ORIGINAL RESEARCH – QUANTITATIVEMindfulness and perinatal mental health: A systematic review
Introduction
The anticipation of birth and the transition to parenthood is seen by some expectant women as a welcomed challenge, while others can feel significant stress. Although the exact mechanism is not fully understood, there is a wealth of research that indicates that maternal stress is associated with adverse pregnancy outcomes for both the mother and child. For example, stress during pregnancy has been linked with preterm birth and low birth weight,1, 2, 3 increased analgesic use and unplanned caesarean delivery.4 Maternal stress also increases the women's risk of anxiety and depression.5
It is estimated that between 15% and 25% of pregnant women suffer from anxiety or depression.6 However, the true prevalence could be significantly higher as many women who experience mood disorders are not diagnosed.7 Behavioural interventions may offer a safe and acceptable strategy to support mental health during the perinatal period; one such intervention is mindfulness training.
Mindfulness is the intentional, accepting and non-judgemental focus of one's attention on their present moment emotions, thoughts and sensations. The seven attitudinal factors that are fundamental to mindfulness include; non-judging, patience, beginner's mind, trust, non-striving, acceptance and letting go.8 Mindfulness is about being fully aware and focusing attention on the here and now, rather than getting caught up thinking about the past, or worrying about the future. While not its primary purpose, relaxation may also occur as a result of mindfulness practice.
Pioneering work investigating the use of a Mindfulness-Based Stress Reduction (MBSR) programme was conducted in the United States by Kabat-Zinn in the 1990s.8 Using an eight-session MBSR intervention, which included yoga and a one-day silent retreat, Kabat-Zinn demonstrated considerable benefits for patients suffering from a range of conditions, including anxiety and depression. Since his seminal work, numerous studies have found that mindfulness training can lead to improved mental health.9 Mindfulness training has now been used as a clinical intervention for numerous health conditions such as: chronic illness10; chronic pain11; cancer12, 13; cancer survivorship14, 15; mental illness in war veterans16 cigarette addiction17 as well as anxiety and depression during pregnancy.18 Indeed, the evidence-based literature is growing rapidly.19
In the recent past a variety of mindfulness-based programmes and therapies has grown including; Mindfulness-Based Cognitive Therapy (MBCT),20 Mindfulness-integrated Cognitive Behavioural Therapy (MiCBT),21 Acceptance and Commitment Therapy (ACT)22 and Dialectical Behavioural Therapy (DBT).23 These interventions use mindfulness practice to develop awareness and acceptance of one's thoughts, emotions and body sensations, building stress tolerance, reducing reactivity and avoidance of uncomfortable experiences; abilities that are all important for pregnant women and new mothers.
The objective of this systematic review is to critically appraise and synthesise the best available evidence regarding the effectiveness of mindfulness training during pregnancy to support perinatal mental health. For the purposes of this review, perinatal mental health refers specifically to the mother's perceived stress, anxiety and/or depression during pregnancy and the early weeks following birth.
Section snippets
Methods
This systematic review is reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement.24 A protocol was devised by the authors and used as a template for conducting the review according to the following:
Study selection and characteristics
Electronic searches of the databases returned 689 records. After searching other sources and removal of duplicates, a total of 548 abstracts were identified. Following screening, 34 full text articles were assessed for eligibility; 12 studies met the inclusion criteria and were included in the systematic review (Fig. 1).
The 12 studies were conducted in the U.S.A., Australia and New Zealand and compared the effects, feasibility and acceptability of a range of mindfulness-based interventions. The
Perceived stress
Two well validated stress measurements were used to assess participants stress levels. The most common was the Perceived Stress Scale (PSS).28, 31, 36 Byrne et al.,30 used the 21-item Depression, Anxiety and Stress Scale (DASS-21). Woolhouse et al.,27 used two stress measurements: PSS and DASS.
Only one single group pre-post intervention study showed a statistically significant perceived stress reduction at post intervention (MD −5.28; 95% CI −10.14 to −0.42, n = 11).27a The remaining studies
Discussion
Perinatal mental health has received significant attention in recent years with organisations such as BeyondBlue in Australia recommending the routine assessment of emotional health during pregnancy.38 This review sought to investigate the effectiveness of mindfulness training during pregnancy to improve perinatal mental health, specifically in the areas of perceived stress, anxiety and/or depression.
Nine studies (described in eight papers) were included in the data synthesis for this review.
Conclusion
There is currently insufficient evidence from high quality trials on which to base recommendations about the effectiveness of mindfulness training to support perinatal mental health, specifically in terms of women's stress, anxiety and depression. There is however some evidence of benefit which support the design and conduct of one or more adequately powered, longitudinal randomised controlled trials, with active controls. Any future pre- and post-design studies need to address the issue of
Funding
No funding was sought for the conduct of this review.
Ethical statement
This systematic review of the literature did not involve human or animal research and did not require ethical approval.
Acknowledgments
The authors gratefully acknowledge the contribution of Paula Todd, subject librarian, for assistance with the literature search strategy.
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Cited by (72)
Efficacy of contextual therapies in perinatal depression and anxiety: A systematic review and meta-analysis
2024, Journal of Psychiatric ResearchOnline mindfulness-based intervention for women with pregnancy distress: A randomized controlled trial
2023, Journal of Affective DisordersInternet-delivered mindfulness-based interventions for mental health outcomes among perinatal women: A systematic review
2023, Asian Journal of PsychiatryCitation Excerpt :Future high-quality studies are needed to compare the effects of iMBIs with face-to-face MBIs for women in the perinatal period. The risk of maternal depression in the perinatal period is closely related to high levels of rumination (Barnum et al., 2013) and low levels of mindfulness (Hall et al., 2016), which are considered as possible mediators of intervention effects. In our review, only Gammer’s study examined the mediating role of maternal self-compassion in the relationship between iMBIs and maternal mental health (Gammer et al., 2020).
Effects of Maternal Psychological Stress During Pregnancy on Offspring Brain Development: Considering the Role of Inflammation and Potential for Preventive Intervention
2022, Biological Psychiatry: Cognitive Neuroscience and NeuroimagingCitation Excerpt :Robust effects of CBT and interpersonal therapy on reducing depressive symptoms and preventing perinatal depression (10,11,116) have been observed, with CBT also showing efficacy in reducing perinatal anxiety and psychological stress (117,118). MBIs are also feasible and acceptable during the perinatal period (10,115,119,120) and are associated with reductions in anxiety and stress (115,119,120). Mindfulness-based cognitive therapy has a strong evidence base for reducing psychological stress during pregnancy and reducing risk for perinatal depression (10,121,122).