables determined a required sample size of 365 (Tabachnick
and Fidell, 2007). The sample size for each regression analysis
exceeded this number.
Participants were aged between 19 and 44 years (mean 30.32,
SD 4.95), born in Australia (83%), and were married or in a de
facto relationship (95%). Fifty-four per cent of women were
multiparas, 40% had completed tertiary education, and 66% had
experienced a vaginal birth. Primiparas were more likely to be
younger (w2, df 26, 49.27, p ¼ .004) and have completed tertiary
education (w2, df 1, 8.18, p ¼ .004) than the multiparas. In addition,
90% of the primiparas had been employed in full-time or part-
time employment in the past 12 months as opposed to 72% of the
multiparas. The number of children living with the participants
ranged from 1 to 8 (median of 2) children. Ninety-eight women
(19.4%) had another child less than 2 years old.
Demographic characteristics of the participants who com-
pleted all four questionnaires were compared with the character-
istics of all women (N ¼ 4684) who gave birth in the ACT (Table 1).
Overall, participants were slightly older, more likely to be primi-
parous, to be married or in de facto relationship, to have given
birth in a private hospital, and to be of English-speaking back-
ground than all the women giving birth. As a group they were
well educated with 38% (192) having completed tertiary educa-
tion. Adults residing in the ACT have higher levels of tertiary
qualifications compared to the Australian population in general
(26% and 13% respectively) (ABS, 2006).
Independent and dependent variables
Descriptive statistics for all the independent and dependent
variables appear in Table 2.
Correlates of fatigue at 1 week, 6 weeks, 3 months and
6 months after birth
One week after birth 7 independent variables were signifi-
cantly ( o .05– o .01) correlated with fatigue: state anxiety (.47),
completed tertiary education, (.20), being a multipara ( .18),
assisted vaginal birth (.16), postpartum haemorrhage (.14),
increased pain in past 24 hrs (.12), and more depressive symp-
toms (.28). By 6 weeks 8 independent variables were significantly
correlated (p o .01) with fatigue:state anxiety (.59), more difficult
infant (.27), amount of pain in a typical day in past week (.23),
social support from partner ( .22), maternal sleep at night
( .18), maternal age (.13), tertiary education (.11), and being a
multipara (.11).
529 J. Taylor,
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Target population
N = 2598

Excluded Did not receive study

138 information
927

Received study
information
1533

Discharged prior to Declined to Consented to

second contact participate participate
159 501 873

Returned Q1 Returned Q2 Returned Q3 Returned Q4

615 577 561 545

Fig. 1. Recruitment of sample.

Table 1 Significant correlates ( o .05– o .001) 3 months after birth were

Characteristics of participants compared with all women birthing in the ACT.
similar:state anxiety (.57), maternal sleep at night ( .26), more
Characteristic Participants ACT birthing women social support from partner ( .25), difficult infant (.22), multipara
(n ¼ 504) (n ¼ 4684) (.11), tertiary education (.10), and maternal age (.09). By 6 months
the number of independent variables significantly correlated
Maternal age (years)
(p o .01) with fatigue had reduced to 5:state anxiety (.62), maternal
o 20 5(1.0%) 162(3.5%)
20–24 47(9.0%) 608(13.0%) sleep at night ( .30), social support from partner ( .25), social
25–29 178(35.3%) 1470(31.4%) support from others ( .23) and more difficult infant (.18)
30–34 160(31.8%) 1567(33.5%)
35–39 100(19.8%) 754(16.1%)
4 40 13(2.5%) 123(2.6%)
Unknown 1
Married/de facto Regression models at 1 week, 6 weeks, 3 months and 6 months
Yes 479(95.0%) 4246(90.6%) after birth
No 25(5.0%) 438(9.6%)
Country of birth
At each time point demographic factors were the first set of
Australia 421(83.5%) 3814(81.4%)

Other Oceania 11 (2.2%) 88(1.9%)

variables entered into the fatigue model followed by physiologi-
Europe 47(9.3%) 263(5.6%) cal, These
situational and finally,
explanatory psychological
models demonstratefactors. Table 3fitoutlines
increasing of the
Other* 24(4.7%) 517(11.0%) the regression models at each time point. The models presented
Unknown 1(.0%) 2(.0%)
below represent the reduced final models.
Parity
Primipara 233 (46.0%) 1493 (32.0%)
Multipara 271(54.0%) 3191(68.0%) variables at 6 weeks and 6 months, although there is only minor
Type of birth change in the variance explained at the various time points.
Vaginal 330(66.0%) 3078(65.7%) Model 1 demonstrates the predominance of physiological factors
Assisted (vacuum/ 62(12.0%) 570(12.1%)
and also the influence of higher education. Model 2 retains the
forceps)
Caesarean 109(22.0%) 1017(21.7%) influence of education although the presence of situational factors
Vaginal breech none 19(.4%) is now
from evident—the
a b ¼ .38 to .51).more difficult
Anxiety infant.
sharply By 3 months
increases maternal
in its predictive
Birth site sleep has become a strong predictor of fatigue. Across all models
Public hospital 309(61.0%) 3415(73.0%)
maternal state anxiety was a major predictor of fatigue (ranging
Private hospital 184(37.0%) 1207(26.0%)
Unknown 11(2.0%)
strength at the 6 week period when the mother has returned to
n
Other includes Asia, Africa, and the Americas. home to manage the infant herself.
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Table 2
Variable statistics for all variables retained
Time in
1 the modelsTime 2 whereTime 3 Time 4 Recoding
Descriptive and recording it occurred.
Birth (n ¼ 504) 6 weeks (n ¼ 504) 3 months (n ¼ 504) 6 months (n ¼ 504)
M(SD) (%) M(SD) (%) M(SD) (%) M(SD) (%)

Demographic
Age 30.32(4.95) Completed year 10*
Tertiary education 191(40.1%) Completed year 12 (1 ¼ yes 0 ¼ all others)
Tertiary (1 ¼ yes, 0 ¼ all others)
Physiological
Pain experienced in past 24 hrs 3.40(2.60)
Pain in typical week 1.26(1.94)
Partiy
Primipara 233(46%) Primipara ¼ 0
Multipara 271(54%) Multipara ¼ 1
Labour 4 12 hrs 233(46.2%) Not experienced ¼ 0
Experienced ¼ 1
Type of birth
Vaginal 330(66%) Vaginal*
Assisted 62(12%) Assisted birth (1 ¼ yes 0 ¼ all others)
Caesarean 109(22%) Caesarean birth (1 ¼ yes 0 ¼ all others)
Postpartum haemorrhage 83(16.5%) No ¼ 0, yes ¼ 1
Yes 421(83.5%)
No
Breast feeding only 433(86.1%) 383(76.3%) 335(66.7%) 261(51.8%) Breast feeding only*
87U7
Some breast, some artificial 41(8.2%) 48(9.6%) 61(12.2%) 44(8.7%) Breast þ bottle (1 ¼ yes, 0 ¼ all others)

Artificial milk only 22(4.4%) 66(13.1%) 99(19.7%) 161(31.9%) Artificial milk (1 ¼ yes, 0 ¼ all others)
Situational
milk
Maternal sleep measured in

0–4 hrs 29(5.8%) 8(1.6%) 14(2.8%)

5–6 hrs 321(63.9%) 199(39.7) 178(35.4%)
increments of hours
7–8 hrs 143(28.4%) 251(50.1%) 265(52.7%)
4 8 hrs 9(1.8%) 43(8.6%) 46(9.1%)
Difficult infant
Less difficult 444(88.6%) 475(94.4%) 485(96.6%) More difficult infant y

More difficult 57(11.4%) 28(5.6%) 17(3.4%) 0 ¼ no, 1 ¼ yes

Social support (partner) 53(11.2) 52.4(12.4) 52.7(12.4)
Social support (others) 48.5(12.4) 49.8(10.7) 49.6(11.8)
Psychological
EPDS Z 13 46(9.2%) 47(9.4%) 42(8.4%) 35(7.0%) Yes ¼ 1, no ¼ 0
State anxiety 31.25(9.6) 30.75(9.6) 29.75(9.5) 29.25(9.6) Natural log transformation
Fatigue 17.77(5.45) 17.58(5.53) 15.75(5.0) 15.33(5.0) Natural log transformation

Note: Percentages may not total 100% due to missing data.

n
This category is the excluded category against which the other categories were evaluated. There were no significant differences in fatigue levels at 1 week between
women experiencing a planned caesarean birth (n ¼ 65) and women experiencing an unplanned caesarean birth (n ¼ 44) (mean 17.75[sd 5.51] vs. mean 17.92[sd 5.15]
respectively).
y
Infant difficulty: Women were given a list of four statements (my baby is always good natured and easy to settle; my baby is usually good natured and easy to settle;
my baby is usually irritable and difficult to settle; my baby is always irritable and difficult to settle) with scores ranging from 1 (always good natured and easy to settle) to
4 (always irritable and difficult to settle). Women were asked to chose the statement that best described their baby’s temperament with a higher score reflected of their
perception the infant was more difficult. The data were then reduced to two categories (yes, more difficult; no, less difficult infant).

Discussion previous research and the clinical experience of the researcher.

Our study has some limitations. While the participants were
representative of women birthing in the ACT, the demographics of
women birthing in the ACT differ somewhat from the national
statistics. Only 27% of women giving birth in the ACT are not
married (national level is 31%), and ACT women have higher
levels of tertiary education than the national average (26% and
13% respectively) (ABS, 2006). Therefore the results can only be
applied to other samples of well-educated women. No informa-
tion is available about the women who chose not to participate or
who were not given information about the study therefore it is
possible that the experiences of non-responders may have dif-
fered from responders.
This research depends on the notion that the points chosen as
critical to understanding the development of fatigue were appro-
priate. Extending the time period of the study beyond 6 months
was not possible despite evidence that fatigue continues to be a
problem for women. In addition, the factors chosen were based on
Other factors not considered may have explained more of the
variance in the fatigue scores.
Assessment of the hormonal levels, haemoglobin and haema-
tocrit levels were not undertaken in this study. These physical
parameters may influence fatigue levels. In addition, the use of
self-report, as well as transcription, of labour and birth data may
have reduced the reliability of this information, although
women’s recall of events during labour and birth have previously
been found to be valid (Brown et al., 1994). In the present study,
women were guided to the relevant information in the docu-
ments in their possession related to length of labour and blood
loss following birth.
This study sought to explore the relationship between mater-
nal anxiety and postnatal fatigue as well as model the develop-
ment of fatigue over the first 6 months after birth. The socio-
demographic characteristics of the women participating in this
study were similar to women birthing in the ACT in respect to age,
marital status and education. Birthing characteristics were also
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Table 3
Final regression models at birth, 6 weeks, 3 months and 6 months for the dependent variable fatigue (natural log).
Variable Model 1 Model 2 Model 3 Model 4
Birth (n ¼ 460) 6 weeks (n ¼ 460) 3 months (n ¼ 448) 6 months (n ¼ 448)
B (SEB) b B (SEB) b B (SEB) b B (SEB) b

Maternal age 0.00* .08n

Tertiary education .08 (.02) .13n .02(.02) .35 .05(.02) .09nn
Multipara .04(.02) .07 .05(.02) .05(.02) .09nn
Postpartum haemorrhage .07(.03) .10n
Assisted vaginal birth .05(.04) .06
Pain in past 24 hrs 0.00a .08
Pain in a typical day in past week .01(.00) .11nn
b
Amount of maternal sleep at night .04(.03) .08n .07(.02) .17nn .06(.01) .16nn
More difficult infant b
.11(.02) .12nn .01(.02) .02 .13(.06) .08n
b
Social support (partner) .00(.00)a .03 .08(.00)a .03 0.00(.00)a .01
Social support (others) b
ns 0.00(.00)a .02
Maternal state anxiety .38(.05) .38nn .52(.04) .51nn .50(.04) .51nn .56(.04) .56nn
More depressive symptoms .08(.04) .08

2
Model 1: Adj. R ¼ .28 (F ¼ 25.33, p o .01).
Model 2: Adj. R2 ¼ .38 (F ¼ 36.66, p o .01).
Model 3: Adj. R2 ¼ .36 (F ¼ 44.45, p o .001).
Model 4: Adj. R2 ¼ .41(F ¼ 63.93, p o .001).
Note: Normal probability plots of the standardised residuals were satisfactory. High bivariate correlations were identified between state and trait anxiety (r ¼ .70), therefore
only state anxiety was retained in the modelling.
a
Number o 2 decimal places.
b
not measured at this time point.
n
p ¼ .05.
nn
p ¼ .01; ns ¼ not significant.

similar, with the majority (65%) birthing vaginally without assis-
tance. There were some differences between the group and other
women who gave birth in the ACT during the study period, including
fewer participants being born in a country other than Australia, and
a higher proportion in the group having their first child.
Anxiety
The most important and interesting finding from this study is
the association between state anxiety and fatigue. At weeks 6, 12
and 24, state anxiety contributed most to the explained variance
in fatigue scores. The presence of more depressive symptoms
(EPDS 13 or above) was associated with fatigue; however state
anxiety was more strongly associated with fatigue. Similarly,
Pugh and Milligan (1995) demonstrated that state anxiety was a
more significant factor in the development of fatigue in a sample
of 11 antenatal women.
The association between psychological factors and fatigue is
well documented with depression considered the most influential
in the midwifery literature (Milligan, 1989; Milligan et al., 1993;
Thompson et al., 2000a; Bick et al., 2002; Bozoky and Corwin,
2002; Rychnovsky and Beck, 2006; Giallo et al., 2011). Examina-
tion of the correlation matrices at each time point indicated that
the correlations between fatigue, anxiety and depressive symp-
toms (EPDS 13 or above) were gradually becoming stronger.
That is, as time elapsed since birth, fatigue was more strongly
correlated to symptoms of anxiety and depression. This pattern is
similar to the findings of Pugh and Milligan (1995) and may
provide limited support for a cyclical model of anxiety, fatigue,
and depression proposed by them, and based on work by Nixon
(1976). The cyclical model proposes that anxiety leads to fatigue
and then depression, which in turn enhances anxiety and fatigue.
Infant difficulty
Women who perceived their infants to be more difficult to
settle and more irritable had higher levels of fatigue at weeks
6 and 24. Dealing with an infant who cries more and who requires
more time to settle may result in less sleep for mothers leading to
higher fatigue levels. Infant difficulty has been reported as a
better predictor of fatigue at 6 weeks and 3 months than the total
hours of reported sleep (Milligan, 1989). Similarly, Kurth et al.
(2011) also highlighted the interplay between infant crying and
maternal tiredness.
Having a difficult infant may be more mentally and physically
fatiguing, or it may be as McMahon et al.(2001) suggest that
women who were more anxious were more likely to rate their
infants as more difficult. Analysis of this relationship, in this
study, revealed that women with high levels of anxiety
(STAI Z 40) were more likely to rate their infant as more difficult
than women with lower levels of anxiety (STAI o 40).
Sleep
Findings from this study are consistent with previous research
that lack of sleep is a significant predictor of fatigue (Milligan,
1989; Lee and DeJoseph, 1992; Waters and Lee, 1996; Elek et al.,
1997; Lee et al., 2000a, 2000b; Song et al., 2010). Women who
reported more sleep at night during the past week reported lower
levels of fatigue at weeks 6, 12 and 24. Strategies to increase
opportunities for sleep and rest have been examined and
described elsewhere (Taylor and Johnson, 2010).
Age and education
Older maternal age was associated with higher levels of
fatigue at week 6 consistent with other researchers (MacArthur
et al., 1991; Troy and Dalgas-Pelish, 1997). Having completed
tertiary education was also significantly associated with higher
levels of fatigue at week 1 and week 12. The relationship between
older age, higher education and fatigue intensity suggests that
other factors may be involved and the mechanisms through
which these relationships may occur are unclear. One possible
explanation for this relationship is posed. Women who had
completed tertiary education were somewhat more likely to be
older than other participants (r ¼ .30, p ¼ .01), may also have
532 J. Taylor,
J. Taylor,
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M. Johnson
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higher status occupations and may have delayed taking leave
from their jobs until just prior to birth. This could have resulted in
these women having a higher base level of fatigue before birth
and higher levels of fatigue after birth (T1) compared to women
who were more rested before labour.
Birth related factors
Experiencing a postpartum haemorrhage (PPH) was statisti-
cally significantly associated with higher levels of fatigue at week
1, but this association was not evident at subsequent time points.
The number of women reporting a PPH was small (n ¼ 83). In
previous research low ferritin levels and low haemoglobin have
been significantly associated with higher fatigue 1 and 3 months
after birth (Lee and Zaffke, 1999).
Increased pain experienced in the previous 24 hrs was sig-
nificantly associated with increased fatigue at week 6, and is
consistent with findings that pain influenced levels of fatigue in
labouring women (Pugh, 1993).
Changes in factors and models over time and parity
Four models of factors associated with fatigue intensity across
the first 6 months after birth were applied to participant’s fatigue.
Reduced models, including only variables significant at the .05
level explained 27%, 38%, 36% and 41% of the variance in fatigue
scores at weeks 1, 6, 12 and 24, respectively.
By far the most significant and consistent factor contributing
towards the variance in fatigue scores across all time points was
the psychological factor, maternal state anxiety. This contribution
has not been tested in previous research. The findings related to less
maternal sleep and infant difficulty are congruent with previous
models of fatigue development (Milligan, 1989; Wambach, 1998;
Lee and Zaffke, 1999) in the first 3 months after birth. Similarly,
maternal age and education have previously been shown to have
an initial effect which reduced over time (Milligan, 1989; Troy
and Dalgas-Pelish, 1997; Wambach, 1998).
At each time point, the reduced models explained more of the
variance in fatigue scores for the multiparous group (31%, 42%,
42% and 43% at weeks 1, 6, 12 and 24 respectively) as opposed to
the primiparous group (19%, 31%, 25% and 41% at weeks 1, 6, 12
and 24 respectively). By 24 weeks, there was similarity in both
the key factors associated with fatigue (less maternal sleep and
more anxiety) and the explanatory power of the reduced model
for primiparas and multiparas (41% and 43% respectively).
So, why was the model less able to explain fatigue in the
earlier postnatal period (birth to 12 weeks) in the primiparous
group? Birth for a first time mother is a tremendous disruption, to
the physical, as well as the psychological, self (Barclay et al., 1997;
Thompson et al., 2002). Previous research has demonstrated that
primiparas are more likely than multiparas to experience perineal
trauma (episiotomy, tear requiring sutures) and perineal pain,
backache (Thompson et al., 2002), and lack of sleep (Lee et al.,
2000b; Thompson et al., 2000b) in the first 8–12 weeks after
birth. In addition, Wambach (1998) demonstrated that primiparas
who reported more problems with breast feeding in the first
9 weeks after birth were more likely to have higher levels of
fatigue. Amir et al. (1997) linked nipple pain with an increased
score on the fatigue sub-scale of the Profile of Mood States. These
factors (perineal pain, backache, breast-feeding problems includ-
ing sore nipples, less sleep) were not specifically examined at
1 week after birth and may have contributed to the difference in
explained variance between the groups. Although the amount of
pain experienced in the previous 24 hrs (1 week) and on a typical
day in the previous week (6 weeks) were significantly associated
with fatigue, further examination of specific painful problems
29 (2013)
29 (2013)
526–534
526–534 532
such as perineal pain, backache, and sore nipples may have
increased the explained variance in the primiparous group.
In addition, at 1 week primiparas had less association between
anxiety and fatigue and little evidence of association between
depressive symptoms and fatigue. This is in contrast to the
multiparas where anxiety and depressive symptoms contributed
strongly to the explained variance of fatigue at this time. So,
although primiparas reported higher levels of fatigue, anxiety and
depressive symptoms explained less of their fatigue. The stronger
explanatory power of state anxiety for fatigue levels in multiparas
persisted across the remaining time periods. Although multiparas
did not report higher levels of state anxiety compared to primi-
paras, at any time point, their anxiety contributed more to fatigue.
The reason for this is unclear but may relate to the worries
multiparas experience regarding their ability to mother more
than one child and juggle the additional tasks associated with
their new role. It may be that adjusting to the mothering role,
whether as a first time mother or as an experienced mother is
associated with worry, although the focus of that worry may be
different for primiparas (role acquisition) and multiparas (role
expansion).
Overall, between 60% and 70% of the variance in fatigue scores
between weeks 1 and 24 was not explained. Since a significant
proportion of the variance remains unexplained, more elaborate
models are needed to understand the complex factors involved in
the development of fatigue. The inclusion of other factors (in
addition to those previously outlined), such as marital relationships,
recent other stressful life events, and the woman’s confidence in her
ability to cope with change, not measured in this study, may have
improved the model’s overall predictive value for the both groups.
Depressive vs. anxiety symptoms
Despite the fact that the EPDS was developed for use as a
screening instrument, it has been used extensively in postnatal
depression research. This study used the validated EPDS cut-off
score of 13 or above (Matthey et al., 2006) to indicate probable
depression. The finding that the presence of more depressive
symptoms did not contribute significantly to the variance in
fatigue was unexpected.
Would use of the total interval level score of the EPDS better
reflect the continuum of depressive and anxiety symptoms
resulting in more explained variance in fatigue scores? Substitu-
tion of the EPDS (total score) only, for the STAI plus the EPDS in
the regression analysis reduced the explanatory power of the
model at the various time points.
Social support
The finding that more social support does not reduce the
intensity of fatigue is similar to other research findings (Milligan,
1989; Milligan et al., 1991). Although support from a partner was
significantly negatively correlated with fatigue levels at weeks 6,
12 and 24, when state anxiety scores were entered into the
regression analysis, this relationship did not persist. Further
exploration of the relationship between social support and state
anxiety demonstrated that women with high state anxiety
(STAI Z 40) rated their social support from a partner and from
others as significantly less at each time point than mothers with
lower anxiety scores (STAI o 40). Research by Barnett et al. (1991)
showed similar results using trait anxiety levels as the measure.
Implications for practice
For midwives and maternal child health nurses, this research
highlights that the care of new mothers must include recognition
533 J. Taylor,
J. Taylor,
M. Johnson
M. Johnson
/ Midwifery
/ Midwifery
that higher levels of state anxiety are associated with higher
levels of postnatal fatigue.
The contribution that state anxiety made to the development
of fatigue in this group of low risk women highlights the
importance of assessing symptoms of anxiety in all childbearing
women. Focusing on depressive symptoms limits the extent to
which anxiety symptoms, which occur in parallel with depressive
symptoms, are addressed.
Anxiety is a normal response to the changes in roles and
responsibilities that occur following birth. However, the belief
that all new mothers worry excessively and that anxiety is not as
harmful as depression may have influenced the way midwives
and maternal child health nurses view postnatal anxiety. Assess-
ment of anxiety, and use of interventions, such as cognitive and
behavioural strategies, and self-care practices, can be used to
assist women to reduce anxiety levels (Austin et al., 2007).
Issues for further investigation emerged from this research.
First, the application of these models of fatigue development to
other samples with differing characteristics and cultural back-
grounds may produce different results. In addition, given the
suggestion that persistent fatigue has detrimental effects on
infant development (Parks et al., 1999), there is a need to
determine if the factors associated with postnatal fatigue found
in this study persist over time, or if persistent fatigue (fatigue
persisting 12 months or longer) is associated with other factors.
Second, interventions to reduce fatigue should also be trialled.
Research by Troy and Dalgas-Pelish (2003) was not able to demon-
strate the effectiveness of a Tiredness Management Guide as a self-
care intervention for the management of fatigue in the first 6 weeks
after birth. Studying the use of a self-care guide based on the causes
identified in this research, but used over a longer period of time and
with the addition of telephone contact (Thome and Alder, 1999) or
home visits (MacArthur, 1999), found effective for supporting
women in other research, may prove more successful.
Conclusions
The findings from this study add to and extend what is already
known about postnatal fatigue. For midwives and maternal child
health nurses, this research highlights that care of new mothers
with fatigue must include recognition and monitoring of anxiety.
In many health services, postnatal assessments already include
screening for mental health risk factors, yet few assessments ask
questions about anxiety routinely. Addressing the worries that
women experience around the time of childbearing and suggest-
ing simple measures such as relaxation techniques time manage-
ment and self-care strategies may reduce anxiety levels and,
ultimately, levels of fatigue. Further research into the effective-
ness of interventions in reducing anxiety and ultimately fatigue is
warranted.
The first 6 months after the birth of a new child is a challenging
period in women’s lives. Midwives and maternal and child health
nurses play a pivotal role in enhancing optimal perinatal mental
health in women.
Acknowledgments
This study was funded by a PhD scholarship from the Uni-
versity 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 recruit-
ment and the women who participated in the study.
29 (2013)
29 (2013)
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