The experience of fatigue and exhaustion is a common health concern for parents, particularly those with young infants
[1, 2]. Emerging research suggests that fatigue is associated with parent mental health and wellbeing difficulties
[3–5], as well as a range of adverse parenting behaviours
[3, 6, 7]. Given that fatigue may have implications for parents’ functioning, there is a need for interventions to support parents to manage experiences of fatigue and exhaustion during the post-partum period. This paper presents the study protocol of a randomised controlled trial of a universal parenting program, Wide Awake Parenting (WAP) designed to assist with the management of fatigue and improve parent wellbeing.
The terms tiredness, fatigue and exhaustion are often used interchangeably by parents, and in the research literature. While tiredness is transient, fatigue refers to persistent exhaustion and lack of energy that is not easily relieved by rest or sleep
. For the purpose of this paper, the terms fatigue and exhaustion will be used interchangeably. In a qualitative study by Herbert
, fatigue was found to be a significant health concern that emerged during the first few days following birth and remained at 3-months post-partum. Additional quantitative studies have also found fatigue to be one of the most commonly reported health concerns during the early post-partum period
[1, 2, 10, 11], and as many as 67% of Australian mothers report persistent tiredness at 6-months post-partum
. Although previous studies have typically focused on fatigue in mothers, emerging research highlights that fathers experience similar levels of fatigue as mothers
[13, 14] and that fatigue is a common experience for many fathers during the early parenting period
There are a variety of reasons why parents of infants may become fatigued or exhausted. Pugh and Milligan
 proposed a model of childbearing fatigue being influenced by physiological, psychological, and situational factors that may put a parent at risk of exhaustion and interfere with daily functioning. Research has found that birth-related factors such as breastfeeding
[17, 18] and caesarean delivery
, as well as demographic and family characteristics including older maternal age
[20, 21], sole parenting
[3, 21] and low income
 to be associated with fatigue in parents. Additionally, during late pregnancy and the post-partum period, parents experience significant changes in their sleep patterns, including less night-time sleep and more disrupted sleep, which may contribute to feelings of exhaustion
[13, 14, 23]. Parents with infants who frequently wake at night are at risk of experiencing clinically significant levels of fatigue and exhaustion
Furthermore, recent Australian research on fatigue in the early parenting period suggests that fatigue can last well beyond infancy
. This study found that a variety of socio-ecological factors place mothers and fathers at increased risk of experiencing fatigue, including poor sleep quality, insufficient social support, poor diet and exercise, ineffective coping styles, sleep quality and child temperament
Effects of fatigue on parent wellbeing and behaviour
The experience of fatigue, while often anticipated, is largely under-prepared for by new parents
. Fatigue not only has the potential to interfere with how parents adjust to their new role as a mother or father, but also for the resumption of previous roles and responsibilities, including those in paid work, social and family settings
[1, 16, 25]. It is well documented that fatigue can impair daily functioning
, social judgment and cognitive functioning, such as memory, decision-making, concentration and planning
[26–29]. The same is true for parents. In a study of 109 Australian mothers attending a public mothercraft unit, mothers who were clinically exhausted were found to experience significant impairments in their daytime functioning and reduced clarity of thought
Fatigue is likely to impact parental wellbeing. A study by Bayer et al.
 found that maternal tiredness in a community sample of Australian mothers with infants (3-6months) was associated with poorer mental and physical health, including symptoms of depression, anxiety, stress and fatigue/energy. The array of extra demands placed on parents along with the experience of fatigue is likely to add to parental stress and decrease mood
. Although fatigue and loss of energy are part of the diagnostic criteria for clinical depression it has been found that the two are separate, distinct, unique psychological constructs
[13, 32–35]. Fatigue has been found to be strongly related to symptoms of depression and anxiety during the prenatal
[1, 36] and postnatal period
[33, 37, 38]. It is likely that the two conditions exacerbate each other
; fatigue can heighten feelings of depression, anxiety and helplessness, which in turn leads to further exhaustion
It is also likely that fatigue adversely affects parenting practices and experiences. Emerging research suggests that fatigue can increase parenting stress
[3, 6, 39], limit patience in coping with infant crying
, and decrease parenting confidence, satisfaction and self-efficacy
[3, 6, 7]. Recent Australian research shows that mothers and fathers who are fatigued are using more irritable, frustrated and impatient parenting behaviours directed towards their child
. Studies also show that fatigued parents are less warm and are less likely to be involved with their child
[3, 7, 40]. Not surprisingly, fatigue has the potential to impact upon parents’ ability to care for and interact with their infant or child
Given that fatigue can adversely affect the ability to parent optimally, it also has the potential to influence child outcomes and development
. Parks et al.
 found an association between mothers reporting persistent fatigue at 18 months post-partum and poorer eye-hand performance in their infants. While research in this area is limited, associations have also been found for other wellbeing difficulties. For example, Kahn, Zuckerman, Bauchner, Homer and Wise
 found that depression in mothers was associated with poorer physical health and increased behaviour problems in their children at age three.
Fatigue plausibly presents a negative cycle for parents; parents who feel tired may not sustain self-care behaviours; they then may become ill, which in turn may influence their ability to get enough sleep and rest as they deal with daily demands; resulting in more fatigue
. Fatigue can also result in increased conflict between partners
 and can have a detrimental impact upon family relationships and family functioning
. The relationships between parental fatigue, parenting and child development described above are also likely to be complex and bi-directional. Reducing or preventing one wellbeing difficulty, such as fatigue, may have a multitude of benefits on other aspects of a parent’s life.
Current interventions and management of fatigue
With growing evidence suggesting that fatigue is a serious health and wellbeing concern for many parents, little research has been conducted on strategies to manage and reduce parental fatigue. Research identifies the need for psycho-education about the effects of fatigue and strategies to promote self-care behaviour to conserve energy, improve quality of diet, increase exercise, reduce daily demands, maintain regular sleep routines, and allowing time for rest
[2, 4, 43]. Although a common experience for many new parents and a topic parents would like to discuss more
, mothers have reported feeling that it is inappropriate to seek professional support for their fatigue and it is often minimised or overlooked by health professionals
A randomised control study of a self-care intervention to reduce fatigue in a sample of 68 first-time mothers was conducted by Troy and Dalagas-Pelish
. Mothers were given a Tiredness Management Guide which described eight potential sources of post-partum fatigue, including infection, lack of daytime rest, pressure to get everything done, interruption in night-time sleep, pain, stress, anaemia and social activities. The guide listed several techniques for each source of fatigue and asked mothers to try some of the suggestions whenever they felt tired. Mothers completed the intervention over a four week period from two weeks post-partum to six weeks post-partum. Results revealed whilst the use of the self-directed intervention reduced morning fatigue at the fourth week post-partum, overall the intervention was not associated with a significant decrease in fatigue from the second week to the sixth week post-partum as compared to mothers in the control group.
A more promising intervention was trialed by Thome and Alder
. Their randomised control study investigated the use of a telephone intervention to reduce symptoms of fatigue. Seventy-six mothers of behaviourally difficult 2-3 month old infants participated in the study. The intervention commenced when infants were 4-6months, lasting approximately two months in duration, where each mother received five telephone calls from a registered nurse. The intervention was based on cognitive-behavioural techniques and information and advice was given on topics related to maternal distress (e.g., fatigue, health problems, role conflict) and infant behaviours (e.g., sleep, crying, feeding and health problems). Results revealed that mothers who received the telephone intervention had a significant reduction in fatigue over time than those mothers in the control condition. This intervention may prove to be effective in managing symptoms of fatigue in parents as they receive one-on-one support from a trained health professional, allowing them a context to discuss and obtain additional information and strategies that are tailored to their specific needs. The results from the control group show that if nothing was done to relive maternal fatigue, it did not decrease overtime, suggesting that mothers need specific and targeted interventions to combat fatigue. Whilst this appears to be evidence for the treatment of fatigue, mothers in this sample were approached to participate as they had reported having a difficult baby in a previous study, these findings may not be generalizable to a community sample of parents.
Taken together the findings from the existing interventions above suggest that a parent-led, self-directed intervention may not be effective in preventing or managing post-partum fatigue. There is promising evidence however, that short-term, direct support from a health care professional may be beneficial in reducing the symptoms of parental fatigue.
Development of Wide Awake Parenting
Research suggests that reducing daily demands, improving quality of diet and exercise, maintaining a regular sleep routine, promoting realistic parenting expectations, and encouraging help-seeking, can be useful for the management of fatigue
[2, 4, 43]. Similar strategies were reported to be beneficial by parents of young children aged 0-6 years attending focus groups
[45, 46]. WAP was developed as a psycho-educational program based on evidence about factors associated with fatigue and strategies for the management of fatigue, as outlined above.
A preliminary study evaluating the content of WAP was conducted with 49 parents of young children aged 0-4 years attending a residential program for sleep and settling problems
. The program was delivered in the form of brief 90-minute workshop that provided psycho-education about fatigue and the potential impact of fatigue on parenting and wellbeing. Practical strategies to recharge and save energy were offered. These included taking time out for self, prioritising, problem solving, getting support, challenging unhelpful thinking, diet and exercise, and sleep hygiene. The program was found to have short-term effects on strengthening parents’ self-efficacy, their intention to engage in self-care behaviours, parents’ beliefs about the importance of self-care and perceived expectations of the benefits from managing fatigue. In addition to the short-term effects, the program was found to be acceptable and relevant to the needs of parents. The results of this pilot therefore provide encouraging support for the use of a psycho-educational based program for the management of parent fatigue in the post-partum period.
The aim of this paper is to present the study protocol for a randomised controlled trial of a psycho-educational intervention, WAP. The aim of WAP is to reduce fatigue, and promote parents’ well-being during the early post-partum period in a self-selected, community sample of parents. The content and development of WAP has been published elsewhere
. The recruitment phase of this trial is currently complete, with intervention delivery and data collection ongoing.