Assessing the effectiveness of mindfulness-based programs on mental health during pregnancy and early motherhood - a randomized control trial

Becoming a mother is often a stressful transition [1], involving long-term processes that qualitatively reorganize both inner thoughts and external behaviors [2]. This transition may be fraught with difficulties and additional stresses that render new mothers more vulnerable to postpartum depression [3].

An increasing body of evidence suggests that perinatal stress and depression are symbolic expressions of powerlessness that negatively affect new mothers’ intimate and social lives (e.g., poor attachment with their babies and reduced interpersonal interactions) and have both short- and long-term negative effects on mothers and newborns [4] (e.g., increased incidence of preterm birth, fetal growth retardation, and low Apgar scores) [5, 6].

These adverse outcomes are associated with increased risks to the neurobehavioral and cognitive development of babies and children [7]. Depression has received increased attention in recent years. The global prevalence of postpartum depression (PPD) is currently estimated at 17.7% (95% confidence interval: 16.6–18.8%) [8]. As women are often required to continue shouldering heavy work, social, and family demands while caring for their newborn child, the mental health of postpartum women deserves particular attention.

A significant body of peer-reviewed and published evidence supports that stress inventories are able to predict depression [9]. Therefore, reducing perinatal psychological distress (stress, depression, and anxiety) during pregnancy and the first-year postpartum should be a crucial public-health goal [10]. Although pregnancy is often presented in the literature as a stressful period, some women welcome pregnancy as a challenge. Pregnancy is also known to be an opportune time for suggesting health interventions [11]. However, the longitudinal effect of psychological antenatal education interventions during the postpartum period have rarely been evaluated. In Taiwan, most hospitals offer a routine, several-hour childbirth education course on a once-monthly basis, with no restriction on the number of women or couples attending the class. These courses adopt a unidirectional teaching strategy, and interactions between instructors and participants or among participants is not encouraged. Course content addresses the physiological changes during pregnancy and self-care for physical discomfort, preparing for labor, comfort measures during labor, epidural anesthesia and cesarean section-related knowledge. However, these courses typically do not teach strategies for self-managing psychological health issues during the perinatal period.

The psychological health of pregnant populations has improved since mindfulness-based interventions (MBIs) were introduced in the 1990s. Evidence now supports MBIs as an effective approach to reducing psychological stress in Europe and North America [12] and as effective in reducing stress [13‐16], anxiety [13‐15, 17‐19], and depression [14, 16, 18‐21] during pregnancy. Furthermore, some researchers have found that the effects of MBIs persist through 4–6 weeks postpartum [14, 15, 20‐22]. Nevertheless, few studies have investigated the duration of mindfulness beyond six-weeks postpartum.

Although the benefits of mindfulness-based interventions during pregnancy and postpartum have been previously demonstrated, the impact of these interventions on mothers during early parenthood is unclear. Therefore, the purpose of this study was to assess the efficacy of an MBI on the long-term psychological health of women during pregnancy and into early motherhood.

A randomized, controlled trial was conducted to measure the effects of the mindfulness-based childbirth and parenting (MBCP) program (intervention group) compared to the hospital’s routine childbirth education (comparison group). In addition, both groups received routine antenatal care from the research hospital.

This study aimed to determine the effects of an 8-week mindfulness training intervention on a sample of pregnant women using a comparison group as the control. A total of 74 women completed the trial, with results empirically supporting most of the hypotheses. There are no significant between-group differences in psychological measures and demographic characteristics were found at T1. The intervention group realized a significantly greater decline in self-reported stress and depression than in the comparison (standard care) group. The mindfulness skills learned during the intervention had long-term mediating effects on the intervention-group participants, who maintained a low level of stress and depression at least to T2. In addition, moderate effect sizes (η² > .06) were observed. The mindfulness intervention may best be administered during both the prenatal and postnatal periods in order to sustain its beneficial effects [18].

The closest comparable study is a pilot RCT conducted by Vieten and Astin (2008), which randomly assigned 31 healthy and pregnant women into two groups, with the intervention group receiving 8 weeks of Mindful Motherhood program training. Although significant differences in anxiety and negative affect were found in the post-test results, no between-group differences in these two variables were detected at 3 months after completion of the intervention. Although another study that focused on a new online course obtained results similar to those of this study, the 8-week postnatal follow-up response rate in that study was excessively low, at only 25.9% [31]. In addition, a randomized trial study that focused on pregnant women with psychological diseases found that 86 pregnant women with histories of depression reported significantly better depressive outcomes at 1 and 6-months postpartum than participants receiving treatment as usual [32]. This difference in findings may be due to the differences in sample populations and sample sizes used. The small to medium effect sizes in depression, anxiety, and stress are necessary factors to be considered for mindfulness in pre- to post-analysis research [12]. This study considered whether the identified differences in mental health persisted into the longer postpartum period.

Although the findings are consistent with previous research that has shown mindfulness to be effective at improving psychological well-being in different perinatal populations [14, 20, 21], the measurements in most of this research were conducted at 4–6 weeks postpartum. Few studies in the literature have assessed the effects of prenatal interventions at three-months postpartum (T2) or later. Thus, the longer-term duration of intervention effectivness is an area that deserves further exploration in future studies.

In terms of mindfulness, a previous study that used a one-group, pre–post experimental design with 18 subjects found that postnatal mindfulness increased between 3 to 12-weeks postpartum [22]. Another study that used a pilot RCT design (n = 47) found that participants in both groups experienced increased mindfulness at 6-weeks postpartum [15]. In this study, with the exception of the non-reactivity subscale of the FFMQ, the between-group differences did not significantly differ at T2. However, the mean FFMQ score for the intervention group increased by 9.29 between T1 and T2, while that for the comparison group increased by only 1.60. A longitudinal study conducted over a longer time period and using a larger sample should be conducted to verify and further explore the observed positive effect on mindfulness.

Two factors may underlie the ameliorating effect of mindfulness on stress-related factors. First, recent research has found that practicing mindfulness reduces depression and increases happiness in practitioners. MBIs are designed to increase psychological flexibility [14], which is a fundamental aspect of health [33]. Psychological flexibility encompasses a wide range of human capabilities and is thus adaptable to a variety of situational needs, helping practitioners keep important aspects of their life in balance and promoting consistent behaviors with awareness and openness [33], which may significantly benefit psychological health during prenatal and postnatal periods [20‐22]. Second, the intervention group may have benefitted from a ‘group therapy’ effect attributable to the regular attention of researchers and study staff in a therapeutic environment. By contrast, the comparison group received only 4 h of total interaction time with the researchers. Therefore, holding weekly sessions may improve the effect of interventions [34].

Some limitations in the design of this study must be considered. First, this study had a high rate of attrition. A loss of 20% or greater indicates a significant risk of bias [35], which may influence the data supporting the potential benefits of mindfulness in the perinatal period. Second, this was a single-blind randomized controlled trial and the researchers were aware of the group assignments of the participants. Third, participants in the intervention group were encouraged to listen to the recorded instructions and to practice the MBCP at home. However, the actual time spent in home practice was not tracked. Future research examining the practice time of participants is needed in order to better understand the effects of mindfulness on postpartum women.

The findings of this study highlight the potential efficacy of an 8-week MBCP intervention in improving stress and depression in postpartum women. Women in Chinese cultural settings typically stay at home for about 30 days after giving birth in order to recover from the birthing experience and return to health. This is a practice known as “doing the month” [36]. Thus, implementing a long-term, effective mental health course during pregnancy is especially important in this population. Mindfulness programs may be an effective approach to enhancing the mental health of women during pregnancy and the postpartum period. As mindfulness must be practiced before giving birth, including mindfulness courses and related practical exercises in prenatal education is recommended in order to promote well-being and reduce stress and depression in the postpartum period.