Can the use of non-pharmacological interventions reduce the levels of stress and anxiety in pregnancy?
By Nicole Arbuckle
Australian Institute of Family Counselling
The aim of the study was to test the benefit of non-pharmacological interventions to reduce stress and anxiety in pregnancy. The interventions used were mindfulness, positive psychology and self-compassion. This study was a two-way between groups pre-test/post-test quantitative design with baseline and ending sample scores. There was an innovation group with two participants that completed the four-week treatment process. There were three participants in the control group who completed the four-week treatment process. The five participants in Australia responded to social media advertising for non-pharmacological treatment of stress and anxiety in pregnancy. Pre-test/post-test changes in stress, anxiety and worry were measured using the DASS-21 and the Penn State Worry Questionnaire. At post-test there was a statistically significant improvement in anxiety for the innovation group between 98% and 99.8%. At post-test there was no statistically significant improvement in stress and worry for the innovation group, between 0% and 50% and 70% and 80% respectively. Considering the limited sample size, the short test period, and the absence of follow-up, the author has discussed the implications of the study and recommendations for further research.
Can the use of non-pharmacological Interventions reduce the levels of stress and anxiety in pregnancy?
Research has proven that increased stress and anxiety in pregnancy can lead to birth issues, including pre-term birth and underweight babies. Primarily the use of pharmacological interventions has been used to target these areas. However, pharmacology is not the only intervention. With further research and more field studies it could be empirically proven that the use of non-pharmacological interventions such as mindfulness, positive psychology and self-compassion can reduce the levels of stress and anxiety in pregnancy and furthermore reduce any risk to mum and baby during pregnancy. Therefore, this paper shall explore the hypotheses that non-pharmacological interventions such as mindfulness, positive psychology and self-compassion can reduce the levels of stress and anxiety during pregnancy. The project tested a field of 6 pregnant women who were all assessed for their stress, anxiety and worry scores based on completion of the DASS-21 and the Penn State Worry Questionnaire. The field project then introduced a series of three interventions across four weeks with the prediction being that the women would experience a reduction in their stress, anxiety and worry scores across the four-week study period. The interventions were all selected based on relevant studies that have been conducted in stress and anxiety management. The interventions included breathing exercises, inspirational statements and self-compassion journaling. The assessment tools used were standardized tools to provide statistical significance between the innovation group and the control group. The innovation group were given active interventions across the four- week study. The control group oversaw facilitating their own interventions across the four- week study. The intention and prediction of the study was that the results between the two groups would be significantly different and therefore support the hypotheses that non-pharmacological interventions can reduce the levels of stress and anxiety in pregnancy.
Pregnancy can be a rewarding experience for expectant mothers. It can also be a time of increased anxiety and stress. Research shows that stress and anxiety in pregnancy are significant risk factors for adverse birth outcomes. Increased stress and anxiety has been associated with preterm delivery. Depending on individual circumstances, pregnancy can be perceived as positive and negative. Some things that can influence pregnancy anxiety include: personality factors, optimism and access to social support. Biomedical issues such as a high-risk pregnancy or a prior health condition; psychological concerns such as depression; and social factors, for example a lack of support from the baby’s father can all increase stress and anxiety in pregnancy. Other factors can be age, education, income and culture, in addition a fear of labour and the fear of pregnancy result often in predicted shorter gestation (Wadhwa, Entringer, Buss & Lu, 2011). Non-pharmacological interventions could help to decrease stress and anxiety in expectant mothers. The author will explore relevant literature on the topic of stress and anxiety in pregnancy. The author will discuss key aspects of the topic as they relate to relevant journals. They will explore therapy issues that may surround the use of non-pharmacological and seek to provide a biblical perspective and draw conclusions that will inform the subsequent project.
Stress in general and anxiety are risk factors for adverse birth outcomes for mother and infant. Literature suggests that the rate of antenatal depression can range between 4.8% and 40% (Grote, Bridge, Gavin, Melville, Iyengar & Katon, 2010; Mohammad, Gamble & Creedy, 2011; Faisal-Cury, Savoia & Menezes 2012; Gourounti, Anagnostopoulos & Lykeridou, 2013). Furthermore, the rate of anxiety is reportedly between 6.8% and 59.5% (Gourounti et al. 2013). The use of non-pharmacological interventions as a coping mechanism can ‘operate to either alter or reduce the negative emotions, even under difficult circumstances in pregnancy’ (Gourounti et al. 2013, p. 354). Rubertsson; Hellstrom; Cross and Sydsjo (2014) state that maternal anxiety may also affect the baby as it develops in utero. They go on so say that depressive illnesses and anxiety in ‘pregnancy also constitutes a risk factor for adverse obstetric outcomes such as preterm birth and post-partum depression’ (Rubertsson et al. 2014, p. 221).
Thomas, Komiti and Judd (2014) made an argument for the importance of early intervention to prevent or reduce the impact of anxiety in pregnancy based on an economic study of the cost of perinatal depression. The cost of Perinatal depression in Australia is estimated at $78.66 million. Thomas, Komiti and Judd (2014) piloted a study into the importance of early intervention. Their evidence-based antenatal group interventions and research project targeting women who are depressed in pregnancy showed benefit in reducing or preventing symptoms in the postnatal period. ‘The study showed that mothers in the intervention group showed significant improvements in depressive symptoms, anxiety and attachment to their baby. The significant improvements in depressive symptoms were maintained two months after the end of the intervention’ (Sockol, 2014 para. 4). Clatworthy (2012) also examined the importance of early interventions designed to prevent depression in the postnatal period. Research undertaken by Keonig (2004) found links between religiosity, spirituality and mental health coping strategies. The research also showed that religion influences mental health through the promotion of a healthy lifestyle; provision of social support; a cognitive framework that promotes adaptive coping; meditation and providing a sense of direction (Moreira-Almeida, Koenig & Lucchetti, 2014).
There has been an increase in women experiencing anxiety in pregnancy and as such there needs to be an increase in non-pharmacological interventions to reduce the risk to the baby and mother (Goodman, (b), Guarino, Chenausky, Klein, Prager & Petersen, et al. 2014). Introducing non-pharmacological interventions such as positive psychology, mindfulness and self-compassion may have beneficial effects in ‘reducing stress, anxiety, depressive symptoms and emotional distress during pregnancy’ (Goodman et al, 2014 p. 374). The research available shows that further studies are needed to adequately understand the effect of interventions during the antenatal period to reduce anxiety.
Therapy issues surrounding anxiety in the antenatal period likely stem from ‘untested assumptions about the maternal and foetal risks…Elevated stress and anxiety during pregnancy (stemming from naturally occurring environmental stressors or psychopathology) carries the burden of transferring the risk to the developing foetus’ (Arch, Dimidjian & Chessick, 2012 p. 446). However, this is also a strong argument for why effective treatment or intervention is important (Buss, Davis, Muftuler, Head & Sandman, 2010; Conde, Figueiredo, Tendais, Teixeira, Costa, Pacheco & Nogueira, 2010). The issue lies with treatment or interventions that can cause physiological or psychological trauma in the immediate term that may in turn harm the baby (Arch et al. 2012).
Research shows that pregnant women are biologically different during pregnancy. The Hypothalamic-pituitary-adrenal axis (HPA) presents differently which means that cortisol levels increase and the stress response is therefore effected by the adrenal release (Entringer, Buss, Shirtcliff, Cammack, Yim & Chicz-DeMet, et al. 2010). This must be considered before the field project commences (Arch et al. 2012). Another issue to be aware of is the client’s previous or current treatment options. Is the pregnant woman being treated with pharmacotherapy, while this may not be the ideal way, we need to respect their decision and that of their doctor. Another therapy issue is the limitation caused by the sample size being small (Bowen, Baetz, Balbeuna & Muhajarine, 2014). Another cause for concern is that it is individual and relies on the participant completing tasks independently at home, as such this may not address the issue of social support. However, research has shown an improvement of 60% using individual interpersonal therapy. In comparison group intervention improved only 15% (Bowen et al. 2014). Another therapy issue is ‘women who are improperly or untreated for depression or anxiety are at an increased risk for post-partum depression (Bowen, et al. 2014). For this reason, it is important to ensure that the safety of participants is the priority always. Another therapy issue was that the participants aren’t of a similar gestational time and the risk of miscarriage which would cause trauma and require the participant to exit the program to do grief counselling (Rubertsson, Hellström, Cross & Sydsjö, 2014). Another common therapy issue during pregnancy surrounds body image and self-compassion. A study into Mindfulness Based Therapy during pregnancy showed a need to provide interventions designed to decrease anxiety around some stressors in pregnancy like body awareness, emotional patterns, self-compassion and a decrease in labour fear (Bowen, et al. 2014). ‘Recruitment and retention were a challenge: This limited our ability to have a wait list for comparison, also women found it difficult to commit to all sessions due to work or school schedules, concurrent prenatal classes, and the health of themselves or other children in their family’ (Bowen, et al. 2015 p. 230).
The bible talks a lot about anxiety and pregnancy respectively but there is nothing exclusively about antenatal anxiety. Instead the author is left to draw conclusions and make assessments from what we have been provided. In the Hebrew Bible, we are led to believe that conception is divine. In Genesis 4:1 it reads ‘and the man had sexual relations with Eve, his woman, and she conceived and bore Cain. I have acquired a man with YHWH’ (Hebrew- English Tanakh, 2004). We also see moments that relate to bareness which would have undoubtedly caused anxiety. In Genesis 25 we see that Isaac prayed to end Rebekah’s infertility and they were in turn blessed with twins (Stiebert, 2010, p.216). Another cause for anxiety in the bible is the importance of honour placed on having a male child. Leah states that she will be honoured because she gave birth to six sons (Gen 30:20) and in Ruth we are told the ideal is seven sons (Ruth 4:15). Hannah prays for a ‘seed of men’ (1 Sam 1:11) which is for a child, but expressly a male. In Psalms 127:3-5 the psalmists equate bearing sons with honour, protection and a divine reward (Stiebert, 2010, p.224).
In Matthew 6:25 it says, ‘Therefore I tell you, do not worry about your life, what you will eat or drink; or about your body…’ (NIV) it is an admonition, advice to trust that God provides, you need not be anxious. In Genesis Eve eats of the tree and her consequence is the pain of childbirth multiplied (Gen 3:16). This creates great anxiety as the time of birth draws near. In John 16:21 it says, ‘A woman giving birth to a child has pain because her time has come; but when her baby is born she forgets the anguish because of her joy that a child is born into the world’ (NIV).
‘Religious involvement has been associated with decreased blood pressure and heart rate. Further, a social presence during a stressful event has been associated with reduced stress as measured by heart rate, blood pressure, and lower self-reported stress’ (Schwartz 2007 p. 1). A study undertaken by Kroll and Sheehan (1989) revealed ‘that patients with major depression and anxiety disorders were the least religious’ (Schwartz 2007 p.14). Koenig et al (2004) discovered that those who participated in organised religious activity such as church, along with those committed to daily spiritual devotion were less likely to experience depression. Furthermore, the study revealed that depressive symptoms were less common with the participants that were involved in activities such as prayer.
Wiegand (2004) found that prayer could promote state anxiety. State anxiety being a temporary response to an external situation. The study used student participants who read either a prayer or a control passage before completing an assessment task. The initial study showed no difference to state anxiety. However, with further investigation participants who prayed in the prayer condition exhibited a reduction in their state anxiety. ‘That is, participants who actually prayed had less anxiety than those who simply read the prayer. This experiment illustrates the complex nature of religious behaviour and the potential benefits that are associated with it’ (Schwartz 2007 p. 16).
The bible speaks of mindfulness through prayers and meditations. This is an example of an intervention to decrease anxiety. ‘Do not be anxious about anything, but in every situation, by prayer and petition, with thanksgiving, present your requests to God. And the peace of God, which transcends all understanding will guard your hearts and minds in Christ Jesus (Philippians 4:6-7 NIV). The bible advocates for positive psychology as an intervention ‘Anxiety weighs down the heart, but a kind word cheers it up’ (Proverbs 12:25 NIV). One study on the link between spirituality and anxiety revealed that ‘the implied presence of a support friend may also reduce stress, and one way to invoke the image of a supportive presence is through prayer to God’ (Belding, Howard, McGuire, Schwartz & Wilson, 2009, p.180). Belding et al. (2009) go on to cite the research done by Peacock and Poloma in 1999 in regard to religious activity having a positive link to overall life satisfaction. The most biblically relevant aspect of the research topic is meditation as an intervention. Dwell in His word and not our own perception. Trust that it is all planned for good and simply release the anxiety. Psalm 1:2 ‘But his delight is in the law of the Lord, and in His law, he meditates day and night’(NIV). The authors of Bible.org (n.d) explain the objectives of meditation from a biblical perspective, stating the first objective is worship: to focus on the Lord, to make space for faith and not the material (Ps 27:4; 77:12). The second objective is instruction: to understand on a head and a heart level the application of His promises through His word (Ps 49:3; 119:27). The third objective is for encouragement (Ps 119:105; Josh 1:7-8). The final objective is transformation. It is designed to change lives, to remove anxieties and replace them with peace (Ps 4:4;19:14; 119:15; Rom 12:2; Col 3:1). A biblical perspective further strengthens the topic in interventions and how they can be used to decrease stress and anxiety during pregnancy. Interventions such as meditation help to renew and reprogram the mind (bible.org, 2017).
A study conducted by Laird, Snyder, Rapoff & Green (2004) found that the frequency of prayer per week and per day, the duration of prayer and the level of belief in prayer outcome were related to stress reduction. Their study revealed that ‘these aspects of prayer were negatively correlated with anxiety, such that the more participants prayed and the more they believed in the effect of their prayers, the less anxiety they reported experiencing in their lives’ (Schwartz 2004 p.40).
Literature reviewed highlights the need for further research into the effect of non-pharmacological interventions to reduce antenatal stress and anxiety. The literature reviewed has promising results, however the consensus was a lack of information to verify the need to treat stress and anxiety in the antenatal stages to avoid adverse birth outcomes such as pre-term delivery and post-partum depression (Goodman, et al. 2014). ‘Many women experience anxiety during pregnancy with potential negative effects on maternal, birth, and child outcomes. Because of potential risks of foetal exposure to psychotropic medications, efficacious non-pharmacologic approaches are urgently needed’ (Goodman, et al. 2014 p.373). Rubertsson, et al. highlighted a need for further research; they stated that ‘Emerging research has also shown that depression during pregnancy also constitutes a risk factor for adverse obstetric outcomes such as preterm birth and postpartum’ however, Anxiety disorders during pregnancy have received less research attention (Rubertsson, et al. 2014 p.220).
Much research has been done into therapies that are ‘empirically supported psychosocial treatments for anxiety in general adult samples. Pregnant women, however, generally have been excluded from the body of research’ (Arch, et al. 2012 p.445). There is evidence to support that women exhibit a differing biological make up during pregnancy (HPA Axis) and further investigation is needed to inform the field regarding the treatment of stress and anxiety in pregnancy using non-pharmacological interventions (Arch, et al. 2012).
Sample and Participant Selection
The participants were selected from a group of eight pregnant women who volunteered because of seeing the field project advertised online. From the initial group of eight, six women were selected that fell within the eligibility criteria. The sample included six pregnant women: two carrying twins, one expecting her first child, one expecting her fourth child and two expecting their second child. The sample ages ranged from 25 to 35 years. Of the sample 83.3% of participants completed the four-week field project. 16.67% of the sample failed to complete the four-week field project.
The six women were assessed during the initial interview to see if they fell within the eligibility criteria. The criteria for the project was a) second trimester gestation b) age 18 years or above c) no pre-existing mental health conditions. Those who fell within the eligibility criteria were invited to sign the informed consent form. The assessments and interviews were conducted by the author during a weekly thirty-minute session with each participant. The sample that were excluded were those that had a) pre-existing psychological concerns b) an elevated depression score on the DASS-21 c) under the age of 18 d) First Trimester gestation. Three participants were assigned to the control sample group and three were assigned to the innovation sample group.
Assessments and Measures
The author used the Depression, Anxiety and Stress Scale 21 (DASS 21). It is a 21-item self-report questionnaire that consists of three subscales measuring the current (‘over the past week’) symptoms of depression, anxiety and stress on a 4-point Likert scale. Subscale scores are calculated by adding the rating scores of the 7 items of each scale, with higher scores indicative of more severe depression, anxiety, or stress. The DASS-21 was designed to enhance the measuring process that defines, explains and measures the ‘ubiquitous and clinically significant emotional states usually described as depression, anxiety and stress’ (Depression Anxiety and Stress Scales- DASS, 2014). The DASS-21 contains three sections that provides the researcher with three scales. Each scale is subsequently divided into subscales that assess 7 items of similar content. The depression scale assesses life dissatisfaction. Hopelessness and similar components. The Anxiety scale assesses autonomic arousal -which includes palpitations, nausea and hyperventilation, situational anxiety and muscular responses that are subjective to the persons anxious affect. The Stress scale is designed to be sensitive to ongoing and prolonged arousal. It examines the persons difficulty with relaxing, arousal, agitation, and their likelihood of over-reacting. The scores are then calculated by summing up the relevant items (Depression Anxiety and Stress Scales- DASS, 2014). ‘As the scales of the DASS have been shown to have high internal consistency and to yield meaningful discriminations in a variety of settings, the scales should meet the needs of both researchers and clinicians who wish to measure current state or change in state over time (e.g., in the course of treatment) on the three dimensions of depression, anxiety and stress’ (Depression Anxiety and Stress Scales-DASS, 2014). The author was only interested in the scores present for stress and anxiety, however, if the participant had an elevated depression score that made them ineligible they were informed, and it was recommended they see their GP for a check- up.
The author also used the Penn State Worry Questionnaire. The PSWQ developed by Meyer, Miller, Metzger and Borkovec in 1990 is designed to assess the non-specific excessive and ‘uncontrollability dimensions of pathological worry’ (Zhong, Wang, Li & Lie, 2009). The PSWQ has been used to self-report the measure of worry. The PSWQ has sixteen items that are rated on a five- point Likert scale. Eleven of the items are designed to assess pathological worry. A higher number indicates more worry. Five items are designed to identify a lack of worry, with higher numbers then indicating less worry. The total PSWQ score is ‘calculated by summing the first 11 items and the reverse-scores of the latter 5 items, with higher PSWQ scores reflecting greater levels of pathological worry’ (Zhong, Wang, Li & Liu, 2009). The author chose to use the PSWQ in addition to the DASS-21 to get an overall picture of the stress and anxiety levels from outside of the seven- day period. The control sample were assessed in the initial interview and again in the fourth concluding session to get a four-week measurement.
The author met with the control sample individually for four thirty-minute sessions. In the first session, an eligibility interview was conducted using the measurement tools mentioned above. This was followed with an introduction to the project and a facilitation of the control interventions for the project. The control sample were responsible for setting their own interventions within the framework of mindfulness, positive psychology and self-compassion.
The author met with the innovation sample individually for four thirty-minute sessions. In the first session, an eligibility interview was conducted using the above-mentioned measurement tools. Following the assessment, the author explained the project requirement in detail and provided them with a structured intervention for each week. The first week was mindfulness, the innovation sample were required to conduct breathing exercises daily. The second week was positive psychology, this required the innovation sample to speak positively about themselves and their expectations for the day. The third week the innovation sample were required to complete a self-compassion exercise every day. All interventions were provided to the innovation group. In the final session the author administered the DASS-21 and the PSWQ to compare the results.
Following the random allocation to sample groups; control and innovation, intake assessments were completed using the DASS-21 and the PSWQ. The results were recorded as baseline scores. Of the six participants that were sampled only five completed the process. As such, the author excluded the baseline figures for participant 17NA-04/007. This left the project with 3 degrees of freedom.
Outcome of Stress Assessment of Pregnant Women
The participants were assessed during the intake session to obtain their stress sub scales within the DASS-21. Using the DASS-21 the author evaluated an average of 20 for the baseline innovation group and an average baseline of 17.3 for the control group. Using the ‘t-Table’ the author was able to see that for 3 degrees of freedom, a ‘t-Score’ of 0.38 sits somewhere between 1.00 and 0.50, this represents a confidence level of between 0% and 50%. This is not statistically significant (over 95%). Therefore, the results of the stress interventions did not show a significant enough improvement to support the hypothesis that the interventions utilised by the innovation group were the cause of the participants improved scores.
The Innovation group was a sample of two participants. One participant failed to complete the field project. As such their data was not included in the calculations. The average stress score of the Innovation sample was 20.0. There was an improvement of 52.1% which reflected an average improvement of 10.00 on their scores. Participant 17NA-04/005 improved by 41.7% decreasing their stress score from 24 to 14. Participant 17NA-04/006 improved their stress score from 16 to 6 which was a 62.5% improvement. Due to the limited sample size there was not enough data to prove statistical significance.
The Control group was a sample of three participants. All three participants completed the field project over the four-week process. As such all data was included in the calculations. The average stress score of the Control sample was 17.3. There was an overall improvement of 15.2% which reflected an average improvement of 6.67 on their scores. Participant 17NA-04/001 maintained their stress score of 14. Participant 17NA-04/002 saw an increase of 40% in their overall stress score increasing their score from 10 to 14. Participant 17NA-04.003 saw an improvement of 85.7% on their stress score, improving it from 28 to 4. Participant 17NA-04/003 exceeded the expectations of the hypothesis set for the control group. Due to the limited sample size there was not enough data to prove statistical significance.
Outcome of Anxiety Assessment of Pregnant Women
The participants were assessed during the intake session to obtain their anxiety subscales using the DASS-21. Using the DASS-21 the author evaluated an average score of 18.99 for the Innovation group and 2.0 for the Control group. Using the ‘t-Table’ the author could see that for 3 degrees of freedom, a ‘t-Score’ of 6.00 sits somewhere between 0.01 and 0.02, representing a confidence level of between 99% and 99.8%. This is statistically significant (over 95%). Therefore, the results of the anxiety interventions show a significant enough improvement to support the hypothesis that the interventions utilised by the Innovation group were the cause of the participants improved scores.
The Control group was a sample of three participants. All three participants completed the field project over the four-week process. As such all data was included in the calculations. The average anxiety score of the Control sample was 2.0. There was an overall improvement of 0% which reflected an average improvement of 0 on their scores. Participant 17NA-04/001 maintained their anxiety score of 1. Participant 17NA-04/002 saw an improvement of 100% in their overall anxiety score decreasing their score from 12 to 0. Participant 17NA-04.003 maintained their anxiety score of 1. Participant 17NA-04/002 exceeded the expectations of the hypothesis set for the control group.
The Innovation group was a sample of two participants. One participant failed to complete the field project. As such their data was not included in the calculations. The average anxiety score of the Innovation sample was 18. There was an improvement of 70.8% which reflected an average improvement of 12.00 on their scores. Participant 17NA-04/005 improved by 58.3% decreasing their stress score from 24 to 10. Participant 17NA-04/006 improved their stress score from 12 to 2 which was an 83.3% improvement. The results of the Innovation group were high enough to support statistical significance. However, the author notes that the baseline scores of the Control group were significantly lower than the Innovation group. The participants were randomly allocated to groups prior to the initial intake DASS-21 assessment.
Outcome of Worry Assessment of Pregnant Women
The participants were assessed during the intake session to obtain their pathological worry scores using the Penn State Worry Questionnaire. Using the PSWQ the author evaluated an average score of 68.5 for the Innovation group and 39.7 for the Control group. The PSWQ has a total score of 80. Using the ‘t-Table’ the author could see that for 3 degrees of freedom, a ‘t-Score’ of 1.61 sits somewhere between 0.30 and 0.20, representing a confidence level of between 70% and 80%. This is not statistically significant (over 95%). Therefore, the results of the worry interventions do not show a significant enough improvement to support the hypothesis that the interventions utilised by the Innovation group were the cause of the participants improved scores.
The Control group was a sample of three participants. All three participants completed the field project over the four-week process. As such all data was included in the calculations. The average worry score of the Control sample was 39.7. There was an overall improvement of 27.2% which reflected an average improvement of 10.67 on their scores. Participant 17NA-04/001 decreased their worry score by 27.3% taking their score from 33 to 24. Participant 17NA-04/002 saw an improvement of 24.5% in their overall worry score decreasing their score from 49 to 37. Participant 17NA-04.003 improved their worry score by 29.7% decreasing their worry score from 37 to 26. Participant 17NA-04/003 exceeded the expectations of the hypothesis set for the control group. Due to the limited sample size there was not enough data to prove statistical significance.
The Innovation group was a sample of two participants. One participant failed to complete the field project. As such their data was not included in the calculations. The average worry score of the Innovation sample was 39.7. There was an improvement of 31.4% which reflected an average improvement of 22.00 on their scores. Participant 17NA-04/005 improved by 24.6% decreasing their worry score from 61 to 46. Participant 17NA-04/006 improved their worry score from 76 to 47 which was a 38.2% improvement. The results of the Innovation group were not high enough to support statistical significance.
The importance of non-pharmacological interventions to reduce stress and anxiety in pregnancy has been highlighted by this study. ‘Many women experience anxiety during pregnancy with potential negative effects on maternal, birth, and child outcomes. Because of potential risks of foetal exposure to psychotropic medications, efficacious non-pharmacologic approaches are urgently needed’ (Goodman, et al. 2014 p.373). Rubertsson, et al. highlighted a need for further research; they stated that ‘Emerging research has also shown that depression during pregnancy also constitutes a risk factor for adverse obstetric outcomes such as preterm birth and postpartum’ however, Anxiety disorders during pregnancy have received less research attention (Rubertsson, et al. 2014 p.220). To date numerous studies have been published into the use of pharmacological interventions for stress and anxiety. The findings of this study are that four sessions of motivational interventions brought about change in their measures of stress, anxiety and worry. While the study did not prove statistical significance in all three areas of stress, anxiety and worry, there was enough evidence of change to support statistical significance for anxiety.
Given that there was a significant change of between 99% and 99.8% in the participant scores during the four-week study it can be concluded with confidence that the causative factor in the improvement of anxiety scores was the non-pharmacological interventions.
The results across the three areas of testing for the Innovation group suggest that the participants saw an improvement in their stress, anxiety and worry scores with greater coping ability and a decrease in their overall worrisome outlook. Although there were changes to the participant scores there are limitations to the study. The principal limitation is the small sample size, and the duration of the testing, along with the absence of follow-up assessment. The small sample size decreased and limited the validity of the study. However, the six participants of the study were sufficient to show change, while not statistically significant, supports the hypothesis and should prompt further study. Confidence can be had in the anxiety findings of this study. However, the small sample size limited the ability to generalize the findings to other populations. The author recommends a larger scale study that incorporates a larger sample of participants per group that are drawn from GP referrals, marketing and social media applications. The author would also recommend changing the interventions of the control group to show a more accurate comparison to the innovation group. A longer study is also needed to map the results across a greater gestational period and with post-partum follow-up at 6 months and 12 months.
In summary, given the lack of significant change, confidence cannot be found in the study in relation to stress and worry. The treatment methods implemented for anxiety resulting in statistically significant change provides valuable support for the use of non-pharmacological interventions in relation to anxiety in pregnancy and therefore, they could safely be recommended to decrease anxiety in pregnancy.
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