The Effect of Postpartum Mandala Coloring on Anxiety, Fatigue, Maternal Attachment and Breastfeeding Self-efficacy

February 26, 2026 updated by: DİDEM KAYA, Nuh Naci Yazgan University

The Effect of Mandala Coloring on Anxiety, Fatigue, Maternal Attachment, and Breastfeeding Self-Efficacy in the Postpartum Period: A Randomized Controlled Experimental Study

The aim of this study is to investigate the effects of mandala coloring on anxiety, fatigue, breastfeeding self-efficacy, and mother-infant bonding in postpartum mothers. The sample consists of women who have had a cesarean section at Kayseri City Hospital within the last year. Data will be collected using a Personal Information Form, the Postpartum Specific Anxiety Scale, the Short Form of the Breastfeeding Self-Efficacy Scale, the Chalder Fatigue Scale, and the Maternal Attachment Scale. Mothers meeting the inclusion criteria will be randomly assigned to intervention and control groups. Mothers in the intervention group will be informed that they will begin mandala coloring one week after their cesarean delivery. They will be asked to color a mandala twice a week for a total of 5 weeks, with each coloring session lasting 30 minutes. To eliminate the possibility of mothers forgetting to color the mandala, the researcher will send reminder messages twice a week starting from the end of the first week. The Personal Information Form will be collected through face-to-face interviews while the mothers are in the hospital. Mothers in the control group will receive routine hospital care and will not paint mandalas. Researchers will call all mothers at the end of weeks 1 and 2 to administer the Postpartum Specific Anxiety Scale and the Short Form of the Breastfeeding Self-Efficacy Scale, and at the end of weeks 4 and 6 to administer questions from the Postpartum Specific Anxiety Scale, Short Form of the Breastfeeding Self-Efficacy Scale, Chalder Fatigue Scale, and Maternal Attachment Scale, recording their responses.

Study Overview

Status

Status

Indicates the current recruitment status or the expanded access status.
Not yet recruiting

Conditions

Conditions

The disease, disorder, syndrome, illness, or injury that is being studied. On ClinicalTrials.gov, conditions may also include other health-related issues, such as lifespan, quality of life, and health risks.

Intervention / Treatment

Intervention / Treatment

A process or action that is the focus of a clinical study. Interventions include drugs, medical devices, procedures, vaccines, and other products that are either investigational or already available. Interventions can also include noninvasive approaches, such as education or modifying diet and exercise.

Detailed Description

The postpartum period is a time of physiological changes as well as the assumption of new roles and responsibilities. Postpartum anxiety has been relatively neglected in recent years. Defined as a condition that causes anxiety and depression of unknown origin, anxiety is seen as a normal reaction to the birth of a new baby in the postpartum period. Clinically, the prevalence of anxiety symptoms in the postpartum period ranges from 12-20%. High levels of anxiety negatively affect the bonding between mother and baby, as well as the baby's behavioral, social, and emotional development. Postpartum fatigue causes women to feel more negative and less competent than usual. Postpartum fatigue negatively impacts the mother's functional recovery, maternal behavior, infant care, relationships with family members, work performance, and self-actualization. While fatigue is common and even expected after childbirth, severe postpartum fatigue can have significant effects on women's health and activities; It has negative effects such as deterioration of maternal health, delayed return to daily life activities, early cessation of breastfeeding, and delayed infant development. Since cesarean delivery is a surgical procedure, postpartum fatigue, pain, and anxiety are higher compared to vaginal delivery. Consequently, the time to start breastfeeding is later, especially in the first 24 hours after cesarean delivery, mothers have lower breastfeeding self-efficacy, and their need for support from healthcare personnel is higher. Art therapy is reported as an effective support method that addresses the physical, mental, social, and emotional aspects of the individual and helps in coping with difficulties. Mandala, one of the art therapy methods, is defined as a method used to transfer emotions and thoughts onto paper, usually in a round shape. Studies conducted on different sample groups have found that mandala painting is effective on anxiety and fatigue. A literature review revealed that anxiety and fatigue are common in the postpartum period, negatively impacting breastfeeding self-efficacy and maternal attachment. Studies have also shown that mandala coloring is effective in reducing anxiety and fatigue. However, the effects of mandala coloring on mothers' anxiety, fatigue, breastfeeding self-efficacy, and maternal attachment in the postpartum period have not been investigated. The aim of this study is to investigate the effects of mandala coloring on anxiety, fatigue, breastfeeding self-efficacy, and maternal attachment in mothers in the postpartum period.

Study Type

Study Type

Describes the nature of a clinical study. Study types include interventional studies (also called clinical trials), observational studies (including patient registries), and expanded access.
Interventional

Enrollment (Estimated)

Enrollment

The number of participants in a clinical study. The "anticipated" enrollment is the target number of participants that the researchers need for the study.
140

Phase

Phase

The stage of a clinical trial studying a drug or biological product, based on definitions developed by the U.S. Food and Drug Administration (FDA). The phase is based on the study's objective, the number of participants, and other characteristics. There are five phases: Early Phase 1 (formerly listed as Phase 0), Phase 1, Phase 2, Phase 3, and Phase 4. Not Applicable is used to describe trials without FDA-defined phases, including trials of devices or behavioral interventions.
  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Contact

The name and contact information for the person who can answer enrollment questions for a clinical study. Each location where the study is being conducted may also have a specific contact, who may be better able to answer those questions.

Study Locations

  • Turkey (Türkiye)
    • Kayseri
      • Kayseri, Kayseri, Turkey (Türkiye)
        • Nuh Naci Yazgan University
        • Contact:
        • Principal Investigator:
          • Didem Kaya, Assistant Professor Doctor

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Eligibility Criteria

The key requirements that people who want to participate in a clinical study must meet or the characteristics they must have. Eligibility criteria consist of both inclusion criteria (which are required for a person to participate in the study) and exclusion criteria (which prevent a person from participating). Types of eligibility criteria include whether a study accepts healthy volunteers, has age or age group requirements, or is limited by sex.

Ages Eligible for Study

  • Adult
  • Older Adult

Accepts Healthy Volunteers

Yes

Description

Inclusion Criteria:

  • Being 18 years of age or older
  • Having had a cesarean delivery after the 37th week of gestation
  • The baby being with the mother and the mother being able to breastfeed
  • Volunteering to participate in the study
  • Having a planned cesarean section

Exclusion Criteria:

  • The mother is currently or has previously received psychiatric treatment.
  • The mother has a physical disability in her upper extremities.
  • The mother has a vision problem.
  • The newborn has a congenital anomaly.
  • The newborn experienced an obstetric complication requiring immediate hospitalization after birth (hemorrhage, infection, bladder damage, preeclampsia, etc.).

Criteria for terminating the study:

  • The baby or mother has a medical condition requiring hospitalization within 6 weeks postpartum.
  • Communication with the mother is not possible within 6 weeks postpartum

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Supportive Care
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm

Participant Group / Arm

A group or subgroup of participants in a clinical trial that receives a specific intervention/treatment, or no intervention, according to the trial's protocol.
Intervention / Treatment

Intervention / Treatment

A process or action that is the focus of a clinical study. Interventions include drugs, medical devices, procedures, vaccines, and other products that are either investigational or already available. Interventions can also include noninvasive approaches, such as education or modifying diet and exercise.
Experimental: Mandala Coloring Group
Mothers in this group will color mandalas.
Behavioral: Mandala coloring
Mothers in the intervention group will be given a circular mandala template coloring book and 12 colored pencils. Mothers in the intervention group will be informed that they will start coloring mandalas one week after giving birth. They will be asked to color one mandala coloring page twice a week for a total of 5 weeks, with each coloring session lasting 30 minutes. To eliminate the possibility of mothers forgetting to color mandalas, the researcher will send reminder messages to the mothers twice a week starting from the end of the first week. Mothers will be asked to send pictures of the mandala pages they have colored to the researcher as a message.
No Intervention: Control Group
Mothers in this group will not color mandalas.

What is the study measuring?

Primary Outcome Measures

Primary Outcome Measures

In a clinical study's protocol, the planned outcome measure that is the most important for evaluating the effect of an intervention/treatment. Most clinical studies have one primary outcome measure, but some have more than one.
Outcome Measure
Measure Description
Time Frame
Postpartum Specific Anxiety Scale
Time Frame: At the end of the 1st, 2nd, 4th and 6th weeks postpartum
The scale was developed by Fallon et al. (2016) as a 56-item scale, and was transformed into a 44-item structure through a Turkish validity and reliability study conducted by Bayri Bingöl et al. (2021). The original version of the scale was developed and validated with mothers who had infants aged 0-6 months. The scale has sub-dimensions of maternal skills and attachment, newborn well-being and safety, infant care practices, and psychosocial adjustment to motherhood. The highest possible score on the Likert-type scale is 176, and the cutoff score is 113.5. Higher scores on the scale indicate a higher incidence of anxiety symptoms. The Cronbach's alpha values for the sub-dimensions of the scale range from 0.83 to 0.90.
At the end of the 1st, 2nd, 4th and 6th weeks postpartum
Short Form of the Breastfeeding Self-Efficacy Scale
Time Frame: At the end of the 1st, 2nd, 4th and 6th weeks postpartum
Developed in 1999 by Dennis and Faux to measure mothers' competence regarding breastfeeding in the postpartum period. The scale was initially developed with 33 items. In the internal consistency analysis of the scale, items with a correlation below 0.60 were removed, and the short form of the Breastfeeding Self-Efficacy Scale with 14 items was created. This scale is a 5-point Likert type. All items are scored as 1, 2, 3, 4, 5 (1=Never sure, 5=Always sure). All items in the scale have positive meanings. The lowest possible score on the scale is 14, and the highest is 70, with no cutoff point. A higher score indicates higher breastfeeding self-efficacy. The Turkish validity and reliability of the scale was established by Aluş-Tokat and Okumuş in 2010. The Cronbach's alpha coefficient of the Breastfeeding Self-Efficacy Scale is 0.86.
At the end of the 1st, 2nd, 4th and 6th weeks postpartum
Chalder Fatigue Scale
Time Frame: At the end of the 4th and 6th weeks postpartum
Developed by Cella and Chalder in 2010 for use in various populations to assess fatigue, it was adapted into Turkish by Adın et al. in 2022. The scale consists of 11 items, divided into two sub-dimensions: physical fatigue and mental fatigue, and uses a 4-point Likert scale. Scores range from 0-21 for the physical fatigue sub-dimension, 0-12 for the mental fatigue sub-dimension, and 0-33 for the total scale score. Higher scores indicate greater fatigue severity.
At the end of the 4th and 6th weeks postpartum
Maternal Attachment Scale
Time Frame: At the end of the 4th and 6th weeks postpartum
The validity and reliability study of the Turkish form of the Maternal Attachment Scale, developed by Mary E. Muller in 1994, was conducted by Kavlak and Şirin in 2009. The scale consists of 26 items on a four-point Likert scale, with higher scores indicating higher maternal attachment. The lowest possible score is 26, and the highest is 104. Cronbach's Alpha internal consistency reliability was found to be 0.77 in 1-month-old infants and 0.82 in 4-month-old infants.
At the end of the 4th and 6th weeks postpartum

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Sponsor

The organization or person who initiates the study and who has authority and control over the study.
Nuh Naci Yazgan University

Collaborators

Collaborators

An organization other than the sponsor that provides support for a clinical study. This support may include activities related to funding, design, implementation, data analysis, or reporting.
TC Erciyes University
Kayseri City Hospital

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Estimated)

Study Start

The actual date on which the first participant was enrolled in a clinical study. The "anticipated" study start date is the date that the researchers think will be the study start date.
March 15, 2026

Primary Completion (Estimated)

Primary Completion

The date on which the last participant in a clinical study was examined or received an intervention to collect final data for the primary outcome measure. Whether the clinical study ended according to the protocol or was terminated does not affect this date. For clinical studies with more than one primary outcome measure with different completion dates, this term refers to the date on which data collection is completed for all the primary outcome measures. The "anticipated" primary completion date is the date that the researchers think will be the primary completion date for the study.
May 20, 2026

Study Completion (Estimated)

Study Completion

The date on which the last participant in a clinical study was examined or received an intervention/treatment to collect final data for the primary outcome measures, secondary outcome measures, and adverse events (that is, the last participant's last visit). The "anticipated" study completion date is the date that the researchers think will be the study completion date.
December 31, 2026

Study Registration Dates

First Submitted

First Submitted

The date on which the study sponsor or investigator first submitted a study record to ClinicalTrials.gov. There is typically a delay of a few days between the first submitted date and the record's availability on ClinicalTrials.gov (the first posted date).
February 26, 2026

First Submitted That Met QC Criteria

First Submitted That Met QC Criteria

The date on which the study sponsor or investigator first submits a study record that is consistent with National Library of Medicine (NLM) quality control (QC) review criteria. The sponsor or investigator may need to revise and submit a study record one or more times before NLM's QC review criteria are met. It is the responsibility of the sponsor or investigator to ensure that the study record is consistent with the NLM QC review criteria.
February 26, 2026

First Posted (Actual)

First Posted

The date on which the study record was first available on ClinicalTrials.gov after National Library of Medicine (NLM) quality control (QC) review has concluded. There is typically a delay of a few days between the date the study sponsor or investigator submitted the study record and the first posted date.
March 4, 2026

Study Record Updates

Last Update Posted (Actual)

Last Update Posted

The most recent date on which changes to a study record were made available on ClinicalTrials.gov. There may be a delay between when the changes were submitted to ClinicalTrials.gov by the study's sponsor or investigator (the last update submitted date) and the last update posted date.
March 4, 2026

Last Update Submitted That Met QC Criteria

Last Update Submitted That Met QC Criteria

The most recent date on which the study sponsor or investigator submitted changes to a study record that are consistent with National Library of Medicine (NLM) quality control (QC) review criteria. It is the responsibility of the sponsor or investigator to ensure that the study record is consistent with the NLM QC review criteria.
February 26, 2026

Last Verified

Last Verified

The most recent date on which the study sponsor or investigator confirmed the information about a clinical study on ClinicalTrials.gov as accurate and current. If a study with a recruitment status of recruiting; not yet recruiting; or active, not recruiting has not been confirmed within the past 2 years, the study's recruitment status is shown as unknown.
February 1, 2026

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

Other Study ID Numbers

Identifiers or ID numbers other than the NCT number that are assigned to a clinical study by the study's sponsor, funders, or others. These numbers may include unique identifiers from other trial registries and National Institutes of Health grant numbers.
  • NuhNaciYazganUdk1

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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