Feasibility of incorporating mindfulness based mental health promotion to the pregnancy care program in Sri Lanka: a pilot study

Introduction

Pregnancy and childbirth represent a time of increased vulnerability, during which a woman is exposed to many physiological and psychosocial changes. This puts pregnant and postpartum women at increased risk of mental health problems. The prevalence of mental health disorders in pregnancy and postpartum period is much greater in low-income countries (LIC) and lower-middle-income countries (LMIC) (Fisher et al., 2012) than in high income countries (HIC) (Hendrick et al., 1998). Of the mental health problems experienced by pregnant and postpartum women, antenatal depression, anxiety, and post-partum depression are the most common (O’Hara & Swain, 1996). These mental health issues may lead to adverse pregnancy and neonatal outcomes such as small for gestational age baby (Dejin-Karlsson et al., 2000), developmental delays (Bernard-Bonnin, 2004), poor mother-infant interaction (Cohn & Tronick, 1989), negative affect in the infant (Tronick & Reck, 2009), problems with cognitive development (Singer & Fagen, 1992) and affective disorders /attention-deficit/hyperactivity disorder (ADHD) in children (Lesesne et al., 2003). This makes the antenatal period a critical time point for intervention on maternal mental health.

Despite having a strong, community-based public health care system, addressing maternal mental health has yet to gain the spotlight in Sri Lanka. The prevalence estimate for antenatal depression in Anuradhapura District, Sri Lanka is 16% (Agampodi & Agampodi, 2013) and the national estimate for postpartum depression is as high as 27% (Agampodi et al., 2011). Furthermore, a secondary analysis of maternal death investigation reports from 2005–2011 in the North Central Province revealed that suicide was the leading cause of maternal mortality in the province, with 17.8% of maternal deaths attributed to suicide (Agampodi et al., 2014). These findings show the urgency of addressing the mental health of pregnant women in Sri Lanka.

Mindfulness is an emerging concept in mental health promotion. It was the original healing method used for centuries in ancient cultures in Asia. Clinical use of mindfulness was widely discussed in late 20^th century (Baer, 2003; Deatherage, 1975). Several recent studies have shown that mindfulness-based interventions for pregnant women have been effective in increasing positive affect, decreasing negative affect (Duncan & Bardacke, 2010; Vieten & Astin, 2008a), decreasing anxiety (Duncan & Bardacke, 2010; Dunn et al., 2012; Vieten & Astin, 2008a), decreasing depression (Duncan & Bardacke, 2010; Dunn et al., 2012), and decreasing stress (Dunn et al., 2012) during pregnancy. These benefits were seen to extend into the postpartum period in some cases (Dunn et al., 2012; Tomfohr-Madsen et al., 2016; Vieten & Astin, 2008a). Nevertheless, two recent systematic reviews (Dhillon et al., 2017; Roy Malis et al., 2017) shows mixed results on mindfulness based interventions in pregnancy. One of these reviews found that “anxiety, depression and perceived stress indicated no differences between the mindfulness intervention group and the control group” in pooled results of RCTs. However, pooled results of non-RCTs showed a “significant benefit for the mindfulness group”. Other review also showed similar results with probable effect on maternal anxiety. Both reviews suggested that more work is needed on this area of research to produce evidence-based guidelines. However, studies on integrating the mindfulness-based activities to routine program to improve maternal and newborn health outcomes are scared. We report here a feasibility study on developing and incorporating a mental health promotion program based on mindfulness for pregnant women of Sri Lanka.

Methods

Results

In total, 12 women were recruited and participated in the training. None of them had known psychiatric problems. The women ranged in age from 18 to 30 years, and were between 10 and 27 weeks gestational age. After completion of the program, participants described many benefits they received through the training. A total of eight participants completed the diaries and the feedback.

Perceived psychological benefits

Perceived physical benefits

In addition to the mental and emotional benefits, all the women reported physical benefits, including feeling a sense of comfort and relaxation for the body when practicing the mindful movement at home. One of the women reported successfully using several of the meditation and body scan techniques help her cope with an experience of abdominal pain, stating,

Every participant reported that they intended to continue the daily practice of various techniques to cultivate mindfulness, learned during the training.

Evaluation of content

Participants evaluated the different components or strategies used to cultivate mindfulness during this training. The mindful movement series was the most popular strategy among women. Of the mindfulness concepts taught, the women found the topics of “introduction to mindfulness,” “staying in the present moment,” “acceptance,” and “avoiding controlling and judging” to be the most interesting and helpful in their daily lives. Of the sitting/lying down meditations, women enjoyed and perceived the most usefulness from the body scan, loving kindness meditation, and mindful breathing practice. Everyone reported that they found the “Mindful Mother Check-in” cards (cards given to them at the beginning of the training with simple steps to bring the mind to the present moment applying the practices they had learned), which they posted around their home, to be helpful to calm their mind, particularly during stressful situations. Of the mindful movements taught, the majority of the women (6 of 8) enjoyed the short mindful movement series the most.

In addition to participant feedback, the facilitators of the training also recorded their thoughts on the program content, structure, and the logistics of conducting it. We experienced that the depth of the material being allocated for each session was advance, so that it cannot be grasped with just a simple explanation for a participant who missed a session. For this same reason, we found it a challenge to complete all the material in the allotted 2-hour time, often running over. Additionally, the women seldom asked questions about the material (which may be a cultural factor) or for clarification during the sessions.

Feasibility and timing

Each participant felt time allocated for each of the training segments was appropriate, except for one who felt it would be better if more time was given for the mindful movement section. Although we took into consideration the demands on the average pregnant woman in our area when deciding a meeting time, we still found that it was very difficult to get the women to come consistently to every session. This is likely due to several cultural factors. In Sri Lanka, many women in more rural areas are stay-at-home wives/mothers, taking care of the household and the children. So unless there is someone at home, usually a relative, who can watch the children or pick them up from school while the mother is out, she may not be able to come, may come late or need to leave early, which we experienced on multiple occasions. All of the women also had to take public transportation to get to the trainings, which added to the challenge.

Feasibility of incorporation into ANC system

Women were asked their thoughts on the potential benefit of incorporating a mindfulness training into routine ANC in Sri Lanka. All the participants felt that this training would be very useful and important for other pregnant women. While agreeing with this, one woman raised the concern of whether one two-hour session every three months would provide sufficient time and guidance for women to fully understand the meaning and feel the value of the concepts taught. It was also suggested that it would be beneficial to have the husbands of the pregnant women involved in the program as well. Overall, all the participants, including the PHM, felt that it would be beneficial and feasible to incorporate a mindfulness program into the national ANC system if the current curriculum was shortened and included in the once per trimester antenatal sessions that are already part of the ANC system in Sri Lanka.

Based on Phase I and Phase II of this feasibility assessment, we prepared the final version of intervention. The final structure of the mindfulness based intervention to improve mental health of pregnant mothers is illustrated in Table 1.

Discussion

This preliminary study shows that a incorporating a mindfulness based mental health program for pregnant mothers to the pregnancy care program in Sri Lanka is feasible and culturally acceptable. It also suggests that learning mindfulness concepts and the techniques to cultivate mindfulness may improve a woman’s ability to cope with stress during her pregnancy. Important future steps should include efforts to capture the latter outcome quantitatively, as has been done in prior pilot studies (Duncan & Bardacke, 2010; Dunn et al., 2012; Vieten & Astin, 2008a).

The program developed in this pilot study was based on the standard 8-week mindfulness intervention used in many other previous studies (Astin et al., 2003)(Byrne et al., 2014)(Dunn et al., 2012)(Vieten & Astin, 2008b). However, a brief mindfulness interventions even for a 3-week duration has proven the potential usefulness of mindfulness interventions (Beattie et al., 2017; Matvienko-Sikar & Dockray, 2017). Although there are number of studies on mindfulness interventions, there is not enough evidence found about the most effective duration for a mindfulness program. Thus, further studies has to be conducted in the future to assess the effective time duration for mindfulness interventions. Taking into account the challenges the facilitators experienced during the intervention, trying to cover all the material in a comprehensible manner within the allotted 16-hour time period of the training may not be feasible. Careful consideration will be needed to select some of these concepts that could practically be covered during the three ANC sessions, and would likely be of greatest benefit and/or interest to the pregnant women. One has to bear in mind that the system integration requires assessment of operational and other aspects; not only the field health worker feedback. However, the feedback from our pilot study participants will be valuable when making these decisions. Though we have not assessed mental health outcomes after the intervention, which was beyond the scope of this study, the reported perceived psychological benefits were positive and noteworthy.

Given the positive response from our small feasibility pilot, the next steps will include using the participants’ feedback to create a modified, shortened mindfulness training curriculum for pregnant women, and running a larger field study using this revised curriculum. Maternal mental health outcomes should also be evaluated using pre- and post-intervention questionnaires that have been validated for use in Sri Lankan populations. This will be an important step in establishing any effect that the mindfulness training may have on maternal mental health-related outcomes, including distress, depression, and coping skills. The possibility of any benefits of the training extending into the postpartum period, as suggested by pilot studies (Roy Malis et al., 2017; Vieten & Astin, 2008a) should also be evaluated. The degree of success of launching such a program nationally, or even locally, will depend heavily on the willingness and enthusiasm of the PHMs, as eventually, if the program is to be sustainable, it will be trained PHMs who will be leading each of the mindfulness sessions. To date, the support from the local PHM community and Medical Officer of Health (MOH) has been strong for this program. When presented an overview of the program and the evidence behind the teachings, many of the PHMs were visibly enthusiastic about the benefits such a program could have for their patients and were eager to offer their support.

The main limitation of our study was the small sample size. Proper feasibility assessment is difficult with a sample of 12 pregnant women. There are many variables to assess in relation to feasibility. In addition, the inconsistent attendance of some of the participants, and having a sample of only Sinhalese-speaking women also limits the generalizability of the pilot work. To serve both the Sinhalese and Tamil populations in Sri Lanka, the curriculum will also need to be translated and tested in a Tamil-speaking population.

Conclusion

This pilot study suggests that a mindfulness-training program is a culturally appropriate It also shows that it is feasible to do a proper trial before deciding on up scaling and system incorporation. Further research must investigate the effectiveness of a shortened, modified program on impacting maternal mental health-related outcomes during pregnancy and beyond.

Data availability