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

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: Not yet recruiting
• Conditions: Postpartum; Mandala Coloring
• Intervention / Treatment: Behavioral: Mandala coloring

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: Interventional
• Enrollment (Estimated): 140
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Didem Kaya, Assistant Professor Doctor; Phone Number: +905343035254; Email: didemkaya86@gmail.com

Study Locations

• Turkey (Türkiye)
  • Kayseri
    • Kayseri, Kayseri, Turkey (Türkiye)
      • Nuh Naci Yazgan University
      • Contact: Didem Kaya, Assistant Professor Doctor; Phone Number: +905343035254; Email: didemkaya86@gmail.com
      • Principal Investigator: Didem Kaya, Assistant Professor Doctor

Participation Criteria

Eligibility Criteria

• 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

How is the study designed?

Design Details

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

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
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

Outcome Measure	Measure Description	Time Frame
Postpartum Specific Anxiety Scale	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	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	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	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

• Sponsor: Nuh Naci Yazgan University
• Collaborators: TC Erciyes University; Kayseri City Hospital

Study record dates

Study Major Dates

• Study Start (Estimated): March 15, 2026
• Primary Completion (Estimated): May 20, 2026
• Study Completion (Estimated): December 31, 2026

Study Registration Dates

• First Submitted: February 26, 2026
• First Submitted That Met QC Criteria: February 26, 2026
• First Posted (Actual): March 4, 2026

Study Record Updates

• Last Update Posted (Actual): March 4, 2026
• Last Update Submitted That Met QC Criteria: February 26, 2026
• Last Verified: February 1, 2026

More Information

Terms related to this study

• Keywords: Anxiety; Fatigue; postpartum; Breastfeeding Self-Efficacy; Maternal Attachment; Mandala Coloring
• Additional Relevant MeSH Terms: Mental Disorders; Pathological Conditions, Signs and Symptoms; Signs and Symptoms; Anxiety Disorders; Fatigue
• Other Study ID 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