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Women and Birth xxx (2018) xxx–xxx

Contents lists available at ScienceDirect

Women and Birth

journal homepage: www.elsevier.com/locate/wombi

Original Research – Quantitative

Mindfulness-based programme on the psychological health

of pregnant women$
Wan-Lin Pana,b , Meei-Ling Gauc,* , Tzu-Ying Leeb , Hei-Jen Joud, Chieh-Yu Liue ,
Tzung-Kuen Wenf
a
Department of Nursing, The University of Kang Ning, Taiwan
b
Department of Nursing, National Taipei University of Nursing and Health Sciences, Taiwan
c
Department of Midwifery and Women Health Care, National Taipei University of Nursing and Health Sciences, Taiwan
d
Department of Obstetrics and Gynecology, Taiwan Adventist Hospital, Taiwan
e
Department of Speech Language Pathology and Audiology, National Taipei University of Nursing and Health Sciences, Taiwan
f
Department of Buddhist Studies, Dharma Drum Institute of Liberal Arts, Taiwan

A R T I C L E I N F O A B S T R A C T

Article history: Problem: Preparation of psychological well-being is an important component of antenatal education for
Received 24 November 2017 childbirth, but few courses focus on this component.
Received in revised form 8 February 2018 Background: The psychosocial health of pregnant women is known to affect perinatal outcomes.
Accepted 23 April 2018
Psychosocial stress in women has been associated with increased obstetric interventions and has been
Available online xxx
shown to affect the health of both mother and child.
Aim: To explore the efficacy of an eight-week Mindfulness-Based Childbirth and Parenting programme on
Keywords:
reducing prenatal stress, depression, mindfulness, and childbirth self-efficacy.
Mindfulness
Stress
Methods: In this prospective and randomized controlled trial study, 104 women between 13 and 28 weeks
Depression gestation were enrolled and assigned randomly into two groups. Participants in the experimental group
Childbirth self-efficacy received mindfulness-based programme and practice-at-home with audio recordings. The comparison
Randomized controlled trial group received traditional education classes. Psychological health was assessed at baseline, post-
intervention, and 36-week gestation.
Findings: Significant differences were seen in both groups in terms of changes over time in stress,
depression, childbirth self-efficacy, and mindfulness, as compared with baseline. In gestation week 36,
stress scores were slightly higher and childbirth self-efficacy and mindfulness scores were lower for both
groups, but all scores were relatively better in the experimental than in the comparison group.
Conclusions: Perinatal mental health problems affect mothers, their infants, and society. The eight-week
mindfulness programme effectively reduced self-perceived stress and depression and increased
childbirth self-efficacy and mindfulness. Future research is needed to explore the potential benefits,
mechanisms, and effects on maternal and infant birth outcomes of mindfulness.
© 2018 Published by Elsevier Ltd on behalf of Australian College of Midwives.

$
Descriptive of the content of the article: This is a RCT research to exam Mindfulness-Based Childbirth and Parenting programme, we found it has clinically differences in
both groups in terms of changes over time in stress, depression, childbirth self-efficacy, and mindfulness.
* Corresponding author.
E-mail addresses: wanlimp@ukn.edu.tw (W.-L. Pan), meeiling@ntunhs.edu.tw (M.-L. Gau), tzuying@ntunhs.edu.tw (T.-Y. Lee), jouheijen@gmail.com (H.-J. Jou),
chiehyu@ntunhs.edu.tw (C.-Y. Liu), tzungkuen@dila.edu.tw (T.-K. Wen).

https://doi.org/10.1016/j.wombi.2018.04.018
1871-5192/© 2018 Published by Elsevier Ltd on behalf of Australian College of Midwives.

Please cite this article in press as: W.-L. Pan, et al., Mindfulness-based programme on the psychological health of pregnant women, Women
Birth (2018), https://doi.org/10.1016/j.wombi.2018.04.018
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Statement of significance
Problem or issue
Perinatal stress affects the health of pregnant women, the
foetus, and the child after birth. The effectiveness of
traditional childbirth classes in preparing expectant mothers
for the challenges of childbirth and early parenting has been
questioned.
What is already known
Mindfulness has been theoretically and empirically associ-
ated with psychological well-being in diverse populations.
There is insufficient evidence for the effectiveness of
mindfulness in promoting perinatal mental health.
What this paper adds
This mindfulness intervention programme has clinically
meaningful benefits for women who are coping with the
stress of childbirth. This programme was also shown to help
pregnant women better face the labour and birth process
and beyond.
1. Introduction
Becoming a mother often requires a woman to make significant
immediate changes to her regular routine and may cause
considerable anxiety with regard to the necessity of making
long-term changes in lifestyle. A recent study of 1522 pregnant
women in the United States found that 78% experienced low-to-
moderate levels of stress and that 6% experienced high levels of
stress during pregnancy.1 Stress during and after pregnancy has
been shown to increase the risks of depression, panic disorder,
drug use, and domestic violence and has been associated with
having multiple medical comorbidities. Furthermore, a stress
response, with attendant emotional, physical, and psychological
consequences such as depression, anxiety and emotional distress,
may ensue.2 According to a recent systematic review, the
prevalence of anxiety and depression during pregnancy is about
7%–20%.3 However, the range of percentages may be even higher.
Prenatal stress is highly related to increased analgesia use. Thus,
pregnant women who receive analgesia face a higher risk of
requiring surgical/caesarean deliveries than their peers who do
not.4 Moreover, infants of these women face an increased risk of
having low Apgar scores.5 Additionally, prenatal stress leads to a
higher emergency service need for both mothers and infants and a
higher risk of infants suffering from malnutrition, mental
disabilities, low body weight, and insecure attachments,6 which
have been shown to impact negatively upon the neurobehavioural
and cognitive development of babies and children.7
While recent research has provided structured antenatal
education and preparation for birth to women, the effects of
these on anxiety, breastfeeding success, and general social support
have rarely been assessed.8 Moreover, preparing women for
childbirth is known to enhance birth success and maternal
satisfaction, especially among young women and first-time
mothers.9 Antenatal education materials and methods urgently
need updating and researching, particularly in the areas of
transition to parenthood, support for fathers, and peer support.10
A qualitative research study conducted in Sweden found that the
topics that parents discussed most frequently during antenatal
classes were distributed evenly between childbirth preparation
and parenting preparation and that parents desired more
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Birth (2018), https://doi.org/10.1016/j.wombi.2018.04.018
information on topics including birth-related issues, pain relief,
child-related issues, breastfeeding, and parenthood.11
At present, there is insufficient evidence to support that
prenatal childbirth education given to the partners of pregnant
women has a protective effect against paternal postnatal depres-
sion or promotes mental health.12 In recent years, some scholars
have studied the effect of other programmes on improving the
mental health of pregnant women. These programmes include
telephone psycho-education counseling,13 Wazzup Mama inter-
vention mapping,14 cognitive behavioural therapy,15 interpersonal
psychotherapy,16 and mindfulness-based programmes.17,18
Interest in mindfulness-based programmes (MBPs), which
include both Mindfulness-Based Stress Reduction (MBSR) and
Mindfulness-Based Cognitive Therapy (MBCT) programmes, has
increased substantially during the last two decades. Robust
evidence supports the ability of MBSR to improve mental health
outcomes in adults with chronic medical diseases.19 Several
potential mechanisms underlying the efficacy of mindfulness of
change have been proposed, including exploring internal experi-
ences such as sensations, cognitions, and emotions:20 -decision
making; self-management; relaxation; and acceptance, suggesting
that this approach may be beneficial to human health.21 In East
Asia, especially in Taiwan, religious people perform mindfulness
meditation on a daily basis, particularly in the monasteries.
However, only recently has mindfulness meditation being used in
clinical practice, with some scholars applying it in cases of cancer22
and psychosis.23 However, research regarding mindfulness medi-
tation for these treatments is still in the initial stages.
Some scholars support the combining of prenatal courses with
mindfulness meditation in programmes such as Mindfulness-
Based Childbirth and Parenting (MBCP) and Mindfulness-Based
Childbirth Education (MBCE).24 The use of these programmes has
clearly reduced mental health problems such as stress and
anxiety,24,25 depression,24–26 and fear27 in pregnant women.
During childbirth, these programmes have been shown to increase
childbirth self-efficacy,27 and mindfulness.24,25 However, most of
the related research to date did not use randomized-control
trials (RCTs) and many used overly small sample sizes in pilot
studies.24–28 RCTs are needed in order to confirm the validity of the
above-mentioned studies.
The purpose of the present study was to explore the efficacy of
the MBCP programme on prenatal stress, depression, mindfulness,
and childbirth self-efficacy. Preventive MBCP interventions were
provided to pregnant women with the objective of alleviating their
psychological problems and promoting a positive experience of
labour and birth.
2. Methods
2.1. Design and data collection
This randomized controlled trial and parallel design study used
the web-based G*Power 3.1.9 software and is based on the size
effect obtained from Goyal et al. (a = 0.05, power = 0.8).29 A
minimum of 86 participants were required plus a 20% margin to
allow for attrition. The research was performed from February
2016 to May 2017 at a regional hospital in northern Taiwan, where
the birth rate is approximately 2000 per 2080 thousand population
per annum.
The participants were assigned to the experimental and
comparison groups using random allocation software,30 and were
randomly allocated in a 1:1 ratio using block sizes of 6, 8 and 12. This
random assignment method was determined by a statistician and
allocations were blinded to the researchers. Because the research
needed to explain mindfulness, the research administrators (RAs)
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Fig. 1. CONSORT diagram. Passage of participants through each trial stage.

who recruited the participants remained blinded to participant 2.3. Intervention

group assignments throughout the trial period.
2.2. Participants
Eligibility for the present study included all pregnant women
who: visited an obstetrician at the target hospital during the
recruitment period, could communicate sufficiently in Chinese,
were at 13–28 weeks gestation with a singleton pregnancy, and
were at least 20 years old. Further, eligible participants were
required to express willingness to give vaginal birth and to attend
childbirth education programmes. Pregnant women were exclud-
ed who had a diagnosed psychosis or if they or their foetuses had
any medical complications. The purpose and methods of the
study were explained to all of the potential participants, and all
enrolled participants signed an informed consent agreement. A
total of 104 women were included in the present study, as shown
in Fig. 1.
The experimental group participated in an MBCP programme
that was designed by Nancy Bardack.25 This programme, based on
MBSR, uses the transformative experience of pregnancy, childbirth,
and postpartum-related adjustments in self-awareness training.
The MBCP programme provides a series of nine three-hour classes
held once per week and one seven-hour day of silent-meditation
practice. However, recent research reported a high attrition rate of
36% at the end of the programme and of 21% at 6 weeks
postpartum,17 indicating that the long (9-week) duration of the
course may increase dropout tendencies.
Therefore, this curriculum was designed using the MBCP time
course outlined by Veringa et al.,31 which combines the first- and
second-week courses of the original MBCP into one week, sets the
time for each class at three hours, and holds one seven-hour silent
retreat (Table 1). Additionally, the participants are required to
listen to programme-related audio recordings at home six times a

Table 1
Adaptation of the Mindfulness-Based Childbirth and Parenting Programme.

Week Summary of the programme

1 The history of MBCP, eating meditation, breathing meditation
2 Body scan, attitudinal foundations of mindfulness, community building.
3 Breathing meditation, physiology of childbirth from a mind-body perspective
4–6 Mindful movement/yoga, sitting meditation, pain meditations using ice, practicing various positions for labour with a partner or support
person, 3-min breathing space meditation
Retreat day Body scan, yoga, sitting meditation, mindful eating, walking meditation, mindful speaking and listening around fear and happiness
7 Loving-kindness meditation and psychoeducation: biological, emotional and social needs of the newborn and the needs of the postpartum family
8 Physiology of breastfeeding, mindfulness as a skill for coping with breastfeeding challenges and the postpartum period, closing graduation ceremony

Please cite this article in press as: W.-L. Pan, et al., Mindfulness-based programme on the psychological health of pregnant women, Women
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week for 30 min each. The course was conducted entirely by the
principal investigator of the present study, who was trained in
Taiwan by the International Childbirth Education Association and
was trained on the MBSR programme designed by Jon Kabat-Zinn.
This investigator had further participated in follow-up MBSR
teacher training, received professional MBCP training from Nancy
Bardack, and taught yoga to pregnant women.
The participants in the comparison group were given conven-
tional childbirth education at the research hospital. The compari-
son group course taught pregnancy-related physiological and
psychological information and self-care skills during pregnancy
and after childbirth. The course was provided for a total of two
times over a two-month period. Standard, undifferentiated
medical care for participants in both groups was provided by
physicians and nurses at the target hospital.
2.4. Measures
The following validated self-report measures were adminis-
tered before (T0) and after (T1) the intervention, as well as during
the follow-up at 36 weeks gestation (T2). The Perceived Stress
Scale (PSS),32 the Edinburgh Postnatal Depression Scale (EPDS),33
the short form of the Chinese Childbirth Self-Efficacy Inventory
(CBSEI-C32),34 and the Five Facet Mindfulness Questionnaire
(FFMQ)35 were completed by all participants at each self-report
measure administration. The measures collectively took approxi-
mately 20 min to complete.
2.4.1. PSS
This study measures perceived stress using 10 items to
determine the self-perceived levels of unpredictability, lack of
control, and burden during the last month of pregnancy. Responses
are rated from 0 (never) to 4 (very often), with higher scores
corresponding to higher perceived stress.32 For the present study,
the Cronbach’s alpha ranged from 0.85 to 0.87.
2.4.2. EPDS
This 10-question questionnaire provides a valuable and efficient
way to identify patients at risk of perinatal depression. Each item is
scored from 0 to 3, with item scores summed to produce a total
score.36 An EPDS score greater than 13 in the antenatal period has
been recommended as an indicator of depression,37 and the cut off
value of 13 has previously been used in populations of Taiwanese
women.38 The Cronbach’s alpha ranged from 0.84 to 0.88 in the
present study.
2.4.3. CBSEI-C32
The present study used a Chinese short-form version,34 the
original CBSEI scale by Lowe39 to evaluate the childbirth self-
efficacy of the participants. This psychometrically sound diagnostic
tool is composed of two factors: outcome expectancy (OE) and
efficacy expectancy (EE). CBSEI-C32 is a 10-point self-report scale,
with scores ranging from 1 (not at all helpful) to 10 (very helpful)
for the OE-16, and from 1 (not at all sure) to 10 (very sure) for the
EE-16. The Cronbach’s alpha ranged from 0.95 to 0.98 in the
present study.
2.4.4. FFMQ
The 39-item FFMQ is based on factor analysis. The five facets of
the FFMQ include: observing, describing, acting with awareness,
non-judging of inner experience, and non-reactivity to inner
experience. Scoring uses a 5-point Likert scale, with 1 representing
“never or very rarely true” and 5 representing “very often or always
true”.35 The Cronbach’s alpha ranged from 0.77 to 0.88 in the
present study.
Please cite this article in press as: W.-L. Pan, et al., Mindfulness-based programme on the psychological health of pregnant women, Women
Birth (2018), https://doi.org/10.1016/j.wombi.2018.04.018
2.5. Ethical considerations
Recruitment began only after the hospital and nursing and
maternity departments granted formal approval (Institutional
Review Board approval number 104-E-20). The date of approval at
2nd February, 2016. The recruited participants and others who met
the study criteria were approached individually. All of the
participants received information regarding the purpose of the
study and each provided oral informed consent to participate. To
ensure confidentiality, all collected data were anonymized and
restricted from use outside of the present research. Furthermore,
the participants were informed of their right to withdraw from
participation at any time during the study period without impact
to their care.
2.6. Data analysis
Data were analysed using SPSS version 22.0 for Windows.
Demographic characteristics were summarized as the mean
(standard deviation, SD) for continuous variables, and as frequency
counts (percentages) for categorical variables. A x2 test was used to
evaluate the differences between the demographic variables of the
two groups, including level of education, marital status, occupa-
tion, and family income. Rank scores and continuous data were
analysed using an independent t test. Longitudinal data analysis
was performed using Generalized Estimating Equation (GEE)
models to measure the outcome variables T0, T1, and T2.
3. Results
A total of 134 participants were interviewed. The data of 30 of
these were excluded from further analysis afterward due to
unwillingness to participate. No significant differences were
reported between the final group of participants (n = 96) and
those who had been lost to follow-up (n = 8) in terms of age, level of
education, marital status, religion, household income, and
occupation (Table 2) or in terms of PSS, EPDS, and CBSEI-32
scores. Differences were apparent between the experimental and
comparison groups in terms of lower scores for the experimental
group on the overall FFMQ scale (p = 0.04) and on the ‘awareness’
subscale (p = 0.02; Table 3).
Multivariate analyses using the GEE model (Table 4) indicated
that, when controlling for the baseline values of stress, gestational
weeks, and age, the mean stress score for the experimental group
was slightly higher at baseline, but no significant differences
between the groups were noted (Fig. 2). The comparison group was
used as the reference to further examine the interaction between
group and time. The mean score for stress in the experimental
group was 2.82 points lower than that in the comparison group
(p = 0.01) at T1 and 2.79 points lower (p = 0.01) at T2.
In terms of depression, although the mean score for the
experimental group was higher than that of the comparison group
at baseline, this difference was not significant. However, as time
progressed, the mean score for the experimental group was 2.56
points lower than that for the comparison group (p < 0.001) at T1
and 2.53 points (p = 0.007) lower at T2. For the childbirth self-
efficacy test, although the mean score for the experimental group
was higher than that for the comparison group at baseline, this
difference was not significant (p = 0.07). However, the mean score
for the experimental group was 26.38 points (p = 0.001) higher
than the comparison group at T1 and 26.92 points higher
(p < 0.001) at T2. On the mindfulness questionnaire, although
the mean score for the experimental group was slightly lower than
that for the comparison group at baseline (p = 0.05), as time
progressed, the mean score for the experimental group was 8.22
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Table 2
Characteristics of participants.

Characteristics All (n = 96) Intervention group (n = 51) Comparison group (n = 45) Statistics p

n % n % n %
Age (M  SD) 32.83  3.83 32.65  3.78 33.04  3.91 5.05 0.62b
Gestational age of infant (M  SD) 20.99  4.96 20.27  4.73 21.80  5.15 1.51 0.14b
Level of education 0.54 0.82a
Junior college or below 12 12.5 6 11.8 6 13.3
University or above 84 87.5 45 88.2 39 86.7
Marital status 0.16 0.90a
Married 92 95.8 49 96.1 43 95.6
Not married 4 4.2 2 3.9 2 4.4
Religious 1.69 0.19a
No 53 55.2 25 49.0 28 62.2
Yes 43 44.8 26 51.0 17 37.8
Employment statusc 0.38 0.54a
Employed 19 19.8 9 17.6 10 22.2
Unemployed 76 79.2 42 82.4 34 75.6
Incomec 3.54 0.17a
Less than US$1500 13 13.5 4 7.8 9 20.0
US$1500–US$2999 29 30.2 17 33.3 12 26.7
More than US$2999 51 53.1 30 58.8 21 46.7
Pregnancy intention 3.02 0.08a
Intentional 30 31.3 12 23.5 18 40.0
Unintentional 66 68.8 39 76.5 27 60.0
Parity 1.56 0.21a
No prior births 87 90.6 48 94.1 39 86.7
1 or more prior births 9 9.4 3 5.9 6 13.3
a
Chi-Square test.
b
Independent t test.
c
Numbers may sum to less than 96 because of missing data.

points higher than the comparison group at T1 (p < 0.001) and the similar to two studies.17,18 Although Dunn et al. was a non-RCT
two scores were significantly equivalent at T2. study with only 19 subjects and Guardino et al. was designed as a
pilot study. The present study also found the following new
4. Discussion information about stress in the run-up to childbirth. While both
groups experienced increased levels of stress, the increases in the
After the intervention, the participants in the experimental experimental group were smaller than in the comparison group.
group earned lower scores for stress and depression and higher Potential factors exacerbating prenatal stress associated with
scores for childbirth self-efficacy and mindfulness than their
comparison group peers. These results support that stress affects
Table 4
variables that relate to depression and childbirth self-efficacy. Assessing the effects of stress, depression, childbirth self-efficacy, and mindfulness
Additionally, both groups showed slight increases in stress and using the GEE model.
declines in childbirth self-efficacy and mindfulness at 36 weeks of
Variable B SE 95% CI Wald x p
pregnancy, while depression declined steadily between T0 and T2.
PSS
The findings of the present study demonstrate that the
Group 1 vs Group 0 0.62 0.48 0.32 1.56 1.66 0.20
experimental group achieved significant reductions in self- T1 vs T0 0.61 0.63 1.85 0.62 0.94 0.33
reported stress, as compared with the comparison group. T2 vs T0 0.45 0.80 1.11 2.02 0.33 0.57
Additionally, significant reductions in the interaction between Group 1*T1 2.82 1.03 4.82 0.77 7.29 0.01
group and time were observed for T1 and T2. These results are Group 1*T2 2.79 1.08 4.94 0.69 6.77 0.01
EPDS
Group 1 vs Group 0 0.17 0.29 0.41 0.74 0.33 0.57
Table 3 T1 vs T0 0.17 0.51 0.83 1.18 0.12 0.73
Baseline physical and psychological health and childbirth self-efficacy. T2 vs T0 0.39 0.75 1.87 1.09 0.27 0.62
Group 1*T1 2.56 0.72 3.98 1.15 12.56 <0.001
Variable Intervention group Comparison group p
Group 1*T2 2.53 0.94 4.37 0.70 7.28 0.007
(n = 51) (n = 45)
CBSEI-C32
(M  SD) (M  SD)
Group 1 vs Group 0 8.18 4.52 0.67 17.03 3.28 0.07
PSS 15.61  6.24 13.69  5.76 0.12 T1 vs T0 6.88 5.90 4.68 18.45 1.36 0.24
EPDS 9.75  0.59 9.02  0.68 0.22 T2 vs T0 1.69 8.14 17.64 14.26 0.04 0.84
CBSEI-C32 229.33  41.76 213.91  44.67 0.08 Group 1*T1 26.38 10.55 6.24 47.61 6.51 0.01
OE-16 115.71  21.69 107.71  22.28 0.08 Group 1*T2 26.92 9.10 8.54 44.23 8.40 <0.001
EE-16 113.63  20.91 106.20  22.48 0.10 FFMQ
FFMQ 129.82  13.73 135.58  13.25 0.04 Group 1 vs Group 0 2.06 1.05 4.12 0.00 3.84 0.05
Observing 28.80  4.57 29.13  4.34 0.72 T1 vs T0 1.26 1.35 1.39 3.91 0.87 0.35
Describing 26.65  4.85 28.27  4.72 0.10 T2 vs T0 1.77 1.78 1.73 5.26 0.98 0.32
Awareness 27.67  3.71 29.42  3.22 0.02 Group 1*T1 8.22 2.68 2.97 13.48 9.41 0.02
Non-judging 23.88  4.31 25.53  4.64 0.07 Group 1*T2 6.53 2.71 1.21 11.85 5.80 0.16
Non- 23.22  3.95 23.22  3.30 0.60
Group 1 = experimental group; Group 0 = comparison group; T0 = before the
reactivity
intervention; T1 = after the intervention; T2 = 36 weeks of gestation. PSS = the
PSS = the Perceived Stress Scale; EPDS = the Edinburgh Postnatal Depression Scale; Perceived Stress Scale; EPDS = the Edinburgh Postnatal Depression Scale; CBSEI-
CBSEI-C32 = the short form of the Chinese Childbirth Self-efficacy Inventory; C32 = the Short Form of the Chinese Childbirth Self-Efficacy Inventory; FFMQ = the
FFMQ = the Five Facet Mindfulness Questionnaire. Five Facet Mindfulness Questionnaire.

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Fig. 2. Differences with 95% CI of stress, depression, childbirth self efficacy and mindfulness in T0, T1 and T2.
timing of birth40 include the many tasks that must be completed
before birth and the unpredictability of the timing of the onset of
labour.
The experimental group experienced lower levels of depression
during pregnancy than the comparison group. One study most
closely resembled to the present study due to its use of a one-group
pre–post experimental design with 27 subjects, similarly found
significantly reduced depression during pregnancy (p < 0.05).25
However, but an Australian study used an MBCE program for eight
weeks with 18 nulliparous women and found no significant
differences (p = 0.104).27 Rouhe et al.41 used the IPT programme to
combine childbirth education courses with 30 min of mindfulness
meditation. They found significant pregnancy - postpartum
differences (p < 0.05) in three measurements in their study of
371 pregnant women, 131 of who were assigned to the
experimental group. The efficacy of mindfulness meditation in
the treatment of depression remains to be confirmed in future
studies. While the participants in both groups may have been
conscious of and motivated to reduce their prenatal stress/anxiety
prior to participation, the effect of the MBCP programme was still
better than conventional childbirth education in the present study.
Using an EPDS score of 13 as the cut off, the prevalence of
depression in this study was estimated at 27.1%, with 15 in the
experimental group and 11 in the comparison group identified as
suffering from depression. Another study found a prevalence rate
of 17.3% among 236 pregnant women in southern Taiwan.38
Additionally, a study that was conducted in China using the
Chinese version of the Self-Rating Depression Scale found that
roughly 28.5% of 292 pregnant women suffered from depression.13
These studies indicate that psychotherapy-related courses and
MBCP programmes are more effective than conventional pro-
grammes in treating extreme depression in pregnant women. This
may be because depression frequently accompanies maternal
stress, which thus may be classified as a symptom of depression.42
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Birth (2018), https://doi.org/10.1016/j.wombi.2018.04.018
However, the application of mindfulness, i.e., paying full attention
to the present moment, may be very helpful in improving the
cognitive symptoms of depression.
Childbirth self-efficacy, an important indicator of the coping
abilities of women during labour and birth,43 is strongly and
negatively correlated with depression.44 Therefore, enhancing self-
efficacy during childbirth is paramount. Studies have indicated
that psycho-educational interventions such as MBCE or MBCP have
statistically improved childbirth self-efficacy and alleviated the
childbirth-related fears of pregnant women.13,26,27 Childbirth self-
efficacy is a psychosocial factor that may be modified using various
efficacy-enhancing interventions. More time should be allocated to
educational interventions such as mindfulness meditation so that
the psychological problems of women during pregnancy may be
addressed effectively in order to enhance childbirth self-efficacy.
Self-confidence with regard to the ability to handle childbirth has
been shown to effectively reduce perceived pain34 and the
psychological trauma of childbirth45 as well as to alleviate
suffering.
The present study found that the experimental group earned
lower pre-test (T0) scores, particularly on the awareness subscale,
than the comparison group. This is likely attributable to the
minimal exposure that pregnant woman in Taiwan receives to
mindfulness meditation. In answering participant queries regard-
ing the meaning of mindfulness meditation, the RAs were required
to answer: “Mindfulness means to be present in the moment”. She
also had an example, such as “whether you had difficulty finding
things easily or if they used the phone or computer while eating”
before this study, so people understand they did not focus a
wandering mind to stay in the present moment. This may have
affected the pre-test scores of the experimental group.
Many researchers of mindfulness meditation use the FFMQ
scale, which offers the potential for comparing results across
studies.18,24,25 However, the decline that was found in the present
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study in mindfulness scores at T2 conflicts with Byrne et al.,27 who
found that postnatal mindfulness increased. Unfortunately, the
current literature contains almost no longitudinal research on
pregnant mindfulness. This may be due to the cessation of courses,
to a decline in number of mindfulness courses offered, or to the
stress of birth. While the present study found a slight reduction in
mindfulness in the experimental group, the reduction was greater
in the comparison group.
5. Conclusions
This integrative RCT study explored the potential effectiveness of
using a mindfulness intervention during pregnancy in terms of
reducing the perceived stress and depression and in increasing the
self-efficacy and mindfulness of expectant mothers. It is recom-
mended that MBCP programmes be conducted in hospitals and
communities in order to allow mindful education help more prenatal
families improve/promote their mental health. A limitation of the
present study was its survey of a single sample population in Taiwan
using a single-blind, randomized controlled trial model. This
approach resulted in a significant difference in the amount of
attention received, respectively, by the participants in each group,
with the experimental group undergoing an intense programme
involving much contact and engagement and the comparison group
receiving sparse attention. More research is needed to examine the
comparative effectiveness of mental-health-related interventions
that involve similar levels of contact/engagement during pregnancy.
Overall, the present paper presents evidence for the suitability and
usefulness of an MBCP intervention during pregnancy.
Ethical statement
Recruitment began only after the hospital and nursing and
maternity departments granted formal approval (Institutional
Review Board approval number 104-E-20). The date of approval at
2nd February, 2016.
Acknowledgements
This study was supported by the University of Kang Ning (Grant
No: D1050206). The authors wish to express their greatest
appreciation to the women who agreed to participate in this
study. The assistance of the nursing staff and administrators of the
Taiwan Adventist Hospital in recruiting women for this study is
gratefully acknowledged. The authors have no conflicts of interest
to report. RCT trial registration: NCT03185910.
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Birth (2018), https://doi.org/10.1016/j.wombi.2018.04.018