Original Research - QuantitativeEffects of a novel positive psychological intervention on prenatal stress and well-being: A pilot randomised controlled trial
Introduction
Low prenatal well-being and its subsequent negative effects have been extensively examined and documented.1 It can have significant negative physical and psychological outcomes including pre and post-natal depression,2 pregnancy complications,3 preterm delivery and low birth weight.4 Low maternal well-being is typically characterised by low levels of positive affect, self-esteem and life satisfaction; it is also characterised by high levels of depression, anxiety and stress. These factors can occur in isolation or in tandem with other indicators of low prenatal well-being; they are not therefore separate constructs but can be viewed in the context of multidimensional facets of well-being.
A commonly reported and examined facet of low well-being during pregnancy is prenatal stress. It is suggested that 25% of all pregnant women experience prenatal stress.5 Prenatal stress can be caused by numerous psychological, biomedical, environmental, psychosocial and socioeconomic factors.1 It can occur as a result of physical symptoms and changes,5 family stressors, current health, socio-economic status, work strain, and inadequate psychosocial resources.1
While a broad range of factors contribute to stress during pregnancy, given the number of pregnancy-related concerns that characterise it, prenatal stress must be conceptualised as a pregnancy-specific construct. Such a conceptualisation is supported by the fact that pregnancy presents unique challenges and changes, thus representing a unique contextually specific stressor in and of itself.6 Examinations of prenatal stress have shown it to be consistently associated with adverse effects for the expectant woman and developing foetus.2, 6, 7 Prenatal stress is a precursor for prenatal and postpartum depression.2 It is associated with an increased risk of engaging in adverse health behaviours, such as cigarette smoking during pregnancy,6 and early cessation of breastfeeding postpartum.6 Prenatal stress is also associated with an increased risk of caesarean section, as well as labour and birth complications.4 It is consistently associated with poor obstetric outcomes, including low infant birth weight,1 shorter length of gestation,9 and risk of preterm labour or birth.1, 9
One mechanism suggested to contribute to these latter outcomes is cortisol. Cortisol is an important mediator between psychological states and health related outcomes. It is an end product of hypothalamic pituitary adrenal (HPA) axis functioning, and helps to regulate the stress response. During pregnancy, the circadian rhythm and cortisol awakening response (CAR), which is a morning peak in cortisol levels, are preserved.10 However, prenatal maternal cortisol levels progressively increase during pregnancy from 25 weeks gestation.11, 12 During pregnancy both the maternal HPA axis and the placenta produce cortisol; it is an important factor for foetal maturation and labour.1 However, increases in maternal cortisol, due to prenatal maternal stressors, can adversely effect production of placental cortisol. These increased cortisol levels can lead to adverse foetal outcomes, including increased risk of low birth weight and birth complications.11 Thus, reducing sub-optimally elevated cortisol levels and maintaining optimal cortisol functioning during pregnancy has the potential to benefit both mother and developing infant.
Research examining potential benefits of positive aspects and protective factors of well-being on prenatal mental health and cortisol outcomes during pregnancy is scarce. In one study of 41 women in late pregnancy,12 prenatal CAR was significantly correlated with prenatal happiness but not with prenatal stress or depression. In a thorough investigation of prenatal well-being with 60 pregnant women,13 positive life events significantly predicted lower morning cortisol in the 3rd trimester; negative life events were not associated with cortisol. A number of recent studies examining the effects of mindfulness interventions on well-being during pregnancy have also been conducted. Mindfulness is defined as non-judgmental observation of all thoughts, feelings and sensations in the present moment.14 Recent reviews of the effects of mindfulness during pregnancy have highlighted some potential benefits for depression, anxiety, negative affect and stress but a need for significantly improved methodological approaches to prenatal mindfulness examinations.15, 16, 17 The need for inclusion of pregnancy specific measures and biomarkers of prenatal stress is also highlighted.17
Given the initial promising findings of mindfulness interventions on prenatal outcomes, as well as the demonstrated effects of protective factors, such as positive life events, it is expected that other positive factors could demonstrate similar positive effects during pregnancy. For instance, gratitude consistently demonstrates benefits for well-being in diverse populations.21 Gratitude can be defined as a worldview towards noticing or appreciating the positive in life.16 Benefits of gratitude include increased life satisfaction and social support22 and health behaviours.23 It has also been associated with reduced stress,21 depression,21 anxiety,23 and physical symptoms.24 To the authors’ knowledge, only one study has examined gratitude in a pregnancy-related context.25 In a content analysis of the subjective, retrospective gratitude of 799 Swedish women, for care provided by medical staff after a stillbirth, the researchers found mothers experienced gratitude for health professionals’ emotional, practical and informative support. No research has yet been published on the effects of gratitude during pregnancy however. This is despite the potential benefits of gratitude for prenatal well-being.
Combining a well-established gratitude intervention that has consistently demonstrated beneficial effects20 with a well-established element of mindfulness practice therefore allows for a robust investigation of a novel approach to prenatal well-being improvement. The detrimental effects of low prenatal well-being have been extensively studied but positive interventions that aim to improve well-being through fostering and maintaining prenatal psychological resources are in their infancy. The current study will therefore examine the effect of a novel gratitude and mindfulness based intervention on prenatal stress, cortisol levels and well-being factors, in comparison to a treatment as usual control group.
Section snippets
Participants
Participants (n = 46) were pregnant women aged 27–40 years (M = 33.87, SD = 3.04). Participants were required to be over 18 years of age and to be between 10 and 22 weeks pregnant at recruitment; the latter criterion was to control for the natural progressive rise in cortisol levels from 25 weeks gestation.26 Participants were also required to not currently be taking asthma or thyroid medication as this can impact on cortisol levels. Participants must also not have received a diagnosis of depression,
Results
Thirty-six participants completed measures at all three time points (see Fig. 1). Ten participants were lost to follow-up due to exiting commitments and time constraints. Characteristics of the pregnant women included in the study are shown in Table 1.
Discussion
This paper provides the first examination of a novel, at-home mindfulness and gratitude based intervention on prenatal stress, cortisol, and well-being. Thirty-six women completed the pilot trial, and findings demonstrate that those in the intervention condition had significant reductions in self-reported prenatal stress in comparison to a treatment-as-usual (TAU) group. Significant reductions over time were also observed for waking cortisol and evening cortisol levels in a within-subjects
Conclusion
The findings of the current study highlight the potential usefulness of a brief mindfulness and gratitude based intervention for reducing stress during pregnancy. Significant reductions were observed in self-report stress and in some indicators of cortisol levels; such reductions have the potential to offset adverse consequences of prenatal stress for mother and infant. The intervention did not demonstrate benefits for all aspects of well-being in the current study. This suggests possible
Acknowledgement
This pilot study was conducted without financial assistance.
The authors would like to acknowledge the assistance of Cork University Maternity Hospital, particularly Dr. Mairead O'Riordan, Professor Louise Kenny, and Professor John Higgins. The authors would especially like to thank all the women who took part in this study.
References (41)
- et al.
Depression during pregnancy and postpartum: contribution of stress and ovarian hormones
Prog Neuro Psychopharmacol
(2010) Maternal depression, anxiety and stress during pregnancy and child outcome; what needs to be done
Best Pract Res Clin Obstet Gynaecol
(2014)- et al.
Physiological stress reactivity in human pregnancy—a review
Neurosci Biobehav Rev
(2005) - et al.
Positive life events predict salivary cortisol in pregnant women
Psychoneuroendocrinology
(2012) - et al.
17 mindfulness and perinatal mental health: a systematic review
Women Birth
(2016) - et al.
Gratitude and well-being: a review and theoretical integration
Clin Psychol Rev
(2010) - et al.
The role of gratitude in the development of social support, stress, and depression: two longitudinal studies
J Res Pers
(2008) - et al.
Gratitude and subjective well-being in early adolescence: examining gender differences
J Adolesc
(2009) - et al.
Validation of the Edinburgh depression scale during pregnancy
J Psychosom Res
(2011) - et al.
State and trait affect as predictors of salivary cortisol in healthy adults
Psychoneuroendocrinology
(2005)
Assessment of the cortisol awakening response: expert consensus guidelines
Psychoneuroendocrinology
Counting blessings in early adolescents: an experimental study of gratitude and subjective well-being
J School Psychol
Longitudinal study of perinatal maternal stress, depressive symptoms and anxiety
Midwifery
Clinical trial implementation and recruitment: lessons learned from the early closure of a randomized clinical trial
Contemp Clin Trials
Psychological science on pregnancy: stress processes, biopsychosocial models, and emerging research issues
Annu Rev Psychol
A prospective study of the impact of psychosocial and lifestyle variables on pregnancy complications
J Psychosom Obstet Gynaecol
Prenatal maternal stress is associated with delivery analgesia and unplanned cesareans
J Psychosom Obstet Gynaecol
Coping and distress in pregnancy: an investigation of medically high risk women
J Psychosom Obstet Gynaecol
Measuring the ups and downs of pregnancy stress
J Psychosom Obstet Gynaecol
Maternal psychosocial well-being in pregnancy and breastfeeding duration
Acta Paediatr
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