Elsevier

Women and Birth

Volume 29, Issue 1, February 2016, Pages 62-71
Women and Birth

ORIGINAL RESEARCH – QUANTITATIVE
Mindfulness and perinatal mental health: A systematic review

https://doi.org/10.1016/j.wombi.2015.08.006Get rights and content

Abstract

Background

Perinatal stress is associated with adverse maternal and infant outcomes. Mindfulness training may offer a safe and acceptable strategy to support perinatal mental health.

Aim

To critically appraise and synthesise the best available evidence regarding the effectiveness of mindfulness training during pregnancy to support perinatal mental health.

Methods

The search for relevant studies was conducted in six electronic databases and in the grey literature. Eligible studies were assessed for methodological quality according to standardised critical appraisal instruments. Data were extracted and recorded on a pre-designed form and then entered into Review Manager.

Findings

Nine studies were included in the data synthesis. It was not appropriate to combine the study results because of the variation in methodologies and the interventions tested. Statistically significant improvements were found in small studies of women undertaking mindfulness awareness training in one study for stress (mean difference (MD) −5.28, 95% confidence intervals (CI) −10.4 to −0.42, n = 22), two for depression (for example MD −5.48, 95% CI −8.96 to −2.0, n = 46) and four for anxiety (for example, MD −6.50, 95% CI −10.95 to −2.05, n = 32). However the findings of this review are limited by significant methodological issues within the current research studies.

Conclusion

There is insufficient evidence from high quality research on which to base recommendations about the effectiveness of mindfulness to promote perinatal mental health. The limited positive findings support the design and conduct of adequately powered, longitudinal randomised controlled trials, with active controls.

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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