The cost associated with perinatal mental illness is far reaching; current research shows that psychological distress in pregnancy is a significant risk factor for adverse child health outcomes (Stein et al., 2014). On a societal level, in the UK it has been reported that for every yearly cohort of births, the total long term cost to society for perinatal mental health problems (including anxiety, depression and psychosis) is £8.1 billion (Bauer et al., 2018). It should be highlighted that 72% of this cost relates to the impact on the child. The NHS long term plan sets out requirements to expand current specialist perinatal mental health services; a key part of this is increasing access to evidence based psychological treatment (NHS, 2019) .
Mindfulness is the act of focussing awareness to the present moment, accepting what is without judgment. Mindfulness based interventions (MBIs) such as Mindfulness based stress reduction (MBSR) and Mindfulness based cognitive therapy (MBCT) are commonly used to improve anxiety and depression across a range of clinical settings, and have been helpful in this context (Gotink et al., 2015). Theoretical models point to MBIs increasing our capacity to self-regulate (Holzel et al., 2011) teaching people to modify attention and in turn, allowing us to increase our experience of positive emotions (Bränström and Duncan, 2014).
Mindfulness-based Childbirth and Parenting (MBCP) is an intervention delivered antenatally and is based on MBSR. Outcomes are to reduce stress, anxiety and depressive symptoms in pregnancy and the post-natal period. Previous research has shown that mindfulness has been used successfully in the perinatal period on a number of wellbeing measures (Duncan and Bardacke, 2010b, Byrne et al., 2014). However, these studies are small in nature and so to determine efficacy it is imperative that randomised controlled trials (RCTs) are used. This study was the first large scale RCT testing the efficacy of MBCP on the aforementioned outcomes in pregnant women.
It had three aims:
- To see if Mindfulness-based Childbirth and Parenting (MBCP) would result in changes in pregnant women’s perceived stress, depression symptoms, positive states of mind and mindfulness skills
- To identify if mindfulness was a mediator for the effects of the intervention
- To investigate the effect of treatment compliance on the outcomes.
The researchers used a randomised controlled trial design with two arms; MBCP and an active control. The mindfulness programme ran for eight group sessions, each for 2hr 15min. Alongside this, participants were asked to complete at home mindfulness practice, for at least 30 minutes a day as well as additional mindfulness practice when sensing foetal movement or other activities. The social support and psychoeducation facets of the MBCP programme were controlled for by the active control being a Lamaze class. The Lamaze group consisted of three 3hr group sessions.
Women considered ‘at risk’ were targeted from eight maternity clinics in Sweden; those with a history of anxiety and/or depression and/or women who had experienced early life adversity, as well as women who experienced high levels of perceived stress (determined by a score on a screening tool). Participants were also required to be fluent in Swedish with no prior experience of mindfulness training or meditation. Clinically, the client must not have been experiencing major depressive disorder or psychotic symptoms contemporaneously with the study.
Both groups received post intervention questionnaires 10-12 weeks after baseline assessment when in 27-34 weeks gestation. Appropriate clinical self-report measures were considered pertaining to the aims of the study, all tools were validated.
In total, 193 participants were randomised; 96 women received MBCP and 97 women had the active control. Clients were comparable on a demographic level on both arms of the study; the average participant was 32 years old. Most women were Swedish (over 85%) and educated beyond secondary level. Additionally, the majority of participants were cohabiting or married to their partners.
In total, 11 participants were lost to follow up in the MBCP arm and 5 participants lost to follow up in the Lamaze class arm. Intention to treat analyses were completed to account for missing data.
To see if Mindfulness-based Childbirth and Parenting (MBCP) would result in changes in pregnant women’s perceived stress, depression symptoms, positive states of mind and mindfulness skills.
- There were significantly larger reductions in perceived stress and postnatal depression scores in the MBCP arm compared with the Lamaze arm
- Mild-moderate effect sizes were found for:
- the intention to treat analysis (PSS p=0.038, d=0.30, EPDS p=0.004 d=0.42)
- and the completers analysis (PSS p=0.028, d=0.35, EPDS p=0.002 d=0.48).
Skills learned from interventions
- A larger increase in scores was found in the MBCP group than the Lamaze group for positive states of mind and mindfulness
- Moderate effect sizes were found for:
- the intention to treat analysis (PSOM p=0.005, d=0.41, FFMQ p=0.039, d=0.30)
- and the completers analysis (PSOM p=0.002, d=0.50, FFMQ p=0.004, d=0.46)
To identify if mindfulness was a mediator for the effects of the intervention
- Mediation analyses were conducted. Data was taken from each sub-scale of the five facets of mindfulness questionnaire (FFMQ)
- The data showed that FFM mediated both perceived stress and symptoms of depression
- Improvements in positive states of mind were also mediated by the FFM
- Taken together, these results suggest that in this study, the improvements seen can be attributed to mindfulness itself in the MBCP.
To investigate the effect of treatment compliance on the outcomes.
- A linear regression analysis measured treatment compliance for MBCP participants
- Participants reported variations in the amount of mindfulness practice completed at home
- Out of all the completers: 6.81/8 sessions were attended and on average 62.2 minutes of formal mindfulness was completed and 41.03 minutes of informal mindfulness
- No significant effects were found on any of the compliance measures such as attendance and informal or formal mindfulness practice on the outcome scales used, suggesting that the amount of extra mindfulness at home did not produce changes in the outcomes
- This may mean that a high amount of mindfulness outside of sessions is not necessary for increased improvements.
Compared to the Lamaze class, parents who received MBCP had greater improvements in perceived stress and a lower risk of perinatal depression. Further analyses suggests that it is the mindfulness training itself that produces these improvements and also that additional mindfulness practice outside of sessions is not necessary to achieve such outcomes.
Strengths and limitations
This study does well to increase our current levels of understanding not only of the potential impact of mindfulness interventions in the perinatal period, but also exactly how these mindfulness interventions might lead to improved outcomes. Strengths of this study include a variation of appropriate, validated outcome measure tools, transparency from the researchers pertaining to attrition rates (including using intention to treat analyses) and conflicts of interest (two of the study authors are MBCP providers), appropriate data analyses conducted, using a participant group as heterogeneous as possible. Additionally, the findings of this study are congruent with previous research in this area.
It can be argued that, in a study like this, a lack of participant blinding is a limitation, since it could mean that the subjective experience of having the intervention, rather than the intervention itself could have led to improvements on the outcome measures. The researchers do acknowledge this. However, by the nature of psychological interventions it is not possible to blind participants or intervention delivery staff to this type of intervention.
A confounder of the study must be highlighted; the intervention arm and the active control arm were not only different in type of treatment, but also the amount of the sessions. Therefore, the superior impact of the MBCP intervention could have been a result of increased contact time in the study, rather than MBCP producing superior results, this is especially important considering that the Lamaze group also produced improvements in the five facets of mindfulness questionnaire (FFMQ).
In terms of measuring treatment fidelity, we are given data around whether treatment adherence from participants impacted the findings. However, it is not clear how treatment fidelity in terms of delivering the intervention was ensured. Though the researchers note that mindfulness teachers met frequently to discuss their teaching, the exact nature of this is unclear, for example, what constitutes frequently in this context? What exactly ensured that treatment fidelity was being closely ensured?
Implications for practice
The results of this study have contributed to our understanding of the usefulness of mindfulness interventions in the perinatal period, pertaining to the experience of depression and stress symptoms. In the UK, in line with government recommendations for the expansion of perinatal mental health services, there is a move to increase access to psychological therapy provision. Additionally, as a clinician working in perinatal services I have seen the positive impact of mindfulness interventions not only on a woman’s level of perceived distress, but also for the promotion of the mother-baby bond. This in turn does produce observable benefit for not only women, but their families. Mindfulness training, in a group format, could be highly beneficial for this high-risk population, particularly for women who have a history of needing mental health support and who may therefore be at risk of relapse in the perinatal period. Holding this in mind, though some findings may be interpreted with caution, this study does have much clinical benefit.
Statement of interests
Lönnberg, G., Jonas, W., Unternaehrer, E., Bränström, R., Nissen, E., & Niemi, M. (2020). Effects of a Mindfulness Based Childbirth and Parenting program on pregnant women’s perceived stress and risk of perinatal depression – results from a randomized controlled trial. Journal of Affective Disorders. 262 133-142
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