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Complementary Therapies in Medicine (2015) 23, 509—515

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.elsevierhealth.com/journals/ctim

The effects of music listening on


psychosocial stress and maternal—fetal
attachment during pregnancy
Hsing-Chi Chang a, Chen-Hsiang Yu b, Shu-Yueh Chen c,
Chung-Hey Chen a,∗

a
Institute of Allied Health Science, College of Medicine, National Cheng Kung University, 1 University
Road, Tainan 701, Taiwan
b
Department of Obstetrics and Gynecology, National Cheng Kung University Medical Center, No. 138,
Sheng Li Road, Tainan 701, Taiwan
c
Department of Nursing, HungKuang University, No. 1018, Sec. 6, Taiwan Boulevard, Shalu District,
Taichung 403, Taiwan

Received 4 September 2014; received in revised form 13 May 2015; accepted 24 May 2015
Available online 27 May 2015

KEYWORDS Abstract
Music; Objective: While music listening has been studied as an intervention to help reduce anxiety
Psychosocial stress; in pregnant women, few studies have explored the effect of music listening on pregnancy-
Perceived stress; specific stress relief. This study examines the effects of music listening on psychosocial stress
Maternal—fetal and maternal—fetal attachment during pregnancy.
attachment Design: A randomized controlled trial was implemented. A valid sample of 296 pregnant women
in their second or third trimester was randomly distributed into an experimental group (n = 145)
and a control group (n = 151).
Interventions: The experimental group received routine prenatal care and music listening. The
control group received routine prenatal care only.
Main outcome measures: Data were collected using a demographic form, Pregnancy Stress
Rating Scale (PSRS), Perceived Stress Scale (PSS), and Maternal—Fetal Attachment Scale (MFAS).
Results: The post-test results identified a significantly lower level of psychosocial stress in the
experimental group than in the control group, particularly in terms of the stresses related to
baby care and changing family relationships and to maternal role identification. However, no
statistically significant differences in terms of perceived stress and maternal—fetal attachment
were found between the post-test results of the two groups.


Corresponding author. Tel.: +886 6 235 3535x5846; fax: +886 6 2377550.
E-mail addresses: elinacelia@gmail.com (H.-C. Chang), mchydr@mail.ncku.edu.tw (C.-H. Yu), shuyueh@sunrise.hk.edu.tw (S.-Y. Chen),
chunghey@mail.ncku.edu.tw (C.-H. Chen).
http://dx.doi.org/10.1016/j.ctim.2015.05.002
0965-2299/© 2015 Elsevier Ltd. All rights reserved.
510 H.-C. Chang et al.

Conclusion: This study provides evidence in support of using of music in interventions designed
to relieve psychosocial stress in prenatal women.
IRB approval number: ER98223
© 2015 Elsevier Ltd. All rights reserved.

1. Introduction one during the early postpartum stage.21 Music listen-


ing has been used as an intervention in pregnant women
Pregnancy is an event that has a significant and long-term in their second and third-trimester,1 or during transvaginal
impact on the life of the expectant mother. The physiologi- ultrasound examinations15 and tocolysis.16 Prior studies
cal and psychological impacts of pregnancy tend to change also showed that music listening significantly reduced
as pregnancy progresses. While many women experience pregnancy-related anxiety in subjects.1,15,16 Although
various dynamic stresses due to physiological and psycholog- anxiety and stress are different constructs, prior research
ical changes that are directly attributable to the pregnancy on the topic of maternal distress has largely used these
event,1 the effects of the pregnancy experience typically terms interchangeably.22,23 In certain contexts, anxiety is
continue to affect a mother for the rest of her life. a symptom of the physical and psychological responses to
Pregnancy is a process that helps women learn and stress. Rallis et al.23 argued the necessity of understanding
assume their new maternal role and which culminates in how the experience of perinatal stress differs from that
the formation of maternal identity.2—4 Mastering the mater- of perinatal anxiety/depression because related research
nal role, a process known as maternal role attainment, had demonstrated that a close correspondence between
includes mimicry, role-play, fantasy, looking for a role fit, the affective state of stress with the sense of feeling over-
and grief work. Mercer5 stated that transition is the specif- whelmed/unable to cope and because the affective state
ically cognitive process of developing the maternal identity of distress may be a significant precursor of depression and
through ‘‘maternal role attainment’’. Mercer6 later sug- anxiety. Finally, a reduction in the stresses of pregnancy,
gested replacing the term ‘‘maternal role attainment’’ a cornerstone life event and the bridge to motherhood,
with ‘‘becoming a mother’’ in order to better reflect the is generally perceived as a positive outcome with the
life-transforming experience of pregnant women. This expe- potential for widespread benefit.
rience relates to the stresses felt by pregnant women during The therapeutic effects of music listening on mater-
the transition to motherhood. Pregnancy is the anticipatory nal/psychosocial stress gathered using a pregnancy-specific
stage of becoming a mother and is a natural life event.6 stress instrument has not previously been tested scien-
However, an effective and natural way to reduce the stress tifically in healthcare studies. Therefore, our aim in this
of pregnancy is required. Music therapy offers one potential study was to examine the effectiveness of music listen-
approach. ing during pregnancy on psychosocial stress, perceived
The use of music in psychological healing has been well stress, and maternal—fetal attachment. We hope this
documented throughout history. Music therapy is a noninva- music treatment will gain greater attention among health-
sive approach to the treatment of psychological symptoms. management practitioners and encourage the development
This approach has minimal or no side effects and is cost of a proper scheme for using music to reduce women’s
effective, convenient, and completely natural. Music has pregnancy-specific stress and, consequently, reduce
been part of the human experience since the beginnings of pregnancy-related depression and anxiety in this vulnerable
history, and history is replete with the belief in the ther- population.
apeutic and healing powers of music.7 Music intervention
may support emotional, spiritual, and psychological needs
of recipients by creating an environment that stimulates 2. Methods
and maintains relaxation, well-being, and comfort to reduce
or control stress.8 As noted by Murrock and Higgins,9 music 2.1. Design
may produce both psychological and physiological responses
that alter the mood of a recipient, leading to improved This study is a randomized control trial with two groups.
health outcomes. Chanda and Levitin10 elaborated the evi- The experimental group received routine prenatal care and
dence that music facilitates health outcomes through the music listening. The control group received routine prenatal
engagement of neurochemical systems, manifested by sev- care only.
eral key neurochemicals mediating the stress response. In
addition, Solanki et al.7 articulated that music influences
the parasympathetic system prevailing over the sympathetic 2.2. Participants
system and consequently facilitates a relaxation response.
Music has been applied to reduce the stress in surgical After the institutional review board approved the study
settings 11,12 and hospice care.13,14 Eight studies reveal that protocol, we recruited a convenience sample of 320 partici-
music has also been applied to improve the well-being of pants from the antenatal clinic of a medical center in Tainan,
women during their transition to motherhood. Three of southern Taiwan between December 2009 and May 2010. The
these studies were performed on women during the ante- inclusion criteria were: (1) pregnant women over 18 years
natal stage,1,15,16 four during labor and delivery,17—20 and of age; (2) gestational age 17 weeks; (3) expected to have
The effects of music listening on psychosocial stress and maternal—fetal attachment during pregnancy 511

uncomplicated vaginal delivery; (4) able to read Chinese; Modified MFAS has demonstrated adequate internal con-
and (5) willing to participate in this study. Otherwise quali- sistency (Cronbach’s ˛ = 0.92) and test-retest reliability
fied women who had experienced a fetal death or stillbirth (r = 0.82).27 In our study, internal consistency (Cronbach’s
previously were excluded. ˛) of the MFAS was 0.95.
Three hundred and twenty (N = 320) pregnant women
were initially enrolled in this study and systematically 2.4. Ethical consideration
assigned after a random start to either the experimental
group (n = 162) or the control group (n = 158). Twenty-four
This study was approved by the Human Experiment and
women lost to follow-up because of one of the following
Ethics Committee of National Cheng Kung University Hos-
reasons: (1) mailing loss (n = 20); (2) preterm labor (n = 4);
pital. Prior to conducting the study, the researcher first
or (3) no time to fill in the required information (n = 1). Ulti-
obtained informed consent from all the participants and
mately, 296 participants were included in the analysis, with
informed them that all questionnaire data would be submit-
145 women in the experimental group and 151 women in the
ted anonymously and that their personal information would
control group (Fig. 1).
be kept confidential.

2.3. Measures 2.5. Data collection

The Demographic Data Form was used to collect demo- After receiving a verbal briefing on the research and
graphic and obstetric data. Outcome measures included the completing informed consent, all participants were asked
pregnancy stress rating scale (PSRS), perceived stress scale to complete the demographic data form, PSRS, PSS and
(PSS), and maternal—fetal attachment scale (MFAS). MFAS. The measures were mailed to them with a stamped
A 36-item revised PSRS (PSRS36) was used to measure addressed envelope at the end of the 2-week period to
psychosocial stress in pregnancy.24 Items were rated on a gather the post-test results.
five-point Likert scale ranging from 0 (definitely no) to 4 Participants in the experimental group received a pre-
(very severe). This scale demonstrated good internal consis- recorded music compact discs (CD) to listen in addition to
tency (˛ = 0.92) and 2-week test-retest reliability (r = 0.82). their routine prenatal care. Participants in the control group
Factor analysis confirmed construct validity and suggested only received the routine prenatal care.
5 prenatal stress dimensions that explained 52.17% of total Five types of prerecorded music compact discs (CD)
variance. The 5 dimensions were: (D1) stress from seeking were created for this study. Each CD contained approx-
safe passage for mother and child through pregnancy, labor, imately 30 min of music, respectively, in five categories:
and delivery; (D2) stress from baby care and changing family crystal music, nature sounds, classical music, lullabies, and
relationships; (D3) stress from maternal role identification; symphonic music. The tempo of the music selections was
(D4) stress from social support seeking; and (D5) stress from selected to mimic the human heart rate (60—80 beats/min).
altered physical appearance and function. PSRS has been Participants in the experimental group were given the pre-
found to be significantly correlated with the Perceived Stress recorded CD and asked to listen to the music at least 30 min
Scale (PSS) (r = 0.40, p < 0.001) and Interpersonal Support a day for 2 weeks, while they were at rest or at bedtime and
Evaluation List (ISEL) (r = −0.27, p < 0.001), supporting con- on a self-regulated basis, that they would feel more relaxed.
vergent and discriminate validities.24 Internal consistency The participants listened to the music in their preferred cat-
reliability (Cronbach’s ˛) in the present study was 0.93. egory, and were permitted to listen to the music either over
The 10-item PSS is designed to assess perceived stress speakers or through earphones.
in pregnant women that results from self-perceptions of
decreased control and decreased ability to cope with life 2.6. Statistical analysis
events.25 The PSS and its response alternatives are easy for
respondents to comprehend. The PSS focuses on subjective
SPSS statistical software (Version 17, SPSS Inc., Chicago, IL,
feelings and thoughts experienced during the previous week.
USA) was adopted for the analysis. The demographic and
Items are designed to determine the degree to which respon-
obstetric data were summarized using descriptive statistics
dents feel their lives are uncontrolled, unpredictable, and
such as frequencies, percentages, and means. Chi-square
overloaded, with responses provided on a five-point Likert
(2 ) tests were used to test differences in categorical data
scale ranging from ‘never’ (0) to ‘very often’ (4). The Chi-
between the experimental group and the control group.
nese version of PSS has demonstrated adequate test-retest
A repeated-measures ANOVA was used to determine the
reliability (r = 0.81 over a 2-week interval) and good inter-
effects of music on participants’ pregnancy stress, perceived
nal consistency (coefficient ˛ = 0.85).26 Internal consistency
stress, and maternal—fetal attachment. The accepted level
(Cronbach’s ˛) was 0.85 in this study.
of significance for all analyses was p  0.05.
The Modified Maternal—Fetal Attachment Scale
(MMFAS)27 was developed by merging Cranley’s
Maternal—Fetus Attachment Scale28 and Muller’s Pre- 3. Results
natal Attachment Inventory.29 This 41-item scale measures
the attachment behavior of pregnant women using a five- In total, 236 pregnant women were enrolled in this study.
point Likert scale, with 5 = always, 4 = often, 3 = sometimes, The experimental group consisted of 116 women (age
2 = seldom, and 1 = never. Higher scores indicate stronger range, 24—41 years; mean: 30.48 years). The control group
maternal—fetal attachment. The Chinese version of consisted of 120 women (age range, 20—39 years;
512 H.-C. Chang et al.

Fig. 1 Flow diagram of participant enrollment.

mean: 29.58 years). The majority of participants were significant. These results indicate that music listening did
college/university graduates or higher (86.8%), and primi- not significantly influence perceived global life stress and
gravida (53.7%). The demographic data on these two groups maternal—fetal attachment.
are shown in Table 1. No significant differences were found The interaction of group and time on PSRS was significant:
between the groups in terms of demographic characteristics. F(1,294) = 6.01, (p = 0.02). In other words, the differences
Table 2 presents the means and standard deviations between pre-test and post-test PSRS scores, respectively,
for the PSRS, PSS, and MFAS scores of the participants in for the experimental group and the control group were sig-
both the experimental and control groups on both pre-test nificant. Fig. 2 illustrates the group by time interaction for
and 2-week post-test. Group comparisons of the pre-tests PSRS. Significant differences between the two groups were
on the three target scales did not achieve statistical observed in 2 of the 5 dimensions of PSRS: D2 ‘‘stress from
significance. baby care and changing family relationships’’ (p < 0.05) and
A two-way ANOVA with repeated measures was used to D3 ‘‘stress from maternal role identification’’ (p = 0.05).
examine the group effect, time effect, and group by time No significant differences between the two groups were
interactions of PSRS, PSS, and MFAS, respectively (Table 3). observed in the other 3 dimensions of ‘‘Stress from seek-
No significant group by time interaction was found for PSS ing safe passage for mother and child,’’ ‘‘Stress from social
and MFAS, indicating the differences between the pre-test support seeking,’’ and ‘‘Stress from altered physical appear-
and post-test PSS and MFAS scores for the groups were not ance and function.’’

Table 1 Characteristics of participants in the experimental group and the control group.

Variable Experimental Control x2 p


(n = 145) (n = 151)
n (%) n (%)

Education 1.99 .16


≤Senior high school 15 (10.3) 24 (15.9)
> Senior high school 130 (89.7) 127 (84.1)
Occupation .76 .38
Housewife 44 (30.3) 53 (35.1)
Employed 101 (69.7) 98 (64.9)
Socioeconomic status 5.18 .08
High 91 (62.8) 76 (50.3)
Middle 41 (28.3) 61 (40.4)
Low 13 (8.9) 14 (9.3)
Gravidity 3.58 .06
Primigravida 86 (59.3) 73 (48.3)
Multigravida 59 (40.7) 78 (51.7)
Type of pregnancy 2.61 .11
Planned 104 (71.7) 95 (62.9)
Unplanned 41 (28.3) 36 (3711)
The effects of music listening on psychosocial stress and maternal—fetal attachment during pregnancy 513

Table 2 Pre- and post-test means (SD), by group.

Experimental Control

Mean SD Mean SD

Perceived Stress Scale (PSS) Pre-test 16.49 4.85 16.40 4.78


Post-test 15.97 5.62 16.38 5.25
Maternal—Fetal Attachment Scale (MFAS) Pre-test 96.11 19.19 92.04 21.26
Post-test 100.96 20.47 95.60 22.83
Pregnancy Stress Rating Scale (PSRS) Pre-test 53.70 24.21 49.92 22.26
Post-test 54.02 23.64 54.94 22.73
Dimension I. Stress from seeking safe passage for mother and child Pre-test 16.21 8.76 15.30 8.38
Post-test 15.22 8.37 15.56 8.51
Dimension II. Stress from baby care and changing family relationships Pre-test 10.81 6.13 10.23 6.17
Post-test 11.23 6.20 11.97 6.28
Dimension III. Stress from maternal role identification Pre-test 13.06 5.45 11.66 5.70
Post-test 13.44 5.67 13.19 4.88
Dimension IV. Stress from social support seeking Pre-test 3.94 3.69 3.38 3.35
Post-test 3.87 3.56 3.81 3.58
Dimension V. Stress from altered physical appearance and function Pre-test 9.69 4.80 9.35 4.68
Post-test 10.26 4.71 10.41 4.79
Note: No group differences were significant at p < 0.05 on all pre-tests.

An analysis of the 2-week diaries maintained by the par- classical music (2.8/14 days) and lullabies (2.7/14 days).
ticipants in the experimental group elucidated their music Over half (56.6%, 82/145) of the participants in the experi-
category preferences and the activities that they performed mental group noted the activities performed while listening
while listening to music. The results revealed a preference to the music. These women generally listened to the music
for crystal music (3.6/14 days), nature sounds (2.9/14 days), when they were at rest (5.8/14 days), engaged in leisure

Table 3 Two-way ANOVA with repeated measures analysis of pregnancy stress, perceived stress, and maternal—fetal attachment
during pregnancy for experimental and control groups.

Group effect Time effect Interaction effect

F p F p F p

Perceived Stress Scale (PSS) 0.09 0.76 1.02 0.31 0.92 0.34
Maternal—Fetal Attachment 4.23 0.04* 24.96 0.00* 0.58 0.45
Scale (MFAS)
Pregnancy Stress Rating 0.32 0.57 7.74 0.00** 6.01 0.02*
Scale (PSRS)
Dimension I. Stress from 0.10 0.76 0.98 0.32 2.95 0.09
seeking safe passage for
mother and child through
pregnancy, labor, and
delivery
Dimension II. Stress from 0.01 0.91 14.12 0.00** 5.27 0.02*
baby care and changing
family relationships
Dimension III. Stress from 2.17 0.14 10.61 0.00** 3.76 0.05*
maternal role
identification
Dimension IV. Stress from 0.66 0.42 1.14 0.29 2.17 0.14
social support seeking
Dimension V. Stress from 0.03 0.86 16.49 0.00** 1.53 0.22
altered physical
appearance and function
* p  0.05.
** p < 0.01.
514 H.-C. Chang et al.

and passively obeying dietary and behavioral taboos during


pregnancy in hopes of nurturing a good baby.24 The present
study supports the positive effects of listening to certain
types music on prenatal education and self-relaxation. Fur-
thermore, Weinstock31 and Mennes et al.32 pointed out that
stress and anxiety during pregnancy have extensive effects
on the pregnant woman and fetus and even the long term
effect on the infant until adulthood. Additionally, Mennes
et al.32 found that a deficit in endogenous cognitive control
in adolescents was related to their mothers’ level of anxiety
during weeks 12—22 of pregnancy. It is plausible to recom-
mend that further study might include pregnant women in
the first trimester.
Fig. 2 Group × time (1 = pre-test, 2 = post-test) interaction Maternal—fetal attachment (MFA) has been defined as
effect on PSRS score. the intimacy developed between a pregnant woman and her
fetus and the level of interactive behavior.28 The present
time activities (4.7/14 days), or performing chores (4.2/14
study did not demonstrate that music listening affected
days).
MFA. Similarly, Shin and Kim15 found no difference between
their music therapy group and control group in terms of
4. Discussion MFA. However, while their study administered a transvaginal
ultrasound about 30 min between pre-test and post-test,
The present study detected a pregnancy-stress reducing we administered music therapy intervention for an inter-
effect for music. This finding differs from the study of Shin val of 2 weeks. Contrarily, a qualitative study by Carolan
and Kim,15 which found no stress-relief effect from music et al.33,34 found that learning to sing lullabies during preg-
listening. The different instruments used in these two stud- nancy benefited women in terms of relaxation and feeling
ies to measure pregnancy-related stress may account for emotionally closer to their infants. Additionally, Arabin and
this discrepancy. Shin and Kim’s study15 used the 20-item Jahn35 claimed that either listening to music passively or
pregnancy stress scale, which is designed to measure fetus- singing songs and playing music had impact on neurodevel-
related stress and self-related stress.15 The present study opment and bonding. Therefore, the effect of music on MFA
used the 36-item PSRS, which measures pregnancy-specific warrants further study.
stress in 5 dimensions, including stress from: (D1) seeking This study has several limitations. First, to avoid the
safe passage for mother and child through pregnancy, labor, Hawthorne effect, the control group was not asked to main-
and delivery; (D2) baby care and changing family relation- tain a diary record. Therefore, we are unable to make
ships; (D3) maternal role identification; (D4) social support conclusions regarding the attention effect of the music
seeking; and (D5) altered physical appearance and function. listening intervention. To resolve this problem, a more
While our findings support the pregnancy-stress reducing deliberate study design is required to further elucidate
effect of music listening, we found that music listening had effectiveness. This future study may use a three-group trial
no significant effect on general stress perceptions. This may approach, with one group listening to 30-min of music daily
indicate that the PSRS instrument is more sensitive at mea- and keeping a diary, the second group asked to relax for
suring pregnancy-specific stress than at measuring general 30 min daily without listening to music, and the third group
stress in pregnant women. given nothing beyond routine care. Another limitation of the
This controlled trial provides preliminary evidence that study was that we were unable to discriminate between the
a 2-week music listening intervention may help woman effects of different types of music. Although we provided a
cope with pregnancy-related stress, which, as reported by CD with music organized into five categories and allowed the
Chen et al.30 gradually increases and peaks during the third participants to listen to music selections according to their
trimester. Further analysis of the PSRS subscales identified preferences, we did not assess their normal music-listening
significant differences between the post-test results of the habits and prior music preferences, which may influence
experimental and control groups in two dimensions: dimen- the effects of the music listening intervention.36 Further
sions 2 and 3 (D2 and D3). D2 addresses the respondent’s research is needed to determine the type(s) of music that
anticipatory competence with regard to mothering, con- best relieves pregnancy-related stress in women. Finally, the
cerns regarding the acceptance of the child by significant effect of music therapy on pregnancy stress was limited to
others, bonding with the child, and contemplations on the 2 weeks of music therapy, further study maybe chose longer
changing relationships between the new mother and her intervals and singing interventions instead and then also
child as well as with other family members. D3 addresses the evaluate pregnancy outcome and infants cognitive function.
respondent’s concerns about her baby’s appearance, gender,
and well-being and the inherent conflicts that arise between
fantasized ‘‘perfect’’ outcomes and dreaded ‘‘problem’’ 5. Conclusions
outcomes.24 Pregnant women may experience anticipated or
floating stress about potential future outcomes. It has been Our findings support the effectiveness of music listening
observed that some prenatal women in Taiwan still adhere in helping pregnant women cope with stress, especially
to ‘‘prenatal education’’ behaviors that include actively pregnancy-related stress. Although this study found no
adjusting mind and mood in order to enhance embryo health effect for music listening on either general perceived life
The effects of music listening on psychosocial stress and maternal—fetal attachment during pregnancy 515

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