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 demindfulnessen 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

Introduction

Pregnancy is not only a physical reality, but related to individual thoughts and attitudes.¹1. Gheibi Z, Abbaspour Z, Haghighyzadeh MH, et al. Effects of a mindfulness-based childbirth and parenting program on maternal-fetal attachment: a randomized controlled trial among Iranian pregnant women. Complement Ther Clin Pract. 2020;41:101226. Increasing anxiety to the point of fear is a common problem related to childbirth.²2. Aksoy M, Aksoy AN, Dostbil A, et al. The relationship between fear of childbirth and women's knowledge about painless childbirth. Obstet Gynecol Int. 2014;2014:1-7. Labor is a normal physiological event, where negative feelings such as aches and pains, fear, and anxiety are experienced by the mother during labor.³3. Pinar SE, Demirel G. The effect of therapeutic touch on labour pain, anxiety and childbirth attitude: a randomized controlled trial. Eur J Integr Med. 2021:41.

Anxiety is associated with negative birth outcomes, which implies that pregnant women with anxiety have poor expectations of labor pain.⁴4. Hulsbosch LP, Nyklícek I, Potharst ES, et al. Online mindfulness-based intervention for women with pregnancy distress: design of a randomized controlled trial. BMC Pregnancy Childbirth. 2020;20:159. 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.⁵5. Goodman JH, Guarino A, Chenausky K, et al. CALM Pregnancy: results of a pilot study of mindfulness-based cognitive therapy for perinatal anxiety. Arch Womens Ment Health. 2014;17:373-87. Approximately 14.5% of women experience anxiety, 9.4% experience moderate anxiety and 8.7% experience severe anxiety during childbirth.⁶6. Amidu N, Alhassan M, Issah H, et al. Perceived stress and anxiety in women during labour: a case of Tamale West Hospital, Tamale. Ghana. Asian J Med Health. 2018;11:1-10. 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.⁷7. Boryri T, Noori NM, Teimouri A, et al. The perception of primiparous mothers of comfortable resources in labor pain (a qualitative study). Iran J Nurs Midwifery Res. 2016;21:239. 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.⁸8. Shirazi MA. Investigating The Effectiveness Of Mindfulness Training In The First Trimester Of Pregnancy On Improvement Of Pregnancy Outcomes And Stress Reduction In Pregnant Women Referred To Mohebyasgeneral Women Hospital. Journal of Fundamental and Applied Sciences. 2016;8:487-500. 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.⁹9. Matthews J, Huberty JL, Leiferman JA, et al. Perceptions, uses of, and interests in complementary health care approaches in depressed pregnant women: the PAW Survey. J Evid Based Complementary Altern Med. 2017;22:81-95.

A high anxiety score is associated with increased labor pain, can increase the risk of negative birth¹⁰10. Curzik D, Jokic-Begic N. Anxiety sensitivity and anxiety as correlates of expected, experienced and recalled labor pain. J Psychosom Obstet Gynaecol. 2011;32:198-203. and increases the mother's willingness to ask for pain medication during labor.¹¹11. Hulsbosch LP, Nyklícek I, Potharst ES, et al. Development of the Labor Pain Relief Attitude Questionnaire for pregnant women (LPRAQ-p). BMC Pregnancy Childbirth. 2020;20:1-12. 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.¹¹11. Hulsbosch LP, Nyklícek I, Potharst ES, et al. Development of the Labor Pain Relief Attitude Questionnaire for pregnant women (LPRAQ-p). BMC Pregnancy Childbirth. 2020;20:1-12.

12. Booth JL, Sharpe EE, Houle TT, et al. Patterns of recovery from pain after cesarean delivery. Pain. 2018;159:2088-96.^-1313. Rondung E, Ekdahl J, Sundin O. Potential mechanisms in fear of birth: the role of pain catastrophizing and intolerance of uncertainty. Birth. 2019;46:61-8.

Ways to reduce maternal anxiety, as well as help to have a positive birth experience should be a public health goal.¹⁴14. Warriner S, Crane C, Dymond M, et al. An evaluation of mindfulness-based childbirth and parenting courses for pregnant women and prospective fathers/partners within the UK NHS (MBCP-4-NHS). Midwifery. 2018;64:1-10. 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.¹⁵15. Kuyken W, Hayes R, Barrett B, et al. Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial. Lancet. 2015;386:63-73. 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.¹⁶16. Dennis CL, Falah-Hassani K, Shiri R. Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis. Br J Psychiatry. 2017;210:315-23. 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.¹⁷17. Goetz M, Schiele C, Müller M, et al. Effects of a brief electronic mindfulness-based intervention on relieving prenatal depression and anxiety in hospitalized high-risk pregnant women: exploratory pilot study. J Med Internet Res. 2020;22:e17593. 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.¹⁸18. Hassed C, Chambers R. Mindful learning: reduce stress and improve brain performance for effective learning. Google Books. Exisle Publishing; 2014. Available from: https://books.google.co.id/books?hl=en&lr=&id=diWNAgAAQBAJ&oi=fnd&pg=PA1&ots=qw5_B-43hn&sig=z3dHYSKVelSMEaceaXR7xzD0GzE&redir_esc=y#v=onepage&q&f=false.
https://books.google.co.id/books?hl=en&l... ^,1919. Grossman P, Niemann L, Schmidt S, et al. Mindfulness-based stress reduction and health benefits: a meta-analysis. J Psychosom Res. 2004;57:35-43. 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.²⁰20. Khoury B, Sharma M, Rush SE, et al. Mindfulness-based stress reduction for healthy individuals: a meta-analysis. J Psychosom Res. 2015;78:519-28.

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.

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.¹⁷17. Goetz M, Schiele C, Müller M, et al. Effects of a brief electronic mindfulness-based intervention on relieving prenatal depression and anxiety in hospitalized high-risk pregnant women: exploratory pilot study. J Med Internet Res. 2020;22:e17593.^,2121. Mackinnon AL, Madsen JW, Giesbrecht GF, et al. Effects of mindfulness-based cognitive therapy in pregnancy on psychological distress and gestational age: outcomes of a randomized controlled trial. Mindfulness. 2021;12:1173-84.

22. Mohamed S, Elashry R. Effect of swaddle bathing versus traditional bathing on physiological stability and comfort level among neonates. Assiut Sci Nurs J. 2022;10:68-79.

23. Veringa-Skiba IK, de Bruin EI, van Steensel FJA, et al. Fear of childbirth, nonurgent obstetric interventions, and newborn outcomes: a randomized controlled trial comparing mindfulness-based childbirth and parenting with enhanced care as usual. Birth. 2022;49:40-51.

24. Yang M, Jia G, Sun S, et al. Effects of an online mindfulness intervention focusing on attention monitoring and acceptance in pregnant women: a randomized controlled trial. J Midwifery Womens Health. 2019;64:68-77.

25. Veringa IK, de Bruin EI, Bardacke N, et al. "I've Changed My Mind", Mindfulness-Based Childbirth and Parenting (MBCP) for pregnant women with a high level of fear of childbirth and their partners: study protocol of the quasi-experimental controlled trial. BMC Psychiatry. 2016;16:377.

26. Zarenejad M, Yazdkhasti M, Rahimzadeh M, et al. The effect of mindfulness-based stress reduction on maternal anxiety and self-efficacy: a randomized controlled trial. Brain Behav. 2020;10:e01561.^-2727. Sbrilli MD, Duncan LG, Laurent HK. Effects of prenatal mindfulness-based childbirth education on child-bearers' trajectories of distress: a randomized control trial. BMC Pregnancy Childbirth. 2020;20:623. Meanwhile, 3 articles stated that mindfulness intervention could reduce stress and depression.²⁸28. Pan WL, Chang CW, Chen SM, et al. Assessing the effectiveness of mindfulness-based programs on mental health during pregnancy and early motherhood - a randomized control trial. BMC Pregnancy Childbirth. 2019;19:346.

29. Sacristán-Martín O, Santed MA, García-Campayo J, et al. A mindfulness and compassion-based program applied to pregnant women and their partners to decrease depression symptoms during pregnancy and postpartum: study protocol for a randomized controlled trial. Trials. 2019;20:654.^-3030. Lönnberg G, Jonas W, Unternaehrer E, et al. Effects of a mindfulness based childbirth and parenting program on pregnant women's perceived stress and risk of perinatal depression -results from a randomized controlled trial. J Affect Disord. 2020;262:133-42. The mindfulness intervention programs carried out vary from MBCP,²³23. Veringa-Skiba IK, de Bruin EI, van Steensel FJA, et al. Fear of childbirth, nonurgent obstetric interventions, and newborn outcomes: a randomized controlled trial comparing mindfulness-based childbirth and parenting with enhanced care as usual. Birth. 2022;49:40-51.^,2525. Veringa IK, de Bruin EI, Bardacke N, et al. "I've Changed My Mind", Mindfulness-Based Childbirth and Parenting (MBCP) for pregnant women with a high level of fear of childbirth and their partners: study protocol of the quasi-experimental controlled trial. BMC Psychiatry. 2016;16:377.^,2828. Pan WL, Chang CW, Chen SM, et al. Assessing the effectiveness of mindfulness-based programs on mental health during pregnancy and early motherhood - a randomized control trial. BMC Pregnancy Childbirth. 2019;19:346.

29. Sacristán-Martín O, Santed MA, García-Campayo J, et al. A mindfulness and compassion-based program applied to pregnant women and their partners to decrease depression symptoms during pregnancy and postpartum: study protocol for a randomized controlled trial. Trials. 2019;20:654.^-3030. Lönnberg G, Jonas W, Unternaehrer E, et al. Effects of a mindfulness based childbirth and parenting program on pregnant women's perceived stress and risk of perinatal depression -results from a randomized controlled trial. J Affect Disord. 2020;262:133-42. online mindfulness,¹⁷17. Goetz M, Schiele C, Müller M, et al. Effects of a brief electronic mindfulness-based intervention on relieving prenatal depression and anxiety in hospitalized high-risk pregnant women: exploratory pilot study. J Med Internet Res. 2020;22:e17593.^,2222. Mohamed S, Elashry R. Effect of swaddle bathing versus traditional bathing on physiological stability and comfort level among neonates. Assiut Sci Nurs J. 2022;10:68-79.^,2424. Yang M, Jia G, Sun S, et al. Effects of an online mindfulness intervention focusing on attention monitoring and acceptance in pregnant women: a randomized controlled trial. J Midwifery Womens Health. 2019;64:68-77. MBSR,²⁶26. Zarenejad M, Yazdkhasti M, Rahimzadeh M, et al. The effect of mindfulness-based stress reduction on maternal anxiety and self-efficacy: a randomized controlled trial. Brain Behav. 2020;10:e01561. mindfulness-based cognitive therapy (MBCT),²¹21. Mackinnon AL, Madsen JW, Giesbrecht GF, et al. Effects of mindfulness-based cognitive therapy in pregnancy on psychological distress and gestational age: outcomes of a randomized controlled trial. Mindfulness. 2021;12:1173-84.^,3131. Zemestani M, Fazeli Nikoo Z. Effectiveness of mindfulness-based cognitive therapy for comorbid depression and anxiety in pregnancy: a randomized controlled trial. Arch Womens Ment Health. 2020;23:207-14. mind in labor.²⁷27. Sbrilli MD, Duncan LG, Laurent HK. Effects of prenatal mindfulness-based childbirth education on child-bearers' trajectories of distress: a randomized control trial. BMC Pregnancy Childbirth. 2020;20:623. The implementation of mindfulness interventions varies, namely carried out for 6-9 weeks.²¹21. Mackinnon AL, Madsen JW, Giesbrecht GF, et al. Effects of mindfulness-based cognitive therapy in pregnancy on psychological distress and gestational age: outcomes of a randomized controlled trial. Mindfulness. 2021;12:1173-84.^,2323. Veringa-Skiba IK, de Bruin EI, van Steensel FJA, et al. Fear of childbirth, nonurgent obstetric interventions, and newborn outcomes: a randomized controlled trial comparing mindfulness-based childbirth and parenting with enhanced care as usual. Birth. 2022;49:40-51.^,2525. Veringa IK, de Bruin EI, Bardacke N, et al. "I've Changed My Mind", Mindfulness-Based Childbirth and Parenting (MBCP) for pregnant women with a high level of fear of childbirth and their partners: study protocol of the quasi-experimental controlled trial. BMC Psychiatry. 2016;16:377.^,2727. Sbrilli MD, Duncan LG, Laurent HK. Effects of prenatal mindfulness-based childbirth education on child-bearers' trajectories of distress: a randomized control trial. BMC Pregnancy Childbirth. 2020;20:623.

28. Pan WL, Chang CW, Chen SM, et al. Assessing the effectiveness of mindfulness-based programs on mental health during pregnancy and early motherhood - a randomized control trial. BMC Pregnancy Childbirth. 2019;19:346.

29. Sacristán-Martín O, Santed MA, García-Campayo J, et al. A mindfulness and compassion-based program applied to pregnant women and their partners to decrease depression symptoms during pregnancy and postpartum: study protocol for a randomized controlled trial. Trials. 2019;20:654.

30. Lönnberg G, Jonas W, Unternaehrer E, et al. Effects of a mindfulness based childbirth and parenting program on pregnant women's perceived stress and risk of perinatal depression -results from a randomized controlled trial. J Affect Disord. 2020;262:133-42.^-3131. Zemestani M, Fazeli Nikoo Z. Effectiveness of mindfulness-based cognitive therapy for comorbid depression and anxiety in pregnancy: a randomized controlled trial. Arch Womens Ment Health. 2020;23:207-14.

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.²⁵25. Veringa IK, de Bruin EI, Bardacke N, et al. "I've Changed My Mind", Mindfulness-Based Childbirth and Parenting (MBCP) for pregnant women with a high level of fear of childbirth and their partners: study protocol of the quasi-experimental controlled trial. BMC Psychiatry. 2016;16:377.

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.²³23. Veringa-Skiba IK, de Bruin EI, van Steensel FJA, et al. Fear of childbirth, nonurgent obstetric interventions, and newborn outcomes: a randomized controlled trial comparing mindfulness-based childbirth and parenting with enhanced care as usual. Birth. 2022;49:40-51.^,3232. Molek-Winiarska D, Żołnierczyk-Zreda D. Application of mindfulness-based stress reduction to a stress management intervention in a study of a mining sector company. Int J Occup Saf Ergon. 2018;24:546-56.

There are various methods that target behavior change for psychological support and anxiety reduction. One of these methods is mindfulness-based intervention.³³33. Malekpoorafshar M, Salehinejad P, Pouya F, et al. A shift toward childbearing in one-child families through a mindfulness-based stress reduction program: a randomized controlled trial. J Family Reprod Health. 2021;15:19-27. 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.³²32. Molek-Winiarska D, Żołnierczyk-Zreda D. Application of mindfulness-based stress reduction to a stress management intervention in a study of a mining sector company. Int J Occup Saf Ergon. 2018;24:546-56.

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.³³33. Malekpoorafshar M, Salehinejad P, Pouya F, et al. A shift toward childbearing in one-child families through a mindfulness-based stress reduction program: a randomized controlled trial. J Family Reprod Health. 2021;15:19-27.

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.³⁶36. Innab A, Al-khunaizi A, Al-otaibi A, et al. Effects of mindfulness-based childbirth education on prenatal anxiety: a quasi-experimental study. Acta Psychol (Amst). 2023;238:103978. 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.³⁷37. Yazdanimehr R, Omidi A, Sadat Z, et al. The effect of mindfulness-integrated cognitive behavior therapy on depression and anxiety among pregnant women: a randomized clinical trial. J Caring Sci. 2016;5:195-204.

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.²⁸28. Pan WL, Chang CW, Chen SM, et al. Assessing the effectiveness of mindfulness-based programs on mental health during pregnancy and early motherhood - a randomized control trial. BMC Pregnancy Childbirth. 2019;19:346.

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.³⁸38. Alidina S. Mindfulness for dummies. 3rd ed. Hoboken, NJ: John Wiley & Sons; 2020. Mindfulness therapy can change anxiety associations by replacing unhelpful thoughts and behaviors with positive alternatives.³⁹39. Krusche A, Crane C, Dymond M. An investigation of dispositional mindfulness and mood during pregnancy. BMC Pregnancy Childbirth. 2019;19:1-8. 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.⁴⁰40. Shaffer FB, Moss D. Review of I. Z. Khazan (2019), Biofeedback and mindfulness in everyday life: practical solutions for improving your health and performance. W. W. Norton and Company. Appl Psychophysiol Biofeedback. 2022;47:357-60.

41. Cuddy AJ. Presence. Bringing your boldest self to your biggest challenges. New York: Little, Brown & Company; 2016.

42. Decker JT, Brown JLC, Ashley W, et al. Mindfulness, meditation, and breathing exercises: reduced anxiety for clients and self-care for social work interns. Soc Work Groups. 2019;42:308-22.

43. The Mindfulness Workbook for Anxiety: The 8-Week Solution to Help You Manage Anxiety, Worry & Stress by Tanya J. Peterson Goodreads [Internet]. [cited 2023 Aug 1]. Available from: https://www.goodreads.com/book/show/39786811-the-mindfulness-workbook-for-anxiety
https://www.goodreads.com/book/show/3978... ^-4444. Twohig MP, Levin ME. Acceptance and commitment therapy as a treatment for anxiety and depression: a review. Psychiatr Clin North Am. 2017;40:751-70.

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.⁴⁵45. Hofmann SG, Sawyer AT, Witt AA, et al. The effect of mindfulness-based therapy on anxiety and depression: a meta-analytic review. J Consult Clin Psychol. 2010;78:169-83.

46. Hofmann SG, Gómez AF. Mindfulness-based interventions for anxiety and depression. Psychiatr Clin North Am. 2017;40:739-49.

47. Late-Breaking Science Abstracts and Featured Science Abstracts from the American Heart Association's Scientific Sessions 2022 and Late-Breaking Abstracts in Resuscitation Science From the Resuscitation Science Symposium 2022. Circulation. 2022;146:e569-605.

48. Parmentier FBR, García-Toro M, García-Campayo J, et al. Mindfulness and symptoms of depression and anxiety in the general population: the mediating roles of worry, rumination, reappraisal and suppression. Front Psychol. 2019;10:438030.^-4949. Vveinhardt J, Kaspare M. The relationship between mindfulness practices and the psychological state and performance of kyokushin karate athletes. Int J Environ Res Public Health. 2022;19:4001.

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.⁵⁰50. Doll A, Hölzel BK, Mulej Bratec S, et al. Mindful attention to breath regulates emotions via increased amygdala-prefrontal cortex connectivity. Neuroimage. 2016;134:305-13.^,5151. Latendresse G. Mindful birthing: training the mind, body and heart for childbirth and beyond. J Midwifery Womens Health. 2013;58:351.

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 regulation⁵²52. Goldin PR, Moodie CA, Gross JJ. Acceptance versus reappraisal: behavioral, autonomic, and neural effects. Cogn Affect Behav Neurosci. 2019;19:927-44.

53. Isgut M, Smith AK, Reimann ES, et al. The impact of psychological distress during pregnancy on the developing fetus: biological mechanisms and the potential benefits of mindfulness interventions. J Perinat Med. 2017;45:999-1011.^-5454. Taylor BL, Cavanagh K, Strauss C. The effectiveness of mindfulness-based interventions in the perinatal period: a systematic review and meta-analysis. PLoS One. 2016;11:e0155720. in control of executive attention during reception of sad images, and in perspective shift and effortful attention during distraction from stressful events.⁵⁵55. Lebois LA, Papies EK, Gopinath K, et al. A shift in perspective: decentering through mindful attention to imagined stressful events. Neuropsychologia. 2015;75:505-24.^,5656. Duncan LG, Bardacke N. Mindfulness-based childbirth and parenting education: promoting family mindfulness during the perinatal period. J Child Fam Stud. 2010;19:190-202.

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.³⁹39. Krusche A, Crane C, Dymond M. An investigation of dispositional mindfulness and mood during pregnancy. BMC Pregnancy Childbirth. 2019;19:1-8.^,5757. Jong J, Ross R, Philip T, et al. The religious correlates of death anxiety: a systematic review and meta-analysis. Religion Brain Behav. 2018;8:4-20.

58. Murakami H, Nakao T, Matsunaga M, et al. The structure of mindful brain. PLoS One. 2012;7:e46377.

59. Neel ML, Yoder P, Matusz PJ, et al. Randomized controlled trial protocol to improve multisensory neural processing, language and motor outcomes in preterm infants. BMC Pediatr. 2019;19:81.^-6060. Kober H, Buhle J, Weber J, et al. Let it be: mindful acceptance down-regulates pain and negative emotion. Soc Cogn Affect Neurosci. 2019;14:1147-58.

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.⁶¹61. Veringa-Skiba IK, Ziemer K, de Bruin EI, et al. Mindful awareness as a mechanism of change for natural childbirth in pregnant women with high fear of childbirth: a randomised controlled trial. BMC Pregnancy Childbirth. 2022;22:47.

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.

References

Publication Dates