Introduction
Rationale
Objectives
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How acceptable for pregnant women are non-pharmacological interventions for reducing the symptoms of mild to moderate anxiety?
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How beneficial do pregnant women consider non-pharmacological interventions to be in reducing the symptoms of mild to moderate anxiety in pregnancy?
Methods
Protocol and registration
Eligibility criteria
Information sources
Search
Study selection
Data collection process
Quality assessment
Analysis strategy
CERQual assessment
Results
Study selection
Study characteristics
First author Country Year | Intervention category (duration) | Primary outcome (secondary outcome) | Gestation at start/post intervention (weeks of pregnancy) | Study type *Description of intervention **Facilitator/facilitator training | Method and timing of outcome measure: acceptability/ satisfaction/ beneficence (n=) | Quality assessment of the methods used to investigate the acceptability/satisfaction/beneficence of the intervention |
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McGregor Canada 2014 | Psychological (6 individual sessions: 8 weeks) | 1. Depression 2. Anxiety 3. Healthcare/ medication utilisation (Intervention evaluation) | 20/28 | Pilot quasi-experimental trial * 10 min CBT sessions: education and behavioural activation; cognitive restructuring; inter-connectedness of thoughts, feelings and behaviours. ** Physicians/two hour training session provided by a psychologist. | Questionnaire Six weeks post-partum (n = 19) | No information provided on the development or the validity/reliability of the questionnaire. Questionnaires contained brief open and closed questions to assess women’s experiences and satisfaction with the CBT intervention. The authors reported that content analysis was conducted on the open ended questions, no further information provided. |
Milgrom Australia 2015 | Psychological (8 individual sessions: 8 weeks) | 1. Depression 2. Anxiety (Infant outcomes, satisfaction) | 20 (mean) / 29 (approx) | Pilot RCT * CBT sessions: ‘Beating the Blues Before Birth’ (Lewinsohn et al. 1984): relaxation; cognitive strategies; support networks; partner sessions; parenting skills; relationship issues and anxiety. ** Psychologists/Trained in pregnancy-specific CBT. | Questionnaire Post-intervention approx 29 weeks (n = 19) | No information provided on the development or the validity/reliability of the questionnaire. Questionnaire contained six items on the helpfulness of and satisfaction with the intervention (Likert scale). Results presented as simple descriptive statistics. |
Bittner Germany 2014 | Psychological (8 group sessions: 8 weeks) | 1. Depression 2. Anxiety (Fear of childbirth, social support, intervention evaluation) | 16 (mean) / 24 | RCT * CBT sessions: coping strategies; self-assurance; problem solving; discussions about anxiety; prevention; treatment; future challenges. ** Psychologist/CBT Training and supervision. | Questionnaire Post-intervention – 24 weeks (n = 36) | No information provided on the validity/reliability of the questionnaire. Questionnaire contained items about participants’ experience of and satisfaction with the intervention (Likert scale). The RCT had a high rate of attrition (46%). Results presented as simple descriptive statics. |
Thomas Australia 2014 | Psychological/Educational (6 group sessions: 12 weeks) | 1. Depression 2. Anxiety 3. Maternal attachment (acceptability, satisfaction) | 26 (mean) /NR | Pilot study * Behavioural self-care; psycho-education; IPT (social support, communication, role transitions, mental health warning signs); parent-infant relationship. ** Clinical psychologist and parent-infant mental health clinicians/experienced in CBT and IPT. | Questionnaire Post-intervention – third trimester (n = 30) | The authors used a validated questionnaire, the CSQ-8 to assess satisfaction. There was no information on the development of the intervention feedback forms. Results were presented as simple descriptive statics. |
Brugha UK 2015 | Psychological/Supportive (up to 3 individual sessions: 22 weeks) | 1.Depression (Anxiety and satisfaction) | 22 / 34 (approx) | Pilot cluster RCT * Care from midwives with additional training on: assessment of depressive symptoms; CBA; facilitating and maintaining therapeutic relationships; Five Areas approach (Williams et al. 2008) ** Midwives/Based on training by Morrell et al. (2009) and adapted for pregnancy. | Qualitative interviews Post-intervention – approx 34 weeks (n = 8) | A stratified subsample of intervention group women with EPDS scores of 12 or more and less than 12 were invited to take part in a qualitative evaluation of the pilot. Limited reporting of the methods of data collection. The authors described the data analysis method and provided quotations to support the findings. |
Breustedt Scotland, UK 2015 | Psychological/Social support (8 group sessions) | 1. Participants’ experience of the intervention | NR | Qualitative study * ‘Mellow Bumps’ psychological and practical techniques to reduce anxiety and promote wellbeing in vulnerable pregnant women; encouraged women to make social connections, share information; addressed individual concerns. | Qualitative interviews Post-partum period (n = 4) | Women who had completed the intervention and maintained contact participated. Authors state this may be related to positive experiences and non-attendees may hold different views. Authors included a description of the topic guide, data analysis method and participant quotations. A second researcher assessed for possible bias in the analysis process. |
Côté-Arsenault US 2014 | Supportive (approx 5 individual sessions: 20 weeks) | 1. Anxiety 2. Depression (Intervention evaluation) | 14 (mean) /NR | RCT * Supportive care for women pregnant after perinatal loss: pregnancy diary, information, skills to reduce anxiety and depression; prenatal attachment. Based on the caring process (Swanson, 1993). ** Nurses with additional training/NR | Qualitative Interviews Six to nineteen months post-partum (n = 12) | Qualitative interviews conducted with the intervention group participants. Limited reporting of the methods of data collection. The authors described the data analysis method and provided participant quotations to support the findings. Used member checking in the data analysis procedure. |
First author Country Year | Intervention category (duration) | Primary outcome (secondary outcome) | Gestation at start/post intervention (weeks of pregnancy) | Study type *Description of intervention **Facilitator/facilitator training | Method and timing of outcome measure: acceptability/ satisfaction/ beneficence (n=) | Quality assessment of the methods used to investigate the acceptability/satisfaction/beneficence of the intervention |
Beddoe US 2009 | Mind body (7 group sessions) | 1. Stress 2. Anxiety 3. Pain 4. Cortisol levels 5. Acceptability | 13–32 / NR | Feasibility study * Mindful yoga intervention combined elements of the Iyengar yoga, MBSR, relaxation and stress management. ** Yoga MBSR instructor/experienced Iyengar yoga instructor with extensive training in MBSR. | Questionnaire Post-intervention (n = 16) | The authors reported that the findings were limited by the inclusion of a small self-selected sample of women. No information provided on the validity/reliability of the questionnaire. Participants rated the acceptability of and satisfaction with the intervention. Results presented as simple descriptive statics. |
Cornsweet Barber New Zealand 2013 | Mind body (Individual self-help material) | 1. Acceptability of the intervention and usability of the self-help material | Second and third trimesters of pregnancy/NR | Feasibility study * computerised self-help package using bio-feedback to teach relaxation and mindfulness skills ** self-help | Qualitative Interviews Post-intervention - Second and third trimester (n = 9) | The authors reported the findings were limited by the inclusion of a small self-selected sample of pregnant women. Limited reporting of the methods of data collection and qualitative data analysis. The authors presented a small number of examples of participant quotations to support the findings |
Davis US 2015 | Mind body (8 group sessions: 8 weeks) | 1. Depression 2. Anxiety 3. Positive and negative affect (satisfaction, adherence) | 21 (mean) / 28–29 | RCT * Ashtanga Vinyasa yoga modified for pregnancy. Instructional video for home use. ** Yoga instructor/Experience in prenatal yoga | Questionnaire Post-intervention (n = 23) | The questionnaire was completed by women in the intervention group. The authors used validated questionnaires, the CSQ-8 to assess satisfaction and a credibility scale questionnaire. The results were presented as simple descriptive statics. |
Dunn Australia 2012 | Mind body (8 group sessions: 8 weeks) | 1. Depression 2. Anxiety 3. Stress 4. Self-compassion 5. Mindfulness Awareness (Participants’ experience) | 12–28 / NR | Pilot quasi-experimental study * Based on MBCT programme (Segal et al. 2002): awareness of each moment; cognitive model; taking a wider perspective; fostering an attitude of acceptance; relating to negative thoughts; managing warning signs. ** Psychiatrist, counsellor/accredited MBCT facilitators. | Qualitative Interviews Six weeks post-partum (n = 10) | Qualitative interviews conducted with the intervention group participants. The authors employed a non-randomised design and reported that the intervention and control groups were unbalanced at baseline (history of anxiety/depression). Limited reporting of the methods of data collection and data analysis. Presented extensive examples of participant quotations. |
Goodman US 2014 | Mind body (8 group sessions: 8 weeks) | 1. Anxiety 2. Depression 3. Self-compassion 4. Mindfulness (Intervention evaluation) | 6–27 / NR | Pilot study * Stress management: using imagination to induce feelings of comfort. Based on hypnotherapeutic methods. ** Stress management expert/NR | Questionnaire Post-intervention – second and third trimester (n = 23) | Open ended questions were used to elicit qualitative feedback concerning participation in the intervention. Qualitative content analysis was used to analyse the data with little further information provided. Quotations were presented to support the findings. |
Woolhouse Australia 2014 | Mind body (6 group sessions: 6 weeks) | 1. Stress 2. Depression 3. Anxiety (Participants’ experience) | 11–34 / 17–40 | Pilot RCT * ‘MindBabyBody’: breathing practice; body-scan; mindfulness of pain and thoughts; meditation; self-compassion; mindfulness skills in motherhood. ** Psychologist and Psychiatrist/Training in facilitation of mindfulness groups. | Qualitative Interviews Post-intervention – 17-40 weeks (n = 4) | Qualitative interviews with a small self selected sample of intervention group participants. Limited reporting of the data collection procedures. A detailed description Interpretative Phenomenological Analysis (IPA) procedure was reported and quotations were provided to support the findings. |
Darwin UK 2013 | Other (individual psycho-social assessment) | 1. Consider how perinatal psychosocial assessment may act as an intervention | 18 (mean) / 25 | Mixed methods study * Participated in a psychosocial assessment at the pregnancy booking appointment as part of routine clinical practice ** Midwives and Healthcare Professionals | Qualitative Interviews Time 1: 10–12 weeks Time 2: 28–36 weeks Time 3: 7–13 weeks post-partum (n = 22) | Author employed sequential mixed methods sampling (cases where the most could be learnt in relation to the research questions). Women participated in up to 3 qualitative interviews. Field notes and a reflective dairy were used to assist analysis. Presented a clear and transparent approach to the data collection process. Participant quotations presented to support the findings. A second researcher completed data analysis to reduce bias. The author described the use of prolonged engagement, member checking and searching for alternative explanations in the analysis procedure. |
Participants
Intervention type | First author/year | Mean anxiety score at baseline | Exclusions based on mental health history, diagnosis or treatment |
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Interventions for women with elevated anxiety scores or risk factors | |||
Mind Body Stress management Group sessions | Goodman 2014 | BAI 12 | DSM criteria: bipolar disorder, substance dependence disorder, psychotic disorder, anxiety disorder other than GAD that was more severe than GAD symptoms or diagnosis; initiated or increased dose of pharmacological treatment for depression/anxiety within past 6 weeks; participating in psychotherapy > 2 times per month; received CBT or stress reduction program in the past 12 months. |
Interventions for women with elevated anxiety and/or depression scores or risk factors | |||
Psychological CBT Group sessions | Bittner 2014 | STAI-S 38 | Severe anxiety, depression, bipolar or schizophrenic disorder or lithium/anti-psychotic drug intake |
Psychological CBT Individual sessions | Milgrom 2015 | BAI 19 | Major health problems, major psychiatric disorders for which the treatment was not designed (psychotic and bipolar disorders; not exclude anxiety disorders), current use of other psychological programmes, |
Psychological Educational, CBT, IPT Group sessions | Thomas 2014 | STAI-S 53 | Currently using illicit drugs or excessive amounts of alcohol, current psychotic symptoms, or acute risk of suicide. |
Mind Body Yoga | Davis 2015 | STAI-S 39 | (1) lifetime diagnosis of schizophrenia or schizoaffective disorder, bipolar disorder, current psychosis, organic mental disorder or pervasive developmental delay, or any other disorders that necessitated priority treatment not provided by the study protocol, (2) imminent suicide or homicide risk (3) high risk pregnancy |
Mind Body Mindfulness Group sessions | Woolhouse 2014 | STAI-S 36 | Current substance abuse; severe suicidal ideation |
Psychological assessment | Darwin 2013 | NR | NR |
Psychological/Supportive | Breustedt 2015 | NR | NR |
Interventions for women with elevated depression scores or risk factors | |||
Psychological CBT Individual sessions | McGregor 2014 | STAI-S 45 | Use of antidepressant or antipsychotic medication |
Interventions for women with a history of pregnancy loss | |||
Supportive care | Côté-Arsenault 2014 | NR | Uncontrolled medical or mental illness |
Interventions for a general population of pregnant women | |||
Psychological, Supportive CBA | Brugha 2015 | NR | In receipt of treatment from specialist mental health services |
Mind Body Mindful Yoga Group sessions | Beddoe 2009 | STAI- 26.7/30.4 | Current psychiatric illness; currently used medications for pain, sleep, depression, or anxiety. |
Mind Body Mindfulness relaxation Self-help material | Cornsweet Barber 2013 | NR | NR |
Mind Body MBCT Group sessions | Dunn 2012 | NR | Current psychosis or active substance abuse |
BAI | Beck Anxiety Inventory (Beck et al. 1988) |
BDI | Beck Depression Inventory (Beck et al. 1988) |
EPDS | Edinburgh Postnatal Depression Scale (Cox et al. 1987) |
GAD-2 | Generalised Anxiety Disorder–2 items (Spitzer et al. 2006) |
GAD-7 | Generalised Anxiety Disorder–7 items (Spitzer et al. 2006) |
PDQ | Prenatal Distress Questionnaire (Yali and Lobel 1999) |
PHQ-9 | Patient Health Questionnaire–9 (Kroenke et al. 2001) |
PSWQ | Penn State Worry Questionnaire (Meyer et al. 1990) |
STAI | State-Trait Anxiety Index (Spielberg et al. 1970) |
Interventions
Outcomes
Study type
Quality appraisal
GRADE-CERQual assessment
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One study was assessed as having moderate coherence (findings well-grounded in the data) (Cornsweet Barber et al. 2013). Six studies were assessed as being highly coherent.
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The adequacy of data was assessed as being highly adequate in six studies where the authors provided detailed accounts of women’s views and experiences and used the results to build theories and explanations (Popay et al. 1998). One study reported only a small number of examples of participant quotations to support the findings and was assessed as being moderately adequate (Cornsweet Barber et al. 2013).
Synthesis of the findings
First author country, year | Intervention description | Motives and barriers to participating in studies | Acceptability of interventions | Satisfaction with interventions | Perceived benefit from participation |
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Interventions for women with elevated anxiety scores or risk factors | |||||
Goodman US 2014 | Mind body Group mindful CBT | Women said the amount of home practice was sometimes too much. They suggested including partners in one session. Some would like ongoing support for their mindfulness practices. | Most women benefited from the experience. Would recommend to friends. | Some women said they learnt different options to deal with anxiety. They developed acceptance of their feelings and were kinder to themselves. Interaction within a supportive group reduced their feelings of isolation. | |
Interventions for women with elevated anxiety and depression scores or risk factors | |||||
Bittner Germany 2014 | Psychological Group CBT | Most women were satisfied with the intervention. | Most women found the intervention beneficial. | ||
Milgrom Australia 2015 | Psychological Individual CBT | Most women were satisfied with the intervention. | Most women found the intervention effective and helpful | ||
Thomas Australia 2014 | Psychological/Educational Group, Behavioural, IPT, psycho-educational. | Reasons for declining to participate included: work commitments, unsuitable timing of sessions, childcare issues, lack of interest or clash with other antenatal appointments | Most women were highly satisfied, and the intervention had met their expectations. | ||
Davis US 2015 | Mind body Group yoga | Women attended an average of 6 out of 8 classes. Reasons for missed classes included travelling and illness. | Most participants found the intervention to be highly credible and were satisfied with the intervention. | ||
Woolhouse Australia 2014 | Mind body Group mindfulness | The opportunity to learn new skills was a common motivation for participation. Women wanted to learn ways to manage mental health challenges. | Some exercises were challenging. Women engaged in different ways, picking the best exercises for them. Group participation was initially uncomfortable, but ultimately enjoyable. | Mindfulness (Body Scan) helped some women to sleep. They valued developing an ability to reflect on their emotions. Some reported improved relationships with family and colleagues. They felt able to respond to challenging situations. | |
Darwin 2013 UK | Other Self-report psychological assessment | Some women were concerned that disclosing their distress may lead to interference by social services or HCPs. Other women were concerned that their feelings would be dismissed | Some women valued interactions where HCPs listened rather than psychosocial assessment being viewed a routine. Some felt confronted by their distress following assessments without the offer of further support. Assessment was often completed without discussion. | The interview enabled some women to reflect about their thoughts and feelings. For some it was the first opportunity to talk about their feelings and experiences. Some women embraced self-reflection through the questionnaires | |
Breustedt Scotland, UK 2013 | Psychological/Social Support Group Psychological, IPT, practical techniques | Some women were uncertain of the reason for referral to the intervention and felt pressured to attend. They feared judgement from other group participants. | Women described the groups created a relaxed, non-judgemental atmosphere. Home visits helped create a welcoming experience. | Some women described the groups as an accepting atmosphere to share experiences. They addressed issues difficult to discuss with others and reduced women’s feelings of isolation. | |
First author country, year | Intervention description | Motives and barriers to participating in studies | Acceptability of interventions | Satisfaction with interventions | Perceived benefit from participation |
Interventions for women with elevated depression scores or risk factors | |||||
McGregor Canada 2014 | Psychological Individual CBT | Reasons for withdrawing included not having time to complete homework. Some women would have liked more time and in-depth discussions with their physician about their mood difficulties. | Some women said the intervention helped them be aware of their moods and subsequently were able to change their mood in a positive direction. | ||
Interventions for women with a history of pregnancy loss | |||||
Côté-Arsenault US 2014 | Psychological Individual supportive interactions | Home visits, pregnancy diary, relaxation and problem solving exercises received positive comments. Women found visualisation exercises somewhat difficult. Fetal movement counting was reassuring although women felt anxious until they felt their baby move. Some valued learning assertiveness techniques. | Most women found participation easy and the home visits were described as valuable. Women in the control group were disappointed that they did not receive an intervention but grateful research was being done. | The women found the nurse non-judgmental, knowledgeable, and supportive. They reported reduced feelings of isolation, stress, anxiety and greater confidence. Women felt more positive about pregnancy and the intervention helped to normalise their anxiety. Completing the diary helped them reflect on their feelings over the pregnancy. | |
Interventions for a general population of pregnant women | |||||
Brugha UK 2015 | Psychological Enhanced psychological training of community midwives (assessment, CBA) | Some women had not felt the need to share their feelings but felt they had the support if needed. Where women felt they would not have been able to share their feelings, it was attributed to the fact that they had not built a relationship with the CMW. | One woman offered CBA commented that two home visit sessions were sufficient for her needs. Women mostly found the EPDS helpful and important. A few women did not find it easy to discuss their emotions. | Most women valued the CMW exploring and discussing their feelings and welcomed the availability of support. Women were mainly positive about CMWs administering the EPDS. | For home visits, women mostly felt that CMWs were open, caring and supportive. Home visits offered reassurance and guidance. The EPDS increased women’s awareness of their moods and anxiety. Women appreciated that support was available if required. |
Beddoe US 2009 | Mind body Group mindfulness and yoga | Women who lived further away found sessions difficult to attend. | Most participants were satisfied and would recommend the intervention to other women | Most women felt more hopeful and confident and said they were taking better care of themselves. They developed awareness about the sources of their stress which helped them to cope with stressful situations. | |
Cornsweet Barber New Zealand 2013 | Mind body Individual mindfulness and relaxation | Initial frustration with completing exercises, but it became easier. Some said the language used was confusing. One participant did not complete all content. | All women found the intervention enjoyable, would recommend to others. | Women said the exercises were helpful to do before sleeping. Some felt the exercises might be helpful during labour. | |
Dunn Australia 2012 | Mind body Group mindfulness | Women with a history of anxiety or depression had increased interest in and engagement with the intervention. Wanted to create a positive pregnancy experience. | Most women valued group participation and forming new relationships. | Sharing experiences and stories with the group had the benefit of normalising women’s own experience. |
Acceptability of and perceived benefit of interventions | Confidence in the evidence | Relevant papers | Explanation of confidence in the evidence assessment |
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Groups and individual home visits by HCPs provided an opportunity to discuss emotional issues which women found difficult to discuss with others. Discussions and supportive interactions reduced feelings of isolation. | High confidence | In general the studies were moderately well conducted. The finding was seen across most studies and settings. | |
Most women were satisfied with interventions which they found enjoyable and would recommend to others. | High confidence | In general the studies were moderately well conducted. The finding was seen across most studies and settings. | |
Initially women had concerns about disclosing their symptoms. They feared the judgement of others (in group interventions) and interference from HCPs. | Moderate confidence | In general the studies were moderately well conducted. The finding was seen across several studies and settings. | |
Mindfulness and CBT helped women to develop self-awareness and most women felt more positive and confident following the intervention. | Moderate confidence | In general the studies were moderately well conducted. The finding was seen across several studies and settings. | |
Women with history of anxiety/depression were motivated to participate in interventions. | Low confidence | In general the studies were moderately well conducted. The finding was seen across a few studies and settings. | |
Some CBT, mindfulness and relaxation exercises were initially challenging but became easier with practice. | Low confidence | In general the studies were moderately well conducted. The finding was seen across a few studies and settings. | |
Women welcomed a choice of exercises and variety of techniques to practice. | Low confidence | In general the studies were moderately well conducted. The finding was seen across a few studies and settings. |