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Vol. 38. (In progress)
(January 2024)
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Mindfullness based intervention reduce anxiety in labor
Intervención basada en mindfulness para reducir la ansiedad en el parto
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Finta Isti Kundartia,
Corresponding author
fintaistikundarti@gmail.com

Corresponding author.
, Kiswatia, I. Nengah Tanu Komalynab
a Department of Midwifery, Health Polytechnic Ministry of Health Malang, Malang, Indonesia
b Department of Nutrition, Health Polytechnic Ministry of Health Malang, Malang, Indonesia
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Table 1. Synthesis of previous research.
Abstract
Objective

To determine the effectiveness of mindfulness interventions on anxiety through a systematic review.

Method

Systematic review by searching articles through the PubMed, ProQuest, Science Direct, Wiley Library, Sage Journal, and Cochrane Library databases with publication years January 2012 to January 2022

Results

Eleven articles met the inclusion criteria covering several countries, including Canada 1 article, Egypt 1 article, Taiwan 1 article, Amsterdam 2 articles, Iran 1 article, Austria 1 article, San Francisco 1 article, Germany 1 article, Sweden 1 article, China 1 article, and Spain 1 article.

Conclusions

Management of anxiety about childbirth is important for pregnant women. Mindfulness interventions are effective for reducing anxiety about labor and increasing comfort during labor. Mindfulness intervention mechanisms have the potential to reduce anxiety by increasing skills to regulate emotions.

Keywords:
Mindfulness
Anxiety
Labor
Resumen
Objetivo

Determinar la efectividad de las intervenciones de mindfulness en la ansiedad, el dolor de parto y el resultado neonatal a través de una revisión sistemática.

Método

Revisión sistemática mediante búsqueda de artículos en las bases de datos PubMed, ProQuest, Science Direct, Wiley Library, Sage Journal y Cochrane Library entre enero de 2012 y enero de 2022.

Resultados

Once artículos cumplieron los criterios de inclusión, que corresponden a diversos países, incluyendo Canadá 1 artículo, Egipto 1 artículo, Taiwán 1 artículo, Ámsterdam 2 artículos, Irán 1 artículo, Austria 1 artículo, San Francisco 1 artículo, Alemania 1 artículo, Suecia 1 artículo, China 1 artículo y España 1 artículo.

Conclusiones

El manejo de la ansiedad debida al parto es importante para las gestantes. Las intervenciones de mindfulness son efectivas para reducir la ansiedad ante el trabajo de parto y aumentar la comodidad durante este. Los mecanismos de intervención de mindfulness tienen el potencial de reducir la ansiedad al aumentar las habilidades para regular las emociones.

Palabras clave:
Mindfulness
Ansiedad
Parto
Full Text
Introduction

Pregnancy is not only a physical reality, but related to individual thoughts and attitudes.1 Increasing anxiety to the point of fear is a common problem related to childbirth.2 Labor is a normal physiological event, where negative feelings such as aches and pains, fear, and anxiety are experienced by the mother during labor.3

Anxiety is associated with negative birth outcomes, which implies that pregnant women with anxiety have poor expectations of labor pain.4 Based on prevalence data anxiety has been reported to be 12.2-39% depending on the type of anxiety in pregnant women two or three times higher than the general population.5 Approximately 14.5% of women experience anxiety, 9.4% experience moderate anxiety and 8.7% experience severe anxiety during childbirth.6 The incidence of anxiety in Indonesia reaches 373,000,000 or 28.7% one of them related to anxiety about childbirth. Every day 810 pregnant women die from complications related to pregnancy or childbirth. About 295,000 women die during and after pregnancy and childbirth. The main causes of death in women during pregnancy, childbirth and the puerperium are complications. Almost all complications develop during pregnancy. Approximately 80% of the causes of complications in the mother are bleeding, infection, hypertension during pregnancy (preeclampsia and eclampsia), and unsafe abortion. Maternal health and newborn baby are related. About 2.5 million children die in the first month of life, and about 2.6 million babies are stillborn.

Maternal anxiety that is not treated properly can cause great risk to both mother and fetus and can affect quality of life.7 Anxiety will increase pain or pain during labor such as prolonged parturition which can increase the risk of interference with the fetus, head compression, fetal death, low Apgar score, injury to the neonate, risk for fetal growth, early miscarriage, low birth weight, and premature labor.8 Excessive anxiety that causes depression can increase the risk of complications during pregnancy and childbirth such as preeclampsia in the mother, postpartum depression and various other health complications.9

A high anxiety score is associated with increased labor pain, can increase the risk of negative birth10 and increases the mother's willingness to ask for pain medication during labor.11 This is due to personality and social background, folklore and scary stories about unpleasant experiences from previous births and lack of social support are some of the causes that influence pregnancy or re-pregnancy, prenatal fear, beliefs about reasons that have nothing to do with individual behavior, previous epidurals, nullipara, surgical intervention, tissue damage during childbirth, lack of stress management.11–13

Ways to reduce maternal anxiety, as well as help to have a positive birth experience should be a public health goal.14 Several interventions can be used to reduce the anxiety felt by mothers. Drug therapy such as antidepressants is widely used to reduce anxiety, but it puts risks to the developing fetus. Many mothers are worried about taking these drugs because they are worried about the fetus they contain.

Given the effect of pharmacological therapy on anxiety and pain management, non-pharmacological therapy is used, one of which is non-pharmacology interventions for mothers.15 Interventions that can be used include mindfulness interventions. Mindfulness is defined as the awareness to practice mindfulness with intentional, non-judgmental, and momentary experiences. It is characterized by the acceptance of all stimuli, both internal and external, and the ability to switch consciousness between stimuli. Mindfulness-based interventions conducted on 68 high-risk pregnant women in Heidelberg for 1 week showed a significant reduction in anxiety levels.16 Mindfulness interventions can overcome anxiety, pain in labor, and positive birth outcomes.

Mindfulness is a mental discipline that aims to develop awareness, emotion regulation, and compassion for self and others. Mindfulness encourages self-regulation by increasing acceptance, non-attachment and non-reactivity to temporary experiences, emotions and body sensations.17 Mindfulness interventions include activities such as awareness of breathing, body positions and walking, internal body sensations, thoughts and state of mind. A hypothesis underlying the mindfulness approach is that greater awareness increases insight, well-being, and reduces negative effects, which are important for pregnant women.18,19 Participating in mindfulness interventions can enhance positive birthing experiences. A high level of awareness can reduce negative reactions due to unavoidable negative events and promote effective coping with current events.20

The purpose of this study was to analyze the effectiveness of mindfulness interventions on anxiety during labor through a systematic review.

Method

The method used in this research is a systematic review which aims to determine the effectivenessxof mindfulness interventions on anxiety during labor. Data were identified from January 2012 to December 2022. The search was conducted through the ProQuest, Wiley Library, PubMed, Science Direct, Sage journal, and Cochrane library databases using the keywords “Mindfulness AND anxiety during labor”. Study selection was carried out by selecting relevant titles and abstracts which were carried out directly by the researcher. Then screening was carried out based on inclusion criteria, namely: original research journals in 2011-2022, with a population of pregnant women using mindfulness interventions, journals in English, and full text.

Results

The results of literature observations were obtained through the stages of identification, filtering, and determining criteria from data based proquest, Wiley Library, PubMed, Science Direct, Sage Journal, Cochrane Library (n=478) and similar articles (n=246), articles that were screened based on title and abstract (n=232) and 35 were excluded because only abstracts were available. So the full text articles were 197, the full text articles that were excluded because they did not meet the inclusion criteria 157 so the remaining 40 articles, and the articles that met the criteria for analysis were 12 (Fig. 1). Based on the articles that have been obtained, there are 12 articles that discuss mindfulness interventions for the anxiety felt by pregnant women before giving birth. Number of research subjects were 1331. Mindfulness interventions in the articles found include several countries, including Canada 1 article, Egypt 1 article, Taiwan 1 article, Amsterdam 2 articles, Iran 1 article, Austria 1 article, San Francisco 1 article, Germany 1 article, Sweden 1 article, China 1 article, and Spain 1 article. The articles explained can be seen in Table 1.

Figure 1.

PRISMA flowchart.

(0.35MB).
Table 1.

Synthesis of previous research.

Authors  Method  Population  Intervention  Instruments  Results 
Mackinnon et al.21 (2021),Canada  Randomized controlled trial  n = 60 pregnant women with a gestational age of 12 to 28 weeks with a singleton pregnancyRandomly, 28 pregnant women were allocated to MBCT-PD and 32 pregnant women were given treatment as usual  Mindfulness based cognitive therapy (MBCT)session: 8 weeks, 2 hours  The Pregnancy Related Anxiety (PRA)Generalized Anxiety Disorder (GAD-7) ScalePerceived Stress Scale (PSS)  Psychological outcomes: the significant effect of the intervention group shows that the intervention group predicts changes in psychological distress ratings over time, so that participants with the MBCT-PD intervention report reduced psychological distressThe results of the study show that there is a significant indirect treatment effect of MBCT-PD through reducing pregnancy anxiety after the T2 intervention by reducing symptoms of pregnancy anxiety 
Nasr et al.34 (2022), Egypt  A quasi experimental  n=82 participants.Participants were divided into two groups, namely the intervention group and the control group, each consisting of 41 pregnant women with predetermined inclusion criteria.Primigravida and multigravida women are both in their third trimester (over 28 weeks gestational age).  Mindfulness virtual30 minutes  Pregnancy-Related anxiety questionnaire - revised-2 (PRAQ-R2)Five Facet Mindfulness Questionnaire (FFMQ)  The results showed significant differences in levels of anxiety, the five aspects of attention between the groups afterimplementation (control, intervention group). In addition, there are differences regarding complications during childbirth, problemsneonatal health, and type of feeding between the two groups 
Pan et al.28 (2019), Taiwan  Randomized controlled trial  n=74 pregnant women, with 35 participants in the comparison group and 39 participants in the intervention group. 13 and 28-weeks gestationsingleton pregnancyat least 20 years of age  MBCP session: 8 weeks, 3 hours  Perceived Stress Scale (PSS-10)Edinburgh Postnatal Depression Scale (EPDS)  The mindfulness intervention program performed significantly better in the intervention group than the comparison groupMindfulness intervention programs effectively reduce perceived stress and depressionMindfulness provides long-term benefits that mothers can receive during pregnancy and the postpartum period 
Veringa-Skiba et al.23 (2021), Amsterdam  Randomized controlled trial  n=141 pregnantIntervension group n=75 and control n=66nulli-, and multi-parous pregnantwomen aged ≥18 years  MBCP session: 9 weeks, 3 hours  Wijma Delivery Expectation Questionnaire (W-DEQ-A)DSM-5 Perinatal Anxiety Disorder Labor (DSM-5 PAD-LCatastrophizing Labor Pain (CLP dan Labor Pain Acceptance Questionnaire (LPAQ)  The main results of the study, namely mean childbirth anxiety decreased after MBCP and enhanced care as usual (ECAU), but the decrease was significantly greater by MBCP 
Zarenejad et al.26 (2020), Iran  Randomized controlled trial  n=60, 30 pregnant women in the control group and 30 pregnant women in the intervention group withfirst pregnancya gestational age of 24-36 weeks,single fetus, no pregnancy complications  Mindfulness based stress reduction (MBSR)session: 6 weeks, 1 hour  Pregnancy Related Anxiety Questionnaire (PRAQ)Mindfulness QuestionnaireSelf Efficacy in Coping with Childbirth Questionnairex  The results of the study assessed changes in pregnancy anxiety scores before, immediately after, and one month after the intervention, indicating that the duration of the intervention affected the anxiety scoreSelf-efficacy scores before, immediately after, and one month after the intervention showed that length of time did not affect self-efficacy scores and there was no significant difference between the two groups 
Zemestani and Fazeli Nikoo31 (2020), Austria  Randomized controlled trial  n=38 pregnant women. The intervention group was 19 people and the control group was 19 peopleaged 18 years or older1 to 6 months of gestational age  Mindfulness based cognitive therapy (MBCT)session: 8 weeks, 2 hours  Beck Depression Inventory II (BDI-II)Beck Anxiety Inventory (BAI)Emotional Regulation Questionnaire (ERQ)  The MBCT group experienced a significant reduction in BAI scores from baseline to post-treatment and the BAI scores remained significantly lower compared to the control group at follow-up 
Sbrili et al. (2020),27 San Fransisco  Randomized controlled trial  n=30 nulliparoussingle baby pregnanciesthird trimester pregnant women  Mind in laborsession: 2-5 days  Center for Epidemiologic Studies Depression ScaleState-Trait Anxiety Inventory (STAI)Perceived Stress Scale (PSS)Five Facet Mindfulness Questionnaire (FFMQ)  Mind in labor can reduce mental health to a greater extent than general treatment 
Sacristán Martín et al.29 (2019), Spain  Randomized controlled trial  n=122, 61 participants of pregnant women and their partners in each intervention group and control groupsecond trimester pregnant women  Mindfulness-based childbirth and parenting (MBCP) programsession: 9 weeks, 3 hours  Edinburgh Postnatal Depression Scale (EPDS)The Perceived Stress Scale (PSS)The Positive and Negative Affect Schedule (PANAS)The Five Facet Mindfulness Questionnaire (FFMQ)The Self-Compassion Scale (SCS)The Parental Evaluation Scale (EEP)The Client Service Receipt Inventory (CSRI)  MBCP is an effective alternative strategy to improve mental and physical health and well-being, to reduce depressive symptoms, and to manage pain and reduce stressMBCP is also useful for expectant parents preparing for labor to manage pain during pregnancy and labor 
Gunilla et al. (2020)30, Sweden  Randomized controlled trial  193 pregnant women; 96 mothers were included in the intervention group and 97 mothers were included in the control group  Mindfulness-based childbirth and parenting (MBCP)session: 8 weeks, 2 hours  Perceived Stress Scale (PSS)Positive States of Mind (PSOM)Five-Facet Mindfulness Questionnaire (FFMQ)  MBCP significantly reduced perceived anxiety, stress, and depressive symptoms compared to the control group 
Yang et al.24 (2019), China  Randomized controlled trial  n=123 pregnant women the intervention group consisted of 62 pregnant women and the control group consisted of 61 pregnant womenA gestational age of 24 to 30 weeks;aged more than 18 years  Mindfulness online (Wechat platform)session: 8 weeks, 40 minutes  Generalized Anxiety Disorder (GAD-7)Patient Health Questionnaire (PHQ-9)  Participants in the intervention group showed a greater reduction compared to the control groupOnline mindfulness interventions can be a technique to help pregnant women reduce depression and anxiety 
Mitho et al. (2020)35, Germany  Randomized controlled trial  280 pregnant women; each intervention group and control group were 140 participants with, gestational age in the third trimester  Electronic mindfulness-based interventionsession: 8 weeks, 45 minutes  The Edinburgh Postnatal Depression Scale (EPDS)State-Trait Anxiety Questionnaire (STAI)Pregnancy-Related Anxiety Questionnaire (PRAQ-R)  E-based solutions can reduce geographic, financial and psychological limitationsInterventions provide effective and cost-effective assistance to pregnant women with psychological distress and can thereby reduce the negative impact on birth outcomes 
Veringa et al.25 (2016), Amsterdam  A-quasi experimental  128 pregnant women with a gestational age of 16 to 26 weeks with high fear of giving birth, primiparous and multiparous womenaged ≥18  Mindfulness-based childbirth and parenting (MBCP)  Wijma Delivery Expectancy Questionnaire (W-DEQ)Depression, Anxiety, Stress Scale (DASS-21)Labour Pain Acceptance Questionnaire (LPAQ)  MBCP can reduce fear of childbirth, reduce non-urgent medical interventions during labor, reduce anxiety, and reduce labor pain 

ECAU: enhanced care as usual; MBCP: mindfulness-based childbirth and parenting; MBCT: mindfulness based cognitive therapy, MBCT-PD: mindfulness-based cognitive therapy for perinatal depression; MBSR: mindfulness based stress reduction.

Discussion

Of the 12 articles found, 9 articles explained that mindfulness interventions had a positive impact and were proven to reduce the anxiety felt by mothers.17,21–27 Meanwhile, 3 articles stated that mindfulness intervention could reduce stress and depression.28–30 The mindfulness intervention programs carried out vary from MBCP,23,25,28–30 online mindfulness,17,22,24 MBSR,26 mindfulness-based cognitive therapy (MBCT),21,31 mind in labor.27 The implementation of mindfulness interventions varies, namely carried out for 6-9 weeks.21,23,25,27–31

Anxiety that is felt during pregnancy can cause labor that cannot be handled by the mother resulting in tension, hindering relaxation of the body, impacting the condition of the fetus in the womb. The muscles of the body tense up during this condition, especially the muscles in the uterine canal also become stiff so that it is difficult to expand.25

The study was conducted in Egypt with a total of 82 third trimester pregnant women (>28 weeks) aged 20-35 years. The intervention group was given virtual mindfulness which was carried out via the WhatsApp group which consisted of two sessions, namely two theoretical sessions and six practical sessions which were carried out twice a week with a duration of 30minutes. While the control group was given treatment as usual. The average anxiety score before the mindfulness intervention was given was 27.1±8.7 and after the intervention the average anxiety score decreased by 21.8±6.5. Whereas in the control group on observation the average anxiety score was 28.4±9.2 after being treated it became 26.1±6.3.

Anxiety in the mother plays a very important role in the progress of the birth process and interventions during labor. Anxiety in pregnancy is associated with shorter gestational age and has negative implications for fetal neurodevelopment and birth outcomes.23,32

There are various methods that target behavior change for psychological support and anxiety reduction. One of these methods is mindfulness-based intervention.33 Mindfulness has been shown to reduce anxiety that occurs for many reasons. Mindfulness as a tool helps pregnant women come to terms with the emotions they are feeling and the physical phenomena they encounter.32

Research study in Amsterdam conducted on 141 pregnant women. The intervention group was given mindfulness based childbirth and parenting for 9 sessions which were carried out once a week with a duration of 3hours each session and were encouraged to do informal mindfulness at home every day for 30minutes. Sessions on mindfulness practice include mindfulness meditations and body scans. Whereas the control group was given enhanced care as usual intervention consisting of two individual sessions in a 10-week period. The average anxiety score as measured by perinatal anxiety disorder labor (DSM-5 PAD-L) before the intervention was 26.76 and after the intervention was 23.53. While the control group in the observation before treatment was 27.80 and after treatment was 26.27.

This study is in line with research conducted on 80 pregnant women showing that mindfulness-integrated cognitive behavior therapy (Mi-CBT) is effective in reducing depression and anxiety in pregnant women, this positive impact can be seen for one month after implementing it.33

The mindfulness training intervention carried out for 8 weeks found that there was a significant decrease in anxiety. The mindfulness training learned during the intervention has long-lasting effects. Mindfulness interventions are best administered during the prenatal and postnatal periods to maintain the beneficial effects.36 Mindfulness based interventions are effective in enhancing perinatal psychological well-being. Mindfulness based intervention is designed to increase psychological flexibility which is a fundamental aspect of health.37

Mindfulness has an alternative way of meeting emotions that are felt in a different way, namely by acknowledging and paying full attention to feelings rather than avoiding or reacting to them. It is very tiring and not effective in the long run. Mindfulness is a radical intervention, which means daring to take steps and challenge towards perceived difficulties, whatever the difficulties. This action can change your relationship with anxiety because it gives freedom for the emotion to move forward.28

Mindfulness has the potential to numb or manage emotional reactivity to anxiety-provoking situations; it helps people pause, overcome chaos, see more clearly, and respond with freedom.38 Mindfulness therapy can change anxiety associations by replacing unhelpful thoughts and behaviors with positive alternatives.39 Mindfulness can rewire our brains so that our reactions to an emotion are less likely to trigger anger. The amygdala is the part of the human brain that is responsible for regulating fear and emotions and managing responses to stressors. Recent magnetic resonance imaging (MRI) data show that mindfulness practice can reduce gray matter in the brain's amygdala, which may dampen the stress response.40–44

Other research has shown that gray matter in the pre-frontal cortex, the area of the brain responsible for higher-order cognitive thinking, such as problem solving, planning, and emotional control, can increase after mindfulness practice. The brain's memory and learning center, the hippocampus, has also been shown to increase in volume after mindfulness practice.45–49

A longitudinal change in brain gray matter concentration after eight weeks of mindfulness practice compared to a control group. The hypothesis of increased gray matter concentration in the left hippocampus was confirmed. Exploratory whole-brain analysis identified significant increases in gray matter concentrations in the posterior cingulate cortex, temporo-parietal junction, and cerebellum.50,51

Mindfulness resulted in increases in brain activation during interventional assessment and reception in the medial, dorsomedial, dorsolateral, and ventrolateral prefrontal cortex; superior parietal and lateral occipital areas; and the caudate nucleus. These results converge with brain patterns detected previously in healthy non-anxious adults using the same autobiographical social situation fMRI emotion regulation52–54 in control of executive attention during reception of sad images, and in perspective shift and effortful attention during distraction from stressful events.55,56

Dispositional mindfulness levels have a significant association with mood so that higher mindfulness scores are associated with lower stress and anxiety scores and pregnancy-related depression, adversity and rates of negative pregnancy experiences. However, it is not clear whether low levels of mindfulness are related to high levels of anxiety and stress.39,57–60

Mindfulness-based childbirth and parenting reduced prenatal fear, reduced labor pain, and non-urgent obstetrical interventions, and increased acceptance of painless labor and delivery without medication.61

Conclusions

Management of anxiety about childbirth is important for pregnant women. Mindfulness interventions are effective for reducing anxiety about labor and increasing comfort during labor. Mindfulness intervention mechanisms have the potential to reduce anxiety by increasing skills to regulate emotions. Mindfulness in the future can be used as a non-pharmacological intervention option to reduce anxiety. Future researchers can conduct long-term research after delivery and delivery outcomes.

What is known about the topic?

In general, the results of a review of previous articles found that mindfulness interventions had a positive impact and were proven to reduce the anxiety felt by mothers before giving birth, especially in mothers with first pregnancies who had greater feelings of fear and anxiety. The duration of the intervention influences the duration of the reduction in anxiety during pregnancy, childbirth and postpartum, although it does not affect efficacy. Mindfulness intervention is an effective and cost-effective intervention.

What does this study add to the literature?

Because there are no systematic reviews that discuss mindfulness which is associated with anxiety in pregnant women before delivery, especially in pregnant women for the first time. This literature can also be used as information for pregnant women about one of the complementary therapies that can be done to reduce anxiety about the dreaded birth.

What are the implications of the results?

Mindfulness is proven to reduce anxiety that occurs for many reasons. Mindfulness is a tool to help pregnant women accept the emotions they are feeling and the physical phenomena they are feeling. Mindfulness is effective in reducing depression and anxiety for pregnant women, the positive impact can be seen for one month after applying it. Mindfulness intervention programs effectively reduce perceived stress and depression. Mindfulness provides long-term benefits that mothers can receive during pregnancy and the postpartum period.

Editor in charge

Carlos Álvarez Dardet.

Authorship contributions

F.I. Kundarti: research draft, collect data, analysis. Kiswati: collecting literature, selecting literature. I.N.T. Komalyna: data analysis, editing, and conclusions.

Funding

None.

Conflicts of interest

None.

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