Comparative effectiveness and certainty of exercise-based interventions for postpartum depressive symptoms: a systematic review and network meta-analysis of randomized controlled trials.

Introduction: Postpartum depression is a common mental health condition after childbirth that can adversely affect maternal well-being, social functioning, and the mother-infant relationship. Although pharmacotherapy, psychotherapy, and exercise rehabilitation are available, current evidence is derived mainly from pairwise comparisons, leaving the relative efficacy of different exercise interventions and the certainty of comparative evidence unclear. This study therefore conducted a systematic review and network meta-analysis to compare the effects of different exercise rehabilitation interventions on postpartum depression and to evaluate the certainty of the evidence for clinical decision-making and exercise prescription. Methods: This systematic review and network meta-analysis was conducted according to a prespecified protocol. PubMed, Embase, the Cochrane Library, and Web of Science were systematically searched from inception to March 1, 2026. Randomized controlled trials involving postpartum women were eligible for inclusion. Interventions were classified as active control (AC), exercise combined with other interventions (E+CI), lifestyle physical activity promotion (LPA), mind-body exercise (MBE), passive control (PC), pelvic floor muscle training (PFMT), resistance training (RT), and structured aerobic exercise (SAE). The primary outcome was postpartum depression score treated as a continuous variable. Two reviewers independently screened studies, extracted data, and assessed risk of bias. A frequentist random-effects network meta-analysis was conducted to synthesize direct and indirect evidence, with results expressed as standardized mean differences (SMDs) and 95% confidence intervals (CIs). Treatments were ranked using the surface under the cumulative ranking curve (SUCRA), the probability of being the best treatment, and mean rank. The certainty of evidence was evaluated using Confidence in Network Meta-Analysis (CINeMA) and Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results: A total of 23 randomized controlled trials involving 2,752 postpartum women and 8 intervention/control nodes were included. Most studies were judged as having some concerns, and a few were rated as high risk of bias. No statistically significant global inconsistency was identified. For the primary outcome, SAE significantly reduced postpartum depression scores compared with both passive control and active control, showing the clearest statistically supported comparative effects. MBE showed favorable point estimates and ranking-based performance; however, its key comparisons with passive and active control did not reach statistical significance. Subgroup analyses suggested that MBE may be more favorable among postpartum women with baseline depression, whereas SAE may be more favorable among women without baseline depression who were considered high-risk or included in preventive samples. Sensitivity analyses suggested that SAE was relatively robust, whereas MBE was more sensitive to the influence of individual studies. Overall, the certainty of evidence was low to very low. Conclusion: Among postpartum women, SAE showed the most consistent statistically significant advantages in key comparisons and demonstrated greater robustness in sensitivity analyses. MBE also appeared promising based on favorable point estimates and ranking-based results, but its main comparisons with passive and active control were not statistically significant and should not be interpreted as definitive evidence of superiority. Therefore, current evidence suggests that SAE has the clearest comparative support, while MBE remains a potentially beneficial intervention that requires further confirmation. However, the available evidence is limited by risk of bias, small sample sizes, imprecision, and low overall certainty. Further high-quality randomized controlled trials with larger samples, head-to-head comparisons, and standardized outcome reporting are required to confirm the relative efficacy of different exercise rehabilitation interventions. Systematic review: https://www.crd.york.ac.uk/PROSPERO/, identfier CRD420261352226.