An evaluation of perinatal mental health interventions: An integrative literature review

doi:10.1016/j.wombi.2016.04.004

Women and Birth

Volume 29, Issue 5, October 2016, Pages 399-406

https://doi.org/10.1016/j.wombi.2016.04.004 Get rights and content

Abstract

Background

National statistics related specifically to the mental health of women in the perinatal period is poorly acknowledged in Australia. Maternal deaths related to mental health in the perinatal period can be attributed to a lack of appropriate treatment and/or support. A barrier to women's help-seeking behaviors is the lack of discrete, perinatal specific interventions where women can self-assess and access support.

Aim

This review examines original research evaluating perinatal mental health interventions used by women to improve mental health.

Method

An integrative literature review was undertaken. A comprehensive search strategy using 5 electronic databases resulted in the retrieval of 1898 articles. Use of an inclusion and exclusion criteria and Critical Appraisal Skills Program tools resulted in 4 original research papers. Thematic analysis identified universal themes.

Findings

Cognitive Behavioral Therapy, Behavioral Activation and Mindfulness-based interventions, specifically adapted to meet the needs of women in the perinatal period, demonstrate an overall improvement in mental health. Women involved in the interventions experienced both improvements in symptoms of anxiety and depression as well as secondary benefits from participating in the research.

Conclusion

To improve perinatal mental health outcomes, innovative modes of providing effective perinatal mental health interventions that address the unique needs of women in the perinatal period are needed. Future development of perinatal mental health interventions require adaptions of Cognitive Behavioral Therapy, Behavioral Activation and/or Mindfulness-based methods to address mental health outcomes for women in the perinatal period.

Introduction

Mental health in Australia continues to be a concern in today's society, with approximately 45% of the general population facing longstanding mental health issues and around 20% suffering any form of mental illness over a 12-month period.¹ Australian women are at a higher risk of experiencing mental health issues (in comparison to males) with current statistics indicating a rate of 22% of women experiencing some form of mental health issue compared to 18% for males.¹ Women in the perinatal period have a 10% chance of experiencing symptoms of anxiety and/or depression, with 9% suffering from antenatal depression and 16% developing postnatal depression.² Maternal mental health statistics also indicate 15.2% of childbearing women in Australia experience illnesses related to poor mental health and the deaths of 1 in 136 mothers (from 2008 to 2012) were attributed to inadequate management of mental health issues during the perinatal period.³ National statistics related specifically to the mental health of women in the perinatal period is poorly acknowledged, with statistics concentrating on the general female population.¹ Additionally, the criteria used to diagnose mental health disorders, fails to distinguish between ‘depression’ and ‘postnatal depression’, adding to the poor recognition of women in the perinatal period.⁴

Maternal deaths in Australia related to mental health issues in the perinatal period have been attributed to a lack of appropriate treatment and/or supportive assistance.³ The incidence of maternal deaths in Australia connected with psychosocial problems (an average of 12 deaths per year) has been shown to have a similar prevalence as maternal deaths due to an obstetric haemorrhage.³ These statistics emphasise the need for an improvement in the detection, management and early treatment of maternal mental health issues.

Barriers to seeking mental health support have been shown to incorporate both structural and attitudinal obstacles, whereby individuals with mental health issues either decide to stop treatment or resist attempts to seek help.⁵ Economic adversity, geographic remoteness and inaccessibility of services can be perceived as potential structural barriers to seeking mental health treatment.⁵ Attitudes held by individuals may include believing they do not have a mental health problem, having a perception of being judged negatively if they disclose a potential mental health disorder, preferring not to be offered pharmacological solutions, having experienced negative assistance in the past and feeling what they are experiencing is not serious enough to seek help.⁵ Women in the perinatal period may develop emotional distress from a variety of sources including variations in hormone levels, unwanted advice from individuals, social influences on their role as a mother and/or parent, perceived negative opinions of others and minor discomforts related to pregnancy.6, 7

Pharmacological treatment remains the preferred method within the healthcare system for mental health issues, however behavioral and/or alternative therapies that compliment pharmacological methods are emerging.⁸ In today's age of technology, online mental health information and support websites are also a valuable and appealing way for individuals to carry out their own research about mental health issues, explore care options available and access information autonomously without the fear of disclosure.9, 10 However, the quality of open access sites is problematic. A study by Moore and Ayers¹⁰ examining mental health websites reported there is a lack of research regarding how websites are evaluated for quality and efficacy.

In pregnancy, women are increasingly exploring the use of alternative therapies that focus on the connections between the mind and body to assist with physical and emotional wellbeing.¹¹ Anxiety reducing therapies in pregnancy (such as meditation, yoga, hypnotherapy, tai chi, and other methods of relaxation) have been shown to improve emotional wellbeing. However more research is needed to find a direct correlation between the use of alternative therapies and the prevention of anxiety and/or depression within the perinatal period.11, 12

Group education interventions for expecting couples is another method of providing information about the stresses associated with the changing demands related to transitioning to parenthood. These interventions offer both a supportive group environment and individual methods of dealing with physical and emotional issues during this stage of their lives. Parenting interventions provided in a group environment have shown to provide short-term positive emotional health effects. Further research and development of these interventions are needed to maintain the positive effects of emotional wellbeing for a sustained period.¹³

This integrative literature review examines current evidence related to the evaluation of perinatal mental health interventions used by women in the perinatal period to improve their mental health. This review defines the ‘perinatal period’ as the period from conception through to 12 months post-birth.

Section snippets

Methodology

This review utilises an integrative literature review methodology framework as described by Whittemore and Knafl.¹⁴ Integrative literature reviews encapsulate original experimental and non-experimental research on a specific subject to provide an all-encompassing understanding of the topic question. The broader understanding of the phenomenon available through an integrative review also allows for multiple realities to be presented.¹⁴ Whittemore and Knafl outline a five-stage strategy for an

Discussion

This integrative literature review identified four interventions used by women that employed Mindfulness, MBCT, CBT or BA therapies to improve symptoms of mental health issues such as anxiety, depression and/or awareness of mindfulness.7, 18, 24, 26 The various modalities employed focused on supporting women to alter thought patterns, explore behavior modification, develop an awareness of the mind-body connection and to acquire enhanced coping mechanisms in an aim to improve emotional health

Conclusion

Perinatal mental health continues to be an issue for the women, their families and our society. This integrative literature review explored the literature surrounding the evaluation of perinatal mental health interventions. Due to the limited research on this topic, further research is required to evaluate the types of interventions that are appropriate for women in the perinatal period. Furthermore, future interventions should be rigorously evaluated in order to validate the effectiveness and

Conflicts of interest

The authors declare that there are no potential conflicts of interest or financial support in relation to the research, composition and/or publication of this literature review.

References (27)

H. O’Mahen et al.
Modifying CBT for perinatal depression: what do women want? A qualitative study
Cogn Behav Pract
(2012)
Australian Bureau of Statistics
National survey of mental health and wellbeing: summary of results
(2007)
BeyondBlue
Pregnancy and early parenthood: mental health conditions
(2015)
Australian Institute of Health and Welfare
Maternal deaths in Australia 2008–2012
(2015)
American Psychiatric Association
Diagnostic and statistical manual of mental disorders
(2013)
L.H. Andrade et al.
Barriers to mental health treatment: results from the WHO World Mental Health surveys
Psychol Med
(2014)
J.H. Goodman et al.
Perinatal dyadic psychotherapy: design, implementation, and acceptability
J Fam Nurs
(2013)
H. O’Mahen et al.
A pilot randomized controlled trial of cognitive behavioral therapy for perinatal depression adapted for women with low incomes
Depress Anxiety
(2013)
K. Shinohara et al.
Behavioural therapies versus other psychological therapies for depression
Cochrane Database Syst Rev
(2013)
A. Bennett et al.
e-hub: an online self-help mental health service in the community
Med J Aust
(2010)

D. Moore et al.

A review of postnatal mental health websites: help for healthcare professionals and patients

Arch Womens Ment Health

(2011)

I. Marc et al.

Mind-body interventions during pregnancy for preventing or treating women's anxiety

Cochrane Database Syst Rev

(2011)

M. Sado et al.

Hypnosis during pregnancy, childbirth, and the postnatal period for preventing postnatal depression

Cochrane Database Syst Rev

(2012)

Cited by (36)

Effect of eHealth interventions on perinatal depression: A meta-analysis
2024, Journal of Affective Disorders
Perinatal depression (PND) is a common mental health problem, and eHealth interventions may provide a strategy for alleviating PND.
This meta-analysis aimed to determine the effect of eHealth interventions on PND.
Six databases were searched to retrieve published randomized controlled trials (RCTs) on the effect of eHealth interventions on PND. A meta-analysis was performed on the data of these studies using a random effects model.
A total of 21 RCTs were included in the meta-analysis, which revealed that eHealth interventions significantly reduced antenatal depression (WMD = −1.64, 95 % CI [−2.92, −0.35], P = .013), postpartum depression (SMD = −0.41, 95 % CI [−0.52, −0.29], P < .001), anxiety (SMD = −0.39, 95 % CI [−0.51, −0.28], P < .001), stress (WMD = −2.93, 95 % CI [−4.58, −1.27], P = .001), and improved self-efficacy (SMD = 0.42, 95 % CI [0.21, 0.63], P < .001) compared with the control group. However, eHealth interventions did not significantly improve social support (SMD = 0.27, 95 % CI [−0.01, 0.56], P = .058). For antenatal depression, significant subgroup differences were observed in the digital platform and material presentation format. In addition, for postpartum depression, significant subgroup differences were found in the type of therapy.
The meta-analysis results suggest that eHealth interventions can relieve depression, anxiety, and stress symptoms and improve self-efficacy in perinatal women. However, these interventions did not improve social support. Additional high-quality studies on eHealth interventions in PND are needed to validate these results.
Psychological impact of hypnosis for pregnancy and childbirth: A systematic review
2023, Complementary Therapies in Clinical Practice
Citation Excerpt :
During this highly sensitive period for women's mental health [3], preventive interventions seem particularly welcome. However, the literature highlights the lack of strongly designed research exploring the impact of perinatal interventions on women's mental health [4]. This article focuses on exploring the impact of perinatal, hypnosis-based interventions on women's mental health in order to provide a comprehensive overview useful for future experimental studies.
The use of hypnosis as a complementary therapy in the perinatal field is expanding, however, there is little research for its impact on perinatal mental health. Here, we review studies that evaluate the effect of hypnosis on women's mental health and subjective experiences.
A systematic review was conducted according to the PRISMA protocol for articles with experimental designs of hypnosis that measured their impact on several psychological variables, such as the presence of symptoms of anxiety, depression or fear of childbirth. Studies were evaluated according to the Critical Appraisal Skills Program Checklists (CASP), and analyzed for their designs and intervention themes.
Seven studies were included and six themes emerged: preparation for birth and unexpected events; change in the perception and experience of pain; pregnant body as a natural process; connection with the baby during pregnancy; development of inner resources; and progressive relaxation and guided imagery. Although results were partly mitigated, most studies found positive effects of hypnosis in alleviating anxiety, depression, and fear towards birth, empowering women with a higher sense of confidence and improving the overall emotional experience. Two studies also indicate encouraging outcomes in postnatal wellbeing.
While it is still argued as to what extent hypnosis has positive effects on physical aspects of labor, the empowerment and the increase in confidence associated with hypnosis seem to bring a significant contribution to a more positive subjective experience of pregnancy and childbirth, and on women's overall wellbeing in the perinatal period.
Midwives’ experiences of supporting women's mental health: A mixed-method study
2022, Midwifery
To explore midwives’ skills, knowledge and experiences of supporting women's mental health.
This paper reports the second phase of a larger project, the ‘Mothers’ Mood Study’, which recruited women and midwives to explore their experiences of perinatal mental health and service provision and focuses on midwives’ experiences of supporting women with perinatal mental health problems. This paper reports on midwives’ experiences through self-administered questionnaires and focus groups. Descriptive statistics were used to analyse questionnaire data and focus group data were thematically analysed.
All midwives employed at one Health Board in South Wales UK, were eligible to participate. Recruitment took place between February and October 2018. Questionnaires were completed by 145 midwives and 15 attended one of three focus groups.
Questionnaire data showed the majority of midwives had cared for women with mental health problems, most commonly anxiety (95.0%, n = 138) and depression (87.0%, n = 127). Midwives assessed women's mental health informally by observing or asking questions about mood (99.3%, n = 144), anxiety levels (94.5%, n = 137), levels of support (91.0%, n = 132) and mental health history (95.9%, n = 139). The majority of midwives (82.8%, n = 120) indicated they would make some sort of mental health assessment at least 50% of the time. Around a third of midwives 31.7% (n = 46) reported receiving training relating to perinatal mental health in the previous two years, however only 21.4% (n = 31) of these suggested this had helped them in their practice. Three themes were generated from the focus groups, 1) Conversations 2) Support 3) Knowledge and skills.
A lack of time and continuity at appointments and a focus on physical health of mother and baby reduced the opportunity for conversations around mental health. In addition a lack of experience reduced midwives’ confidence resulting in a low threshold for referring women to other services for support. Midwives’ main concerns were a need for training on aspects of day-to-day practice and referral options to support women's mental health. A package of training to improved skills and confidence as well as a clear pathway of care will enable midwives to be better placed to support women's mental health.
Implementation Methods of Virtual Reality Simulation and the Impact on Confidence and Stress When Learning Patient Resuscitation: An Integrative Review
2022, Clinical Simulation in Nursing
Citation Excerpt :
A methodological quality score of ≥7 was determined to be the cut off point for achieving the required degree of methodological rigor. This score was chosen as this value has been observed as a common cut-off point during evaluation within other published reviews using 11-point tools/scales (Buckley et al., 2009; Lavender, Ebert, & Jones, 2016). This resulted in five articles included in this review.
In the context of performing resuscitation, research has demonstrated that provider confidence and stress levels are related to patient survival outcomes. Virtual reality (VR) offers innovative simulation training opportunities to improve confidence and reduce stress.
Whittemore and Knafl's (2005) integrative review method was used. An electronic database literature search and evaluation of studies using the BEME critical appraisal tool yielded five papers for this review.
Four studies examined confidence and one stress. Identified themes included: Variation in virtual reality intervention; Timing of measurement outcome; and variation in VR interactivity.
Confidence was noted to generally increase through the use of VR across the studies reviewed, with no significant impact on stress outcomes. Differences in study heterogeneity reflects that further research is required to determine if the use of VR technologies impacts on confidence and stress in resuscitation training.
Epidural use among women with spontaneous onset of labour – an observational study using data from a cluster-randomised controlled trial
2021, Midwifery
Citation Excerpt :
Women's self-efficacy expectancy to cope with labour pain and a low level of anxiety is associated with reduced perception of pain and a decreased need of anaesthesia during labour (Lang et al., 2006; Manning and Wright, 1983; Reading and Cox, 1985). Mindfulness-based interventions reduce anxiety, depression and stress in the perinatal period (Lavender et al., 2016; Lever Taylor et al., 2016; Matvienko-Sikar et al., 2016). Mindfetalness can be perceived as a type of mindfulness method, which includes the unborn baby in the process.
To investigate whether the proportion of pregnant women who use epidural analgesia during birth differed between women registered at a maternity clinic randomised to Mindfetalness or to routine care.
An observational study including women born in Sweden with singleton pregnancies, with spontaneous onset of labour from 32 weeks’ gestation. Data used from a cluster-randomised controlled trial applying the intention-to-treat principle in 67 maternity clinics where women were randomised to Mindfetalness or to routine care. ClinicalTrials.gov (NCT02865759).
Midwives were instructed to distribute a leaflet about Mindfetalness to pregnant women at 25 weeks’ gestation. Mindfetalness is a self-assessment method for the woman to use to become familiar with the unborn baby's fetal movement pattern. When practising the method in third trimester, the women are instructed to daily lie down on their side, when the baby is awake, and focus on the movements’ intensity, character and frequency (but not to count each movement).
Of the 18 501 women with spontaneous onset of labour, 47 percent used epidural during birth. Epidural was used to a lower extent among women registered at a maternity clinic randomised to Mindfetalness than women in the routine-care group (46.2% versus 47.8%, RR 0.97, CI 0.94–1.00, p= 0.04). Epidural was more common among primiparous women, women younger than 35 years, those with educational levels below university, with BMI ≥25 and with a history of receiving psychiatric care or psychological treatment for mental illness.
Pregnant women who were informed about a self-assessment method, with the aim of becoming familiar with the unborn baby's fetal movement pattern, used epidural to a lower extent than women who were not informed about the method. Future studies are needed to investigate and understand the association between Mindfetalness and the reduced usage of epidural during birth.
Effects of interventions for women and their partners to reduce or prevent stress and anxiety: A systematic review
2021, Women and Birth
Citation Excerpt :
Interventions for prenatal and postpartum stress and/or anxiety to date include, but are not limited to, cognitive behavioural therapy (CBT), mindfulness, music, and exercise [31]. While intervention effects are inconsistent [31], approaches including psychosocial [32], psychotherapeutic [19], CBT [33], and mind-body interventions [19,33,34] demonstrate greater positive effects for women at risk for mental health issues and/or experiencing elevated prenatal stress or anxiety, than for women who are not at risk. For men, a lack of support and tailored stress and anxiety treatment options during adjustment to the transition to fatherhood have been identified [35].
The period from conception to two years postpartum (the first 1000 days) represents a normative transitional period, which can be potentially stressful for some parents. Parental stress and anxiety adversely impacts psychological and physical health for parents and children.
The aim of this review is to systematically examine effects of interventions for women and their partners to reduce or prevent stress and/or anxiety during the first 1000 days.
MEDLINE, Embase, CINAHL, PsychINFO, and Maternity and Infant Care were searched from inception to March 2019. Randomised controlled trials examining intervention effects on parental stress and/or anxiety during first 1000 days were eligible for inclusion. Data were independently extracted by two reviewers and narratively synthesised.
Fifteen interventions, reported in 16 studies, met inclusion criteria (n = 1911 participants). Overall, findings were inconsistent and the majority of trials demonstrated high risk of bias. Interventions were predominantly delivered to women during pregnancy and only two studies included fathers. There was some evidence that adapting interventions to the pre and postnatal periods provided benefits for stress and anxiety reduction, however there was limited evidence for individual intervention types or approaches.
There is currently inconsistent evidence of what interventions are most effective for women during the first 1000 days and there is insufficient evidence for any interventions for male partners during this period. There is a clear need for rigorous development and examination of interventions developed specifically to reduce or prevent stress and/or anxiety across the first 1000 days.

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REVIEW ARTICLEAn evaluation of perinatal mental health interventions: An integrative literature review

Abstract

Background

Aim

Method

Findings

Conclusion

Introduction

Section snippets

Methodology

Discussion

Conclusion

Conflicts of interest

Cogn Behav Pract

National survey of mental health and wellbeing: summary of results

Pregnancy and early parenthood: mental health conditions

Maternal deaths in Australia 2008–2012

Diagnostic and statistical manual of mental disorders

Barriers to mental health treatment: results from the WHO World Mental Health surveys

Psychol Med

Perinatal dyadic psychotherapy: design, implementation, and acceptability

J Fam Nurs

A pilot randomized controlled trial of cognitive behavioral therapy for perinatal depression adapted for women with low incomes

Depress Anxiety

Behavioural therapies versus other psychological therapies for depression

Cochrane Database Syst Rev

e-hub: an online self-help mental health service in the community

Med J Aust

A review of postnatal mental health websites: help for healthcare professionals and patients

Arch Womens Ment Health

Mind-body interventions during pregnancy for preventing or treating women's anxiety

Cochrane Database Syst Rev

Hypnosis during pregnancy, childbirth, and the postnatal period for preventing postnatal depression

Cochrane Database Syst Rev

REVIEW ARTICLE
An evaluation of perinatal mental health interventions: An integrative literature review