Coping during pregnancy: a systematic review and recommendations

An integrative review of the literature on screening for gender-based violence during pregnancy: barriers, facilitators, and tools

An integrative review of the literature has been developed to explore barriers and facilitators in screening for gender‐based violence in pregnant women and identify available tools for this screening. Studies were identified via a systematic search on the PubMed, CINAHL Plus (Cumulative Index of Nursing and Allied Health Literature Complete), Scopus, and LILACS (Latin American and Caribbean Health Sciences Literature) databases and a manual reverse reference search to obtain literature published between 2015 and 2020. The methodology followed the recommendations made by Whittemore & Knafl. The quality of studies was evaluated using the Critical Skills Appraisal Program tool. Twenty‐three of the 4202 articles fulfilled the inclusion criteria. The principal barriers identified were lack of training for professionals (mainly nurses and midwives), lack of support policies, and lack of human and material resources. The main facilitators were to increase professional training programs on case detection, availability of effective instruments, and greater investment in resources to guarantee safety and referral of cases. With regard to the available tools, the Abuse Assessment Screen (AAS) continues to be the most widely used, although others such as the Humiliation, Afraid, Rape, and Kick questionnaire (HARK) could be suitable for antenatal care settings.

Perceived stress during the prenatal period: assessing measurement invariance of the Perceived Stress Scale (PSS-10) across cultures and birth parity

Maternal prenatal stress places a substantial burden on mother's mental health. Expectant mothers in low- and middle-income countries (LMICs) have thus far received less attention than mothers in high-income settings. This is particularly problematic, as a range of triggers, such as exposure to traumatic events (e.g. natural disasters, previous pregnancy losses) and adverse life circumstances (e.g. poverty, community violence), put mothers at increased risk of experiencing prenatal stress. The ten-item Perceived Stress Scale (PSS-10) is a widely recognised index of subjective experience of stress that is increasingly used in LMICs. However, evidence for its measurement equivalence across settings is lacking. This study aims to assess measurement invariance of the PSS-10 across eight LMICs and across birth parity. This research was carried out as part of the Evidence for Better Lives Study (EBLS, vrc.crim.cam.ac.uk/vrcresearch/EBLS). The PSS-10 was administered to N = 1,208 expectant mothers from Ghana, Jamaica, Pakistan, the Philippines, Romania, South Africa, Sri Lanka and Vietnam during the third trimester of pregnancy. Confirmatory factor analysis suggested a good model fit of a two-factor model across all sites, with items on experiences of stress loading onto a negative factor and items on perceived coping onto a positive factor. Configural and metric, but not full or partial scalar invariance, were established across all sites. Configural, metric and full scalar invariance could be established across birth parity. On average, first-time mothers reported less stress than mothers who already had children. Our findings indicate that the PSS-10 holds utility in assessing stress across a broad range of culturally diverse settings; however, caution should be taken when comparing mean stress levels across sites.

Correlation between religious coping, demographic and fertility factors, and pregnancy anxiety of Iranian primiparous women: a cross-sectional study

BACKGROUND

Anxiety during pregnancy can have side effects for both the mother and the baby. Therefore, it is necessary to study the factors that affect anxiety during pregnancy. This study aimed to investigate the role of religious coping and demographic and fertility factors in predicting pregnancy anxiety in Iranian primiparous women.

METHODS

We conducted a cross-sectional study on 300 primiparous women (n = 100 in each trimester of pregnancy) referred to seven health centers affiliated to the Iran University of Medical Sciences, Tehran, Iran. The sampling method was multistage. It lasted from July 2018 till August 2019. Data collection tools included the demographic and fertility questionnaire, valid and reliable Iranian Religious Coping Scale (IRCS), and standard State-Trait Anxiety Inventory (STAI).

RESULTS

Religious practices, benevolent reappraisal, and active religious coping had a significant inverse relationship with state and trait anxiety. Whereas negative and passive religious coping had a significant direct relationship with state and trait anxiety. The mean scores of state anxiety had a significant relationship with the women's education, spouse's education and occupation, economic status and housing status. There was no relationship between state anxiety and fertility variables. Based on multiple linear regression, negative and active religious coping predicted 27% of state anxiety and 15% of trait anxiety. Among these two variables, the negative religious coping was the more effective in predicting state and trait anxiety.

CONCLUSION

With increasing positive religious coping, the anxiety of pregnant women decreased. Whereas with increasing negative religious coping, their anxiety increased. Our results emphasize the role of negative religious coping in predicting pregnancy anxiety.

Coping with Covid-19: stress, control and coping among pregnant women in Ireland during the Covid-19 pandemic

Background

The aim of the current study is to investigate the relationship between perceived control, coping and psychological distress among pregnant women in Ireland during the Covid-19 pandemic. It is hypothesised that lower levels of perceived control, greater use of avoidant coping and greater Covid-19 related pregnancy concern will be associated with psychological distress. In addition, it is hypothesised that the relationship between Covid-19 related pregnancy concern and psychological distress will be moderated by perceived control and avoidant coping.

Method

The study is cross-sectional, utilizing an online questionnaire, which was completed by 761 women in January 2021. The questionnaire includes measures of perceived control, coping style, perceived stress, anxiety and depression.

Results

Correlation analyses found that lower levels of perceived control were associated with higher levels of avoidant coping and psychological distress. There was also a significant positive relationship between avoidant coping and psychological distress. Using multiple regression, perceived control, avoidant coping and Covid-19 related pregnancy concern were found to predict 51% of the variance in psychological distress. However, in the moderation analysis, perceived control and avoidant coping were not found to moderate the relationship between Covid-19 related pregnancy concern and psychological distress.

Conclusion

The results from this study suggest that pregnant women in Ireland are experiencing increased levels of psychological distress during the Covid-19 pandemic. The findings also suggest that perceptions of control and avoidant coping are associated with psychological distress in this group and could be used as intervention targets.

The mediating role of coping styles in the relationship between perceived social support and antenatal depression among pregnant women: a cross-sectional study

Background

Antenatal depression (AD) is common in pregnant women and is associated with adverse outcomes for the mother, fetus, infant and child. The influencing factors of AD among pregnant women have been studied; however, the mechanisms of these factors remain unclear. This study was designed to examine the direct and serial mediating roles of coping styles in the relationship between perceived social support and AD among pregnant women.

Methods

A cross-sectional study was conducted among 1486 pregnant women who registered to give birth at a tertiary hospital. A self-developed questionnaire was administered to obtain sociodemographic and obstetric data. The Perceived Social Support Scale (PSSS), Simplified Coping Style Questionnaire (SCSQ), and Edinburgh Postnatal Depression Scale (EPDS) were administered to measure the perceived social support, coping styles, and depressive symptoms of pregnant women, respectively. Multiple linear stepwise regression analysis was used, and then, the specific relationships among influencing factors were determined through structural equation modelling (SEM).

Results

The prevalence of AD was 24.02%. The average scores of intrafamily support, extrafamily support, positive coping styles, negative coping styles and EPDS reported by pregnant women were 24.16 ± 3.09, 44.52 ± 6.16, 27.34 ± 4.89, 9.79 ± 3.82, and 7.44 ± 3.56, respectively. Multiple regression analysis showed that pregnant women with a higher level of intrafamily support exhibited a positive coping style and a decreased risk of AD. Compared with extrafamily support, the direct effect (-0.16 vs. -0.10, P < 0.05) and indirect effect of intrafamily support through coping styles (-0.028 vs. -0.027, P < 0.05) on AD were stronger. Two indirect pathways explained 17.46% of the variance in the EPDS scores.

Conclusion

Higher social support decreased the likelihood of AD, not only directly but also through the mediating roles of coping styles. Social support should be strengthened, and positive coping styles should be advocated in every stage of pregnancy. Specifically, intrafamily support should be given more attention for pregnant Chinese women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04377-9.

Coping strategies and depression during the COVID-19 pandemic in pregnant women: a cross sectional study

BACKGROUND

Pregnant women are vulnerable to psychological problems depending on the adaptive capacities of their personality and coping strategies. This study aimed to investigate the association between coping strategies of pregnant women during the COVID-19 pandemic and depression.

METHODS

This web-based cross-sectional study was conducted in 2021 on 318 pregnant women in Amol, Iran. Data collection was performed via questionnaires (Brief cope, Edinburgh Postnatal Depression Scale, CDA, and Demographic questionnaire). The questionnaires were completed through the WhatsApp and Telegram applications. Data were analyzed using the hierarchical regression analysis and SPSS software (v. 21) at the significance level of 0.05.

RESULTS

About 40% of participants had depression. The most prevalent coping strategy used by pregnant women was the avoidance strategy. Hierarchical regression revealed that the coping strategy of avoidance was a significant predictor of depression (β = 0.226, p = 0.046) after controlling background characteristics.

CONCLUSIONS

The findings of this study suggest that avoidance style associated with depression in pregnant women. Therefore, obtaining further knowledge about impacts of coping strategies on pregnant women seems to be essential.

Stress, coping and silver linings: How depressed perinatal women experienced the COVID-19 pandemic

BACKGROUND

Research on perinatal mental health during the COVID-19 pandemic has largely focused on data from community samples. This study sought to understand the experiences of pregnant and postpartum women with histories of clinically elevated symptoms of depression.

METHODS

Participants included 60 perinatal women who participated in wellness intervention trials for women with antenatal depression. We used a mixed methods approach, assessing depression, anxiety, stressors and coping behaviors, along with narrative responses to questions regarding COVID-specific effects on mental health.

RESULTS

Over three-fourths of the sample indicated a worsening of mental health during the pandemic, with 31.7% of women endorsing clinically elevated depression symptoms and 36.7% screening positive for anxiety. Women reported negative impacts on their emotional wellbeing, especially a resurgence of mental health symptoms. Participants also articulated positive experiences during the pandemic, including an appreciation for increased time with family, especially infants. Women detailed numerous, mostly adaptive, coping strategies they had used to mitigate stress; self-isolation and spending time outdoors were associated with having depression above or below the clinical cut off, respectively.

LIMITATIONS

The study had a small sample, and the generalizability of findings may be limited, given that participants were clinical trial completers.

CONCLUSIONS

Although the pandemic upended many aspects of life for perinatal women and raised mental health concerns, many also reported adaptive means of coping and positive experiences or 'silver linings' related to pandemic restrictions. Some coping strategies that were utilized, including wellness-based behaviors, may have helped to mitigate the impact of COVID-19 related stress.

Psychological factors and coping strategies in pregnancies complicated by hypertension: A cluster-analytic approach

BACKGROUND

Hypertensive disorders are important causes of maternal and perinatal morbidity and death. Considering the role of both physical and psychological factors in pregnancies complicated by hypertension, the aim of this study is to examine psychological factors and coping strategies in pregnancies complicated by hypertension.

METHODS

Cross-sectional study. A sample of 552 pregnant women, 343 with pregnancies complicated by hypertension, were assessed in terms of depression, anxiety, stress and coping.

RESULTS

The hypertensive group had higher scores of depression, stress and anxiety than the control one. Coping strategies were different between hypertensive and control groups (except for confrontive and self-reliant coping styles). When splitting up the hypertensive group into gestational hypertension, chronic hypertension and preeclampsia syndrome, differences between this new classification reached the statistical level. Our data suggests that women with preeclampsia have more symptoms of depression and worse coping strategies - they are less optimistic and more fatalistic. However, after a cluster analysis, two different subgroups of hypertensive women were found: one with worst coping strategies and more vulnerability to negative affective states and another with better coping and more resilient to mental health problems.

LIMITATIONS

Data were cross-sectional. We excluded women with some comorbidities, such as a diagnosis of kidney disease, diabetes or fetal malformation.

CONCLUSIONS

It is important to consider distinct profiles of pregnant women, in order to be able to better understand the peculiarities of mental health and coping during the gestation, especially in pregnancies complicated by hypertension.

The Construct Structures of Psychological and Behavioral Responses to COVID-19 Pandemic in Pregnant Women

AIM

The present study aimed to investigate the construct structure behind the psychosocial response, behavioral response, prenatal depression, and post-traumatic stress disorder (PTSD) in pregnant women during the COVID-19 pandemic in China.

METHOD

The validated Chinese version of the Edinburgh Postnatal Depression Scale (EPDS), PTSD CheckList (PCL)-6, and two newly established scales for COVID-19-related psychological and behavioral responses were used. Structural equation modeling (SEM) analysis was applied to evaluate the structural relationships of psychological and behavioral responses during the COVID-19 pandemic.

RESULTS

Of the 1,908 mothers who completed the questionnaires, 1,099 met the criteria for perinatal depression, and 287 were positively screened for PTSD, where 264 women exceed the cut-off points for both. Pregnant women with full-time or part-time jobs tended to have the lowest scores of EPDS (10.07 ± 5.11, P < 0.001) and stress levels (23.85 ± 7.96, P = 0.004), yet they were more likely to change their behavior in accordance with the COVID-19 outbreak (13.35 ± 3.42, P = 0.025). The structural model fit the data (χ² = 43.260, p < 0.001) and resulted in satisfactory fit indices (CFI = 0.984, TLI = 0.959, RMSEA = 0.072, and χ²/df = 10.815), all path loadings were significant (p < 0.05). The SEM indicates that the level of QoL was attributable to the occurrence of PND, leading to PTSD, and COVID-19 related behavioral and psychological responses.

CONCLUSION

The inter-relationships between the COVID-19-related psychosocial and behavioral responses have been assessed, indicating that the pandemic increased the burden of perinatal depression. Psychoeducation, as well as other psychological interventions, may be needed to alleviate the COVID-19-based anxiety and increase their engagement in protective behaviors.

Positively Pregnant: Development and piloting of a mobile app for social and emotional well-being in pregnancy

This paper describes development of a mobile e-health application, Positively Pregnant, which provides tools to meet the psychological challenges of pregnancy and transition to parenthood. Positively Pregnant was developed with input from maternity carers and consumers, incorporating local cultures and contexts as well as international research on effective interventions for stress management and mental well-being. The prototype app was piloted with 88 New Zealand women. Participants in the pilot used an average of 11.96 (SD = 7.44) components, and most were satisfied (45.1%) or neutral (40.3%) regarding the app. For 23 of the 26 interactive components, the majority of those who tried the component reported that they found it helpful. Participants reported a significant reduction in subjective stress (η²  = .088, p = .023). Feedback from pilot participants was incorporated in a version of the app that was publically launched as a free tool to support developing families. Mobile e-health applications are a promising medium for providing preventative interventions and psychoeducation about the social and emotional challenges of pregnancy and early parenting; Positively Pregnant is an example of a tool, grounded in strength-based, empirically supported strategies, to provide parents with support and information at this critical time.

The mediational role of social support in the relationship between stress and antenatal anxiety and depressive symptoms among Australian women: a mediational analysis

Background

Pregnancy can be a stressful period for most women and their family members, and the mental wellbeing of pregnant women can face serious challenges. Social support can play a role in improving the psychological well-being of pregnant women by enhancing the stress coping ability and alleviating stressful conditions. The current study aimed to assess the mediating effects of social support in the relationship between perceived stress and depressive symptoms as well as anxiety symptoms during pregnancy among Australian women.

Methods

Of the 8,010 women who completed Survey 6 of the 1973–78 Australian Longitudinal Study on Women’s Health (ALSWH) cohort in 2012, those who reported being pregnant (n = 493) were included in the current analyses. Antenatal depressive and anxiety symptoms were assessed using the 10 item Center for Epidemiological Studies Depression (CES-D-10) scale, and the 9-item Goldberg Anxiety and Depression scale (GADS) respectively. The 19 item-Medical Outcomes Study Social Support index (MOSS) was used to examine social support. A parallel mediation model was used to explore the mediational role of each domain of social support between perceived stress and antenatal depressive and anxiety symptoms.

Result

The study found that emotional/informational support has a partial mediating effect on the relationship between perceived stress and antenatal depressive symptoms (β = 0.371, 95% CI: 0.067, 0.799) and on the relationship between perceived stress and antenatal anxiety symptoms (β = 0.217, 95% CI: 0.029, 0.462). Affectionate support/positive social interaction and tangible support was found to play no significant mediation role between stress and antenatal depressive and anxiety symptoms.

Conclusions

Emotional/informational support appears to play a mediating role in the relationship between stress and antenatal depressive as well as between stress and antenatal anxiety symptoms. In order to further protect pregnant women from the effects of stress, policy makers and maternal health professionals are advised to develop community-based social support programs to enhance prenatal psychosocial support and ensure pregnant women have adequate emotional/information support.

Social support is a resource or a means that an individual can use to cope with stressful events and improve psychological wellbeing. It improves emotional and physical well-being and promotes health for a successful pregnancy. However, the relationship between domains of social support and antenatal depressive and anxiety symptoms remains understudied in Australia. Therefore, our study intended to examine the mediating role of domains of social support in the linkage between stress and depressive and anxiety symptoms during pregnancy among Australian Women.

Data were obtained from Survey 6 of the 1973–78 ALSWH cohort, which was conducted in 2012, and those who reported being pregnant were part of the study (n = 493, aged 34–39 years). Social support provided for a pregnant woman was the outcome variable, assessed using the 19-item Medical Outcomes Study Social Support index (MOS-SSS-19 item). A parallel mediation model was used to explore the mediational role of each domain of social support between perceived stress and antenatal depressive and anxiety symptoms.

Emotional/informational support plays a mediating role in the relationship between stress and antenatal depressive as well as between stress and antenatal anxiety symptoms. So, to further protect pregnant women from the effect of stress, policymakers and maternal health professionals are advised to develop community-based social support programs.

Prenatal anxiety and the associated factors among Chinese pregnant women during the COVID-19 pandemic--a smartphone questionnaire survey study

BACKGROUNDS

The uncertainty of the pandemic of Coronavirus Disease 2019 (COVID-19) brought about tremendous psychological harm for pregnant women, causing their high rates of prenatal anxiety. The impacts of COVID-19 pandemic and symptoms of pregnant status are highly linked with prenatal anxiety. Whereas, self-efficacy and support from family and friends could attenuate the development of prenatal anxiety. Thus, the purpose of the study is to evaluate the prevalence of prenatal anxiety and its influence factors among pregnant women during the pandemic of COVID-19 in Shenyang, China.

METHODS

A cross-sectional study with face-to-face interview between April 24, 2020 and May 3, 2020 during the COVID-19 pandemic was applied among pregnant women in Shenyang Women's and Children's Hospital. Chi-square tests were calculated to determine the differences in prenatal anxiety among categorical variables. Multivariable logistic regression was employed to investigate the risk factors of prenatal anxiety.

RESULTS

The percentage of prenatal anxiety (GAD-7 score ≥ 7) among pregnant women during the pandemic of COVID-19 was 34/304 (11.18%). Logistic regression indicated that vomiting (OR 4.454, 95% CI 1.113-17.821) and feeling susceptible to SARS-CoV-2 infection (OR 2.966, 95% CI 1.151-7.642) increased the odds of prenatal anxiety. Satisfaction with medical care (OR 0.303, 95% CI 0.113-0.813) and self-efficacy (OR 0.253, 95% CI 0.100-0.639) decreased the odds of prenatal anxiety. High monthly income (OR 0.246, 95% CI 0.078 ~ 0.780) reduced the chances of suffering from prenatal anxiety.

CONCLUSION

The pregnant women in China exerted a higher prevalence of prenatal anxiety during the COVID-19 pandemic than that without COVID-19 pandemic. Effective management on symptoms of pregnant status should be delivered to relieve prenatal anxiety for the pregnant women. Furthermore, interventions on self-efficacy enhancement and high-quality medical prenatal care should be provided to prevent from the susceptibility of SARS-CoV-2 infection and reduce prenatal anxiety.

Early Association Factors for Depression Symptoms in Pregnancy: A Comparison between Spanish Women Spontaneously Gestation and with Assisted Reproduction Techniques

Women with assisted reproduction techniques (ART) have a different psychological profile than women with a spontaneous pregnancy. These differences may put the former group at higher risk for depressive symptomatology. Our aim was to determine what sociodemographic factors and psychological variables interact with early depressive symptoms in pregnant women with ART. This is a cross-sectional, non-interventional, and observational study where a total of 324 women were analyzed in the first trimester of pregnancy at the Hospital Universitario Central de Asturias (Spain). Women completed a sociodemographic questionnaire, the Patient Health Questionnaire (PHQ-9), the Generalized Anxiety Disorder 7-item Scale, the Resilience inventory, the General concerns (ad hoc scale), the Stressful life events, and the prenatal version of Postpartum Depression Predictors Inventory-Revised (PDPI-R), including socioeconomic status, pregnancy intendedness, self-esteem, partner support, family support, friends support, marital satisfaction, and life stress. According to our models, women undergoing ART had significantly increased the PHQ-9 scores (β = 6.75 ± 0.74; p-value < 0.001). Being single also increased the PHQ-9 score. Related to the psychological variables, anxiety (β = 0.43 ± 0.06; p-value < 0.001) and stressful life events (β = 0.17 ± 0.06; p-value = 0.003) increased PHQ-9 scores. In contrast, resilience (β = -0.05 ± 0.02; p-value = 0.004), self-esteem (β = -1.21 ± 0.61; p-value = 0.048), and partner support (β = -1.50 ± 0.60; p-value = 0.013) decreased PHQ-9 scores. We concluded that women undergoing ART need interventions to reduce anxiety and stressful life events, and to improve resilience, self-esteem, and emotional partner support to prevent depressive symptomatology during this important phase in their lives.

Promoting Attachment Through Healing (PATH): Results of a retrospective feasibility study providing trauma-and-violence-informed care to pregnant women

AIM

To evaluate the impact of a trauma and violence-informed cognitive behavioural therapy (TVICBT) intervention, compared with standard care on mental health, coping, bonding and maternal-infant attachment among pregnant women with a history of intimate partner violence and who displayed symptomatology consistent with anxiety, depression or post-traumatic stress disorder (PTSD).

DESIGN

A mixed-methods case study design was employed, where women either received standard perinatal care or were referred to a specialized TVICBT program.

METHODS

Data were collected through a retrospective obstetric medical chart audit in 2017 at an Ontario hospital in a large urban centre. Multiple choice and 'yes/no' questions were analysed using measures of central tendency and dispersion, in addition to frequency counts. Qualitative data from clinical notes were subjected to an inductive content analysis approach to identify key concepts.

RESULTS

In total, 69 women participated (intervention group = 37, standard care group = 32). Prevalence of mental illness between groups was consistent, apart from the TVICBT group having a significant increase in PTSD. In the TVICBT group, 83.8% of women (n = 31) expressed perinatal concerns, compared with only 37.5% (n = 12) of the standard care group. More women in the intervention group (94.6%, n = 35) coped successfully in the intrapartum period than the standard care group (78.1%, n = 25). However, more women in the standard care group (97.0%, n = 31) exhibited appropriate bonding behaviours than the TVICBT group (88.6%, n = 31).

CONCLUSION

The TVICBT intervention was effective in assisting women to identify triggers during their pregnancy journey, develop appropriate coping strategies and advocate for their needs to best cope.

IMPACT

TVICBT offers an effective, individualized, trauma and violence-informed approach to optimize the health outcomes of perinatal women and their infants by promoting positive coping and maternal-infant bonding, thus filling an existing practice gap of a lack of individualized, trauma-informed care.

The correlation between levels of prenatal attachment and styles coping with stress in pregnant women

BACKGROUND

Pregnancy is a very important period in the development of attachment.

OBJECTIVE

To determine the correlation between prenatal attachment levels of healthy pregnant women and their styles of coping with stress and those of high-risk pregnant women.

METHOD

This descriptive study consisted of 76 women in their third-trimester of pregnancy hospitalised at the Obstetrics and Gynaecology service at a hospital and 210 women in their third-trimester of pregnancy who were experiencing a healthy pregnancy process and admitted to the Gynaecology Outpatient Clinic for pregnancy follow-up. The data were collected with the Personal Information Form, the Prenatal Attachment Inventory and the Stress Coping Styles Scale.

RESULTS

There was a statistically significant difference between the prenatal attachment levels of healthy and high-risk pregnant women. There was a positive correlation between the prenatal attachment levels and the self-confident and optimistic approaches among the styles of coping with stress in the healthy and high-risk pregnant women .

CONCLUSION

The attachment levels of the high-risk pregnant women were higher than were those of the healthy pregnant women. As the use of the self-confident and optimistic approach styles in coping with stress increases among healthy and high-risk pregnant women, so do their prenatal attachment levels.

Depression and Anxiety in Mothers Who Were Pregnant During the COVID-19 Outbreak in Northern Italy: The Role of Pandemic-Related Emotional Stress and Perceived Social Support

The COVID-19 pandemic is a collective trauma that is threatening citizens' mental health resulting in increased emotional stress, reduced social support, and heightened risk for affective symptoms. The present study aimed to investigate the effects of antenatal pandemic-related emotional stress and perceived social support on the symptoms of depression and anxiety of mothers who were pregnant during the initial COVID-19 outbreak in northern Italy. A sample of 281 mothers was enrolled at eight maternity units in the first hotspot region of the COVID-19 outbreak in northern Italy. Participants filled out online questionnaires assessing the direct or indirect exposure to the SARS-CoV-2 virus, pandemic-related stress, perceived social support, as well as symptoms of depression and anxiety. Depressive and anxious symptomatology was above clinical concern, respectively, in 26 and 32% of the respondents. Mothers who reported no exposure to SARS-CoV-2 during pregnancy and those who reported at least one direct or indirect exposure did not differ in terms of affective symptoms. Continuous scores and risk for severe depression and anxiety were positively associated with prenatal pandemic-related emotional stress and negatively linked with perceived social support during pregnancy. Women who become mothers during the COVID-19 emergency may be at high risk for affective problems. Dedicated preventive programs are needed to provide adequate preventive support and care for maternal mental health during and after the COVID-19 pandemic.

Explaining the Black-White Disparity in Preterm Birth: A Consensus Statement From a Multi-Disciplinary Scientific Work Group Convened by the March of Dimes

In 2017-2019, the March of Dimes convened a workgroup with biomedical, clinical, and epidemiologic expertise to review knowledge of the causes of the persistent Black-White disparity in preterm birth (PTB). Multiple databases were searched to identify hypothesized causes examined in peer-reviewed literature, 33 hypothesized causes were reviewed for whether they plausibly affect PTB and either occur more/less frequently and/or have a larger/smaller effect size among Black women vs. White women. While definitive proof is lacking for most potential causes, most are biologically plausible. No single downstream or midstream factor explains the disparity or its social patterning, however, many likely play limited roles, e.g., while genetic factors likely contribute to PTB, they explain at most a small fraction of the disparity. Research links most hypothesized midstream causes, including socioeconomic factors and stress, with the disparity through their influence on the hypothesized downstream factors. Socioeconomic factors alone cannot explain the disparity's social patterning. Chronic stress could affect PTB through neuroendocrine and immune mechanisms leading to inflammation and immune dysfunction, stress could alter a woman's microbiota, immune response to infection, chronic disease risks, and behaviors, and trigger epigenetic changes influencing PTB risk. As an upstream factor, racism in multiple forms has repeatedly been linked with the plausible midstream/downstream factors, including socioeconomic disadvantage, stress, and toxic exposures. Racism is the only factor identified that directly or indirectly could explain the racial disparities in the plausible midstream/downstream causes and the observed social patterning. Historical and contemporary systemic racism can explain the racial disparities in socioeconomic opportunities that differentially expose African Americans to lifelong financial stress and associated health-harming conditions. Segregation places Black women in stressful surroundings and exposes them to environmental hazards. Race-based discriminatory treatment is a pervasive stressor for Black women of all socioeconomic levels, considering both incidents and the constant vigilance needed to prepare oneself for potential incidents. Racism is a highly plausible, major upstream contributor to the Black-White disparity in PTB through multiple pathways and biological mechanisms. While much is unknown, existing knowledge and core values (equity, justice) support addressing racism in efforts to eliminate the racial disparity in PTB.

Childbirth anxieties in the shadow of COVID-19: Self-compassion and social support among Jewish and Arab pregnant women in Israel

The study examined two angles of childbirth anxieties of Jewish and Arab pregnant women in Israel during the COVID-19 pandemic (March-April, 2020). Specifically, we examined the contribution of personal resources: self-compassion and perceived social support, as well as a couple of COVID-19-related fears of being infected and concern for the foetus, to both the woman's global fear of childbirth (FOC) and her COVID-19-related childbirth anxiety. Participants were Jewish and Arab pregnant women (n = 403) aged 20-47, who completed a set of structured self-report questionnaires from 18 March to 9 April 2020. Findings indicated that Arab women reported higher level of COVID-19-related childbirth anxiety and COVID-19-related fears of being infected and concern for the foetus. In addition, poorer health, being an Arab woman, being in the third trimester, lower self-compassion, and higher COVID-19-related fears contributed significantly to greater COVID-19-related childbirth anxiety. Furthermore, poorer health, being primiparous, at-risk pregnancy, lower self-compassion and higher fear of being infected contributed significantly to greater FOC. Importantly, social support was found to moderate the association between self-compassion and FOC. The results highlight the need to be attentive to pregnant women in times of crisis, and in particular to especially vulnerable subgroups, such as cultural minorities. They also highlight the importance of personal resources that may be applied in targeted interventions to reduce distress in vulnerable populations.

Suicidal ideation and associated factors among pregnant women attending antenatal care in Jimma medical center, Ethiopia

BACKGROUND

Suicidal ideation (SI) among pregnant women is a major public health concern worldwide and is associated with a higher risk of completed suicide. However, there are limited studies that determined the prevalence and the potential determinants of suicidal ideation in Sub-Saharan Africa, including Ethiopia. Therefore, this study aimed to explore the prevalence of suicidal ideation and associated factors among pregnant women attending antenatal care in Jimma, Ethiopia.

METHODS

An institutional-based cross-sectional study was conducted among 423 pregnant women attending Jimma medical center in Southwest, Ethiopia. A systematic random sampling technique was used to select the study participants. Suicidal ideation assessed using the Suicidality Module of the World Mental Health survey initiative version of the World Health Organization Composite International Diagnostic Interview (CIDI). Other tools used are EPDS, Abuse Assessment Scale (AAS), DASS -21, PSS, Maternity Social Support Scale (MSSS), and Pittsburgh Sleep Quality Index (PSQI). A multivariable logistic regression analysis was used to explore the potential determinants of suicidal ideation among the participants.

RESULT

The prevalence of SI among women who are on antenatal care was found to be 13.3% (95% CI (10.1,16.4). In multivariable analysis, marital status with lack of cohabiting partners (AOR = 2.80,95%CI:1.23,6.37), history of abortion (AOR = 2.45,95% CI:1.03,5.93), having depression (AOR = 4.28,95% CI:1.75,10.44),anxiety(AOR = 2.99,95% CI:1.24,7.20), poor sleep quality (AOR = 2.85,95% CI:1.19,6.79), stress (AOR = 2.50, 95% CI:1.01,5.67), and intimate partner violence (AOR = 2.43, 95% CI:1.07,5.47) were found to be significant predictors of suicidal ideation.

CONCLUSION

The prevalence of SI among pregnant women was found to be huge. Lack of cohabiting partners, previous history of abortion, depression, anxiety, intimate partner violence, poor sleep quality, and stress were variables that are independent predictors of suicidal ideation. Screening and interventions of antenatal SI are needed.

Brief report: the moderating effect of stress mindsets on associations between stress during pregnancy and symptoms of depression and anxiety

BACKGROUND AND OBJECTIVES

Research suggests that the extent to which stress is perceived as enhancing or debilitating can impact how stress is experienced, stress reactions, and stress-related outcomes. Given that there is a salient perception of stress as harmful during pregnancy, our aim was to investigate stress mindsets as a moderator of established associations between prenatal stress and elevations in anxiety and depression.

DESIGN

A survey design was used, yielding cross-sectional and longitudinal data.

METHODS

Participants (n = 388) completed a survey that included measures of stress, anxiety and depression, and stress mindsets during their pregnancy; a subset responded to a brief follow-up questionnaire assessing mental health outcomes six to eight weeks postpartum (n = 103).

RESULTS

Stress mindsets in pregnancy moderated the effect of perceived and pregnancy stress on prenatal anxiety and depression, as well as the effect of prenatal ratings of the pregnancy as a stressor on postpartum depression. The positive effect of stress on mental health outcomes grew stronger when stress was viewed as more debilitating, but was no longer significant when stress was viewed as more enhancing.

CONCLUSIONS

Though further research is needed, a positive stress mindset could be protective against some of the negative effects of prenatal stress.

Acculturative stress and coping among migrant workers: A global mixed-methods systematic review

No existing review has synthesized key questions about acculturation experiences among international migrant workers. This review aimed to explore (1) What are global migrant workers' experiences with acculturation and acculturative stress? (2) What are acculturative stress coping strategies used by migrant workers? And (3) how effective are these strategies for migrant workers in assisting their acculturation in the host countries? Peer-reviewed and gray literature, without time limitation, were searched in six databases and included if the study: focused on acculturative stress and coping strategies; was conducted with international migrant workers; was published in English; and was empirical. Eleven studies met the inclusion criteria. Three-layered themes of acculturation process and acculturative stress were identified as: individual layer; work-related layer; and social layer. Three key coping strategies were identified: emotion-focused; problem-focused; and appraisal-focused. These coping strategies were used flexibly to increase coping effectiveness and evidence emerged that a particular type of acculturative stress might be solved more effectively by a specific coping strategy. Migrant workers faced numerous challenges in their acculturative process. Understanding this process and their coping strategies could be used in developing research and interventions to improve the well-being of migrant workers.

Smoking Cessation among Pregnant and Postpartum Women from Low-Income Groups in the United States

INTRODUCTION

Pregnancy creates a unique window of opportunity for smoking cessation. However, pregnant women from underserved groups can face personal, social, and environmental challenges that impede quitting. This study draws upon the socioecological framework to explore perspectives on smoking cessation among pregnant and postpartum women from low-income groups in the mid-South of the United States.

METHODS

Semistructured interviews were conducted with 60 women who were pregnant or postpartum. Data were analyzed in Dedoose qualitative software using the directed content analysis approach.

RESULTS

Findings reveal that at the individual level, motivations for smoking cessation included the fact of being pregnant, risks associated with the infant's health, and desire to breastfeed. However, some pregnant women perceived that slowing down on smoking during pregnancy was adequate to prevent harm to their fetuses. Individual-level factors that made smoking cessation difficult included nicotine addiction and habit, boredom, stressful life circumstances, fear of weight gain, and perceived lack of willpower. At the interpersonal level, living in a smoke-free environment where loved ones do not smoke and emotional and practical support from social network members including partners and family members were thought to facilitate smoking cessation. At the organizational level, access to nicotine replacement therapies and counseling aided in their abilities to quit smoking. At the policy level, pregnant women viewed increase in cigarette prices, warning labels on the cigarette pack, and the potential for a ban on cigarette sales as having some effect in helping them quit smoking.

DISCUSSION

This study offers theoretical insights into factors that function as barriers or facilitators of smoking cessation among pregnant and postpartum women from low-income groups in the United States. Designing multilevel smoking cessation interventions while considering the interplay of individual, interpersonal, organizational, and policy level factors may lead to better cessation outcomes.

Mass Incarceration and Children's Health: A State-Level Analysis of Adverse Birth Outcomes and Infant, Child, and Teen Mortality

Children's health indicators such as mortality and adverse birth outcomes are poorer in the United States than in comparable nations. These measures also show racial inequities within the United States, with Black children experiencing the highest levels. Mass incarceration may partially explain these findings. High incarceration rates can disrupt community functioning, influencing behavior and health. The purpose of the current study was to conduct a macro (state)-level analysis examining whether yearly state incarceration rates predict health outcomes including infant, child, and teen mortality as well as preterm birth and low birth weight. It was hypothesized that prior year incarceration rates would show positive relationships with all outcomes and that relationships would be stronger for Black than for white children. Yearly state-level panel data were gathered from 1990 to 2017. Weighted least squares regression used states' prior year incarceration rates to predict child health outcomes, using controls for overall state effects and year-to-year effects. Time-varying covariates such as state unemployment rate were also included to address the possibility of spurious relationships. Results indicated that as hypothesized, incarceration rates positively predicted infant mortality, child mortality (for Black children only), preterm births, and low-weight births. Relationships tended to be stronger for Black than for white children.

Exercise and Stress in At-Risk Women during Pregnancy and Postpartum

PURPOSE

We aimed to understand the relationship between exercise and stress among socioeconomically at-risk women who participated in a home visitation service during pregnancy and postpartum.

METHODS

A mixed-methods design was used to support and supplement quantitative data using qualitative data. Convenience sampling was used to collect data from at-risk women via questionnaires and follow-up interviews. The Perceived Stress Scale was used to assess stress. Frequency and duration of exercise were assessed based on the American College of Obstetricians and Gynecologists exercise guidelines. Regression analyses examined the association between stress and exercise controlling for covariates. Content analysis was used to understand women's stress management experiences.

RESULTS

N = 114 women completed the questionnaire and a subgroup of 11 received follow-up interviews. Greater frequency of exercise was significantly associated with lower levels of stress. Approximately one-third of women reported experiencing significant stress. Talking to their husband or partner was the most used and exercise was the least used coping strategy. Many women recognized the importance of managing stress and benefits of exercise, but were hindered by barriers such as feeling tired, preventing them from exercising.

CLINICAL IMPLICATIONS

A personalized and safe exercise program has the potential to be a low-cost stress management strategy for women during pregnancy and postpartum.

Differences in interactional behaviour in postpartum depression with and without pre-existing mental disorder

BACKGROUND

Mothers with postpartum depression (PPD) show impaired affects and behaviour patterns in the mother-child interaction, which affects an infant's emotional and cognitive development and the maternal course of disease. However, impairment of the mother-child relationship does not occur in every case of PPD.

AIM

The aim of this exploratory-descriptive video-based study was to investigate the possible associations between mother-child interactions and aspects of maternal biography and clinical history, with a focus on pre-existing mental disorder.

METHODS

Sixty-two mother-child dyads (31 mothers with PPD and pre-existing mental disorders and 31 mothers with PPD but no further mental disorder) hospitalized at the mother and baby unit (MBU) of the LWL-Hospital Herten were included in this study. The Marcé Clinical Checklist and the "Mannheimer Beurteilungsskala zur Erfassung der Mutter-Kind-Interaktion im Säuglingsalter" (MBS-MKI-S) were used to explore sociodemographic and clinical parameters, and video-based interaction behaviour was examined.

RESULTS

Mother-infant interaction behaviour showed a significant group difference on the MBS-MKI-S-Vm subscale (variability in maternal behaviour) before psychiatric treatment (exact Mann-Whitney U test: U = 555, p = 0.023), with higher scores in mothers with a pre-existing mental disorder. Furthermore, significant differences were shown on the MBS-MKI-S-RSm (maternal reactivity/sensitivity) (U = 259, p = 0.019) and MBS-MKI-S-Rc (child's reactivity) subscales at discharge (U = 251, p = 0.021). Among mothers with a pre-existing diagnosis, the MBS-MKI-S-Tm (maternal tenderness) and MBS-MKI-S-Rc (child's reactivity) subscales were significantly correlated after treatment.

CONCLUSIONS

Mothers with PPD and a pre-existing mental disorder displayed significantly more behavioural variability than mothers with only PPD. Maternal behaviour seems to influence the child's responsive behaviour; thus, mothers and their children can benefit from inpatient treatment at an MBU. Further investigations with larger samples should be conducted.

Health-promotion and health-harming behaviours in pregnant women: role of coping strategies, anxiety, and depression

There is a lack information on psychological predictors of health-promotion and health-harming behaviours during pregnancy. The study aimed to examine whether psychological factors including anxiety, depression, and coping strategies could predict the health-promotion and health-harm behaviours of pregnant women. In a cross-sectional study 200 pregnant women with singleton pregnancies, older than 18 years, and with at least 5 years of education were enrolled. The participants completed four questionnaires during their prenatal care appointments. The questionnaires included the prenatal health behaviour scale (PHBS), Revised Prenatal Coping Inventory (NU-PCI), Beck Depression Inventory (BDI-II), and State-Anxiety Inventory. The results revealed that planning-preparation coping was a strong positive independent variable associated with healthy behaviours (health-promoting behavioural/nutrition (β = 0.800, p = .001); health-promoting physical activity (β = 0.191, p = .049)). It was negatively associated with unhealthy behaviours (health-harming behavioural/nutrition (β = 0.290, p < .001) as well as health-harming physical activity (β = -0.290, p = .010)). Anxiety was significantly associated negatively with healthy behaviours. Depression was the strongest positive independent variable correlated with health-harming behavioural/nutrition (β = 0.290, p < .001). Finally, avoidance coping (β = 0.179, p = .037) was significant for health-harming physical activity.Impact statementWhat is already known on this subject? Previous studies have shown that there is a correlation between psychological factors and healthy behaviours of pregnant women.What do the results of this study add? The findings highlight the significant roles of coping strategies, anxiety, and depression for predicting healthy or unhealthy behaviours of pregnant women.What are the implications of these findings for clinical practice and/or further research? The findings implied that pregnant women who use more adaptive coping strategies, especially planning- preparing coping, reported lower levels of anxiety/depression and engaged more in healthy behaviours. The study also suggests that obstetricians and health care providers should pay more attention to the roles of coping strategies, especially planning-preparation and avoidance coping, anxiety, and depression in improving health-promotion/health-harming behaviours of pregnant women.

Coping Styles for Mediating the Effect of Resilience on Depression Among Medical Students in Web-Based Classes During the COVID-19 Pandemic: Cross-sectional Questionnaire Study

Background

Due to strict, nationwide, comprehensive COVID-19 protective measures, including home quarantine, all Chinese medical students began taking web-based classes beginning in the spring semester of 2020. Home quarantine, web-based classes, and the stress surrounding the COVID-19 pandemic may have triggered an increased incidence of mental health problems among medical students. Although there have been increasing amounts of literature on depression among medical students, studies focusing on positive psychological resources, such as resilience during the COVID-19 pandemic, still need to be expanded.

Objective

This study aims to assess depression among medical students who are taking web-based classes during the COVID-19 pandemic and to investigate the role of coping styles as mediators between resilience and depression.

Methods

A cross-sectional study of 666 medical students involving stratified sampling in Shenyang, Liaoning Province, China, was completed between March 20 and April 10, 2020. The participants responded to a self-administered, smartphone-based questionnaire, which included the Patient Health Questionnaire-9, Simplified Coping Style Questionnaire, and Ego Resilience 89 Scale. Hierarchical linear regression and structural equation modeling were used in this study.

Results

The prevalence of depression among the participants was 9.6% (64/666) in this study. The regression analysis revealed that grade (the year in which the medical student was in training) (P=.013), how well students adapted to web-based classes (P<.001), their levels of resilience (P=.04), and their coping styles were independent predictors for depression (P<.001). Resilience and positive coping styles were negatively related to depression (resilience: P=.04; positive coping styles: P<.001), and negative coping styles were positively related to depression (P<.001). The structural equation modeling analysis showed that the effect of resilience on depression was partially mediated by coping styles (P=.007).

Conclusions

In this study, it was found that the prevalence of depression was slightly low and coping styles mediated the association between resilience and depression among medical students during the COVID-19 pandemic. These findings have significant implications for future studies. Future studies and interventions should aim to improve resilience and promote positive coping styles.

The effectiveness of mindfulness training on coping with stress, exam anxiety, and happiness to promote health

BACKGROUND

Mindfulness as an intervention approach in mental health has been increasingly used to promote health in young people. The aim of this study was to investigate the effectiveness of mindfulness training on coping with stress, test anxiety, and happiness to promote health in female high school students.

MATERIALS AND METHODS

The design of this study was quasi-experimental with control group, with pretest and posttest. The statistical population of the study included all the female students studying in the secondary high school in the city of Sanandaj in Iran with 2890 students, 40 of whom were selected by simple random sampling method and were randomly assigned to the experimental (20 individuals) and control groups (20 individuals). Participants completed the Oxford Happiness (0.79), Sarason Exam Anxiety (0.87), and Andler and Parker Stress Management (0.81) Questionnaires. The method of intervention was training based on mindfulness. Data were analyzed using covariance analysis.

RESULTS

The results showed that in the posttest, a significant difference was seen between the mean scores of the participants of the experimental and control groups in the variables of problem-oriented, emotion-oriented, and avoidant coping variables (P < 0.05). In addition, the results showed that in the posttest, there was a significant difference between the mean scores of test anxiety; happiness; and happiness components including life satisfaction, self-esteem, active well-being, satisfaction, and positive mood (P < 0.05).

CONCLUSIONS

Based on the results of the present study, it can be said that mindfulness training is an effective intervention to improve coping styles, test anxiety, and happiness in students.

Anxiety and depression in women hospitalized due to high-risk pregnancy: An integrative quantitative and qualitative study

Literature has shown that hospitalized women with high-risk pregnancy tend to develop anxious and depressive symptoms. Research has used quantitative or qualitative methods. By integrating both quantitative and qualitative methods, this study aims to analyze: a) the level of depression, anxiety, and pregnancy-related anxiety in a group of women hospitalized with high-risk pregnancy (hospitalized high-risk) compared with a group of non-hospitalized women with low-risk pregnancy; b) the content of hospitalization-related emotions in a high-risk group. A cross-sectional study was conducted on 30 hospitalized high-risk pregnant women and 32 women with low-risk pregnancy. Participants completed the Edinburgh Postnatal Depression Scale, Hospital Anxiety and Depression Scale (Anxiety), and Pregnancy Related Anxiety Questionnaire. The hospitalized high-risk group also completed open-ended questions about emotions experienced during hospitalization. Univariate Analysis of Covariance showed that the hospitalized high-risk group reported higher general anxiety and depression than the low-risk pregnancy group. Low-risk group reported higher level of concerns about own appearance than high-risk group. Narratives showed that the anxious and depressive symptoms of hospitalized women are related to the loneliness of being away from family. Despite attempts to understand hospitalization, they express concerns about pregnancy. Psychological support for hospitalized pregnant women should be provided to facilitate the communication of emotions that leads women to elaborate the experience of hospitalization to better adapt and cope with the critical condition.

Facilitators and barriers to substance-free pregnancies in high-income countries: A meta-synthesis of qualitative research

BACKGROUND

Previous studies have associated substance use (alcohol, illicit drugs and smoking) to negative pregnancy outcomes, including higher risk of stillbirth.

AIM

This study aims to identify facilitators and barriers reported by women to remain substance free during pregnancy.

METHODS

A systematic search was conducted in six databases from inception to March 2019 and updated in November 2020. Qualitative studies involving pregnant or post-partum women, from high-income countries, examining women's experiences of substance use during pregnancy were eligible. Meta-ethnography was used to facilitate this meta-synthesis.

FINDINGS

Twenty-two studies were included for analysis. Internal barriers included the perceived emotional and social benefits of using substances such as stress coping, and the associated feelings of shame and guilt. Finding insensitive professionals, the lack of information and discussion about risks, and lack of social support were identified as external barriers. Furthermore, the social stigma and fear of prosecution associated with substance use led some women to conceal their use. Facilitators included awareness of the health risks of substance use, having intrinsic incentives and finding support in family, friends and professionals.

DISCUSSION

Perceived benefits, knowledge, experiences in health care settings, and social factors all play important roles in women's behaviours. These factors can co-occur and must be considered together to be able to understand the complexity of prenatal substance use.

CONCLUSION

Increased clinical and community awareness of the modifiable risk factors associated with substance use during pregnancy presented in this study, is necessary to inform future prevention efforts.

Coping with stress and personality: A study in pregnancies complicated by hypertension

OBJECTIVE

The objective of this work is to investigate the role of personality in pregnancies complicated by hypertension, thru analysis of structure and associations between negative affect and coping strategies, and their role towards psychological distress.

METHOD

A cross-sectional study with 343 women, where 192 pregnancies complicated by hypertension, was carried out by employing the following tools: the five-factor model (Big Five), Depression, Anxiety and Stress Scale (DASS-21), and Jalowiec's Coping Inventory. Two complementary strategies were carried out: an exploratory approach on the interactions between latent variables and a confirmatory technique.

RESULTS

Coping strategies seem to be dissociated in the hypertensive group, and these participants tend to use strategies according to their personality, mostly emotion focused, extraversion, and neuroticism. The extraversion model exclusively shows an acceptable goodness-of-fit after a structural equation modelling. A multigroup analysis reached a full metric invariance level for extraversion.

CONCLUSIONS

These results are of interest for both clinical and research settings. Prenatal screening and associated interventions may reduce perinatal negative affective states and related pregnancy complications.

Perception and Demands of Pregnant and Breastfeeding Women Regarding Their Role as Participants in Environmental Research Studies

A significant proportion of scientific studies consider pregnant and breastfeeding women as vulnerable subjects. The objective of this study was to analyse the perception of pregnant and breastfeeding women regarding their participation in environmental research studies. Our work is a descriptive and interpretative observational study that has been developed under the qualitative research paradigm following a phenomenological and ethnographic perspective. The study involved 173 women selected intentionally in two Spanish autonomous communities. To obtain the primary data, we relied upon 111 interviews, four focused ethnographies and eight focus groups. The data encoding and analysis was carried out with the help of NVivo 12 software (QSR International, Boston, MA, USA). We evidenced the need of pregnant and breastfeeding women for more detailed and accurate information on the risk of environmental pollutant exposure during their crucial life stage. In addition, these women claimed for a more participatory role in research studies. Pregnant and breastfeeding women in Spain ask for greater interaction with researchers and propose a dialogical relationship between valid partners. We conclude that our pregnant and breastfeeding women claim more research focused on their collective, as well as clearer, more accessible and structured information on the risks of exposure to environmental contaminants. In addition, they do not want to simply be informants; rather, they ask to be active and empowered members by providing their opinions and arguments throughout the research process.

Psychosocial status during the prevalence of COVID-19 disease: the comparison between healthcare workers and general population

The prevalence of COVID-19 disease continues to be a significant psychosocial status among health care workers (HCWs) and the general population worldwide. This cross sectional study aimed to compare the psychosocial status between healthcare workers and general population during the prevalence of COVID-19 disease in southeast Iran. Totally 415 health care workers of a medical service center for COVID-19 patients and 1023 people of general population participated in the study. An online socio-demographic characteristics questionnaire, General Health Questionnaire (GHQ −28), and Generalized Anxiety Disorder 7-item (GAD-7) were utilized to evaluate psychosocial status. According to GHQ, the psychological disorders of the HCWs were significantly higher than that of the general population (P < 0.001). According to GAD-7, no significant difference was found between general population and HCWs. Multivariate logistic analysis showed no difference between general population and HCWs in the psychological disorder. Although HCWs suffered from psychological disorders more than general population, nearly one third to half of the participants in both groups had psychosocial disorders.

How stress can influence brain adaptations to motherhood

Research shows that a woman's brain and body undergo drastic changes to support her transition to parenthood during the perinatal period. The presence of this plasticity suggests that mothers' brains may be changed by their experiences. Exposure to severe stress may disrupt adaptive changes in the maternal brain and further impact the neural circuits of stress regulation and maternal motivation. Emerging literature of human mothers provides evidence that stressful experience, whether from the past or present environment, is associated with altered responses to infant cues in brain circuits that support maternal motivation, emotion regulation, and empathy. Interventions that reduce stress levels in mothers may reverse the negative impact of stress exposure on the maternal brain. Finally, outstanding questions regarding the timing, chronicity, types, and severity of stress exposure, as well as study design to identify the causal impact of stress, and the role of race/ethnicity are discussed.

Stress, Coping, and Psychiatric Symptoms in Pregnant Women in Outpatient Care During the 2021 Second-Wave COVID-19 Pandemic

Aims: Women face many sources of stress throughout their lives, and some periods are particularly sensitive; pregnancy is one of them. The COVID-19 pandemic is a likely source of additional stress for pregnant women. Moreover, there is evidence that pregnant women have experienced high levels of anxiety and depression symptoms during the pandemic. Our study aimed to evaluate the association of pregnancy-specific stress, pandemic-related stress, and coping strategies with anxiety, depressive and obsessive-compulsive symptomatology in Italian women during the second wave of the COVID-19 pandemic (December 2020-June 2021). We also investigated whether there were differences in these levels of psychopathology compared to a prior study conducted during the first pandemic wave (April-August 2020) in Italian pregnant women. Methods: We assessed 325 pregnant women receiving outpatient prenatal care, using the Revised Prenatal Distress Questionnaire (NuPDQ), Pandemic-Related Pregnancy Stress Scale (PREPS), the Revised Prenatal Coping Inventory (NuPCI), General Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-2 (PHQ-2), and Obsessive-Compulsive Disorder (OCD) screening. The main analysis was conducted comparing multiple logistic regression models predicting each psychopathological outcome from specific covariates and NuPDQ, PREPS, and NuPCI scores. Results: 42.8% of the sample reported significant levels of anxiety, while 10.3% was positive on depression screening and 13.1% on OCD screening. No significant difference was found in the prevalence of high anxiety, depression, or OCD screening scores compared with the first pandemic wave. Controlling for covariates, we found that GAD-7 and PHQ-2 scores were predicted by pregnancy-specific stress; positive OCD screening was not. The model of high anxiety was improved by adding pandemic-related stress as a predictor (in particular, feeling unprepared for delivery and postpartum). Finally, coping strategies (avoidance, spiritual coping, and planning-preparation) significantly improved prediction of all three psychopathological outcomes. Conclusions: The present study suggests the importance of pregnancy-related stress, COVID-19 pandemic stress, and of coping strategies in counteracting or contributing to psychiatric symptomatology during the current pandemic.

Happiness in Pregnant African American Women: What Are the Biobehavioral Correlates?

The detrimental effects of prenatal stress on maternal-infant well-being have been well established and highlight increased concern for pregnant African American women. Research supports the notion that positive emotions may have a beneficial impact on the stress process and outcomes. However, the data have been largely restricted to non-African American pregnant women. This study's purpose was to examine potential relationships of both positive (happiness) and negative (stress, anxiety, and depressive symptoms) emotions and pro-inflammatory cytokines (interleukins-1β, -6, -8, -12, -17, tumor necrosis factor, and interferon-γ) in 72 pregnant African American women for a more complete picture of the stress process in this at-risk population. Results of this exploratory secondary data analysis show strong positive correlations between negative emotions and strong negative correlations between happiness and negative emotions. Interleukin-8 was positively correlated with negative emotions and negatively correlated with happiness. Results show mean ratings of negative emotions were higher than previously reported with more heterogeneous samples, while happiness ratings were in the moderate range. Findings suggest that pregnant African American women may experience higher stress and depressive symptoms than women in more heterogeneous samples. However, moderate levels of happiness might contribute to buffering the stress response.

Jewish and Arab pregnant women's psychological distress during the COVID-19 pandemic: the contribution of personal resources

OBJECTIVE

The study sought to examine the psychological distress of Israeli pregnant women during the worldwide spread of COVID-19. As Israel has a diverse cultural-religious population, the sample included both Jewish and Arab women, allowing us to explore the differences between them. Furthermore, we examined the contribution of personal resources, both internal (self-mastery and resilience) and external (perceived social support), as well as the level of infection-related anxiety to the women's psychological distress.

METHOD

A convenience sample of 403 Israeli women (233 Jewish and 170 Arab) was recruited through social media.

RESULTS

Arab women reported significantly higher infection-related anxiety and psychological distress than Jewish women. In addition, Jewish women reported significantly higher self-mastery than Arab pregnant women. Finally, poorer health, being an Arab woman, and lower levels of self-mastery, resilience, and perceived social support, as well as a higher level of infection-related anxiety, contributed significantly to greater psychological distress.

CONCLUSIONS

The findings show that pregnant women in general may be at risk of psychological distress in times of crisis, and that minority populations in particular may be at greater risk than others. Moreover, the results highlight the contribution of women's personal and environmental resources in the face of crisis, an understanding that may be used in targeted interventions to reduce distress in vulnerable populations.

Coping strategies mediate the associations between COVID-19 experiences and mental health outcomes in pregnancy

The COVID-19 pandemic has resulted in elevated mental health problems for pregnant women. Effective coping strategies likely reduce the impact of COVID-19 on mental health. This study aimed to (1) understand how COVID-19 stressors are related to different coping strategies and (2) identify whether coping strategies act as mechanisms accounting for the associations between COVID-19 stressful experiences and mental health problems in pregnancy. Participants were 304 pregnant women from Ontario, Canada. Depression, anxiety, insomnia, and perceived stress were assessed using validated measures. COVID-related stressors (i.e., financial difficulties, social isolation), subjective negative impact of COVID-19, and coping strategies used in response to COVID-19 were assessed by questionnaires. Results indicated that the subjective negative impact of COVID-19 was associated with more dysfunctional coping and less emotion-focused coping, whereas specific COVID-19 stressors, namely financial difficulties and social isolation, were associated with more dysfunctional coping and problem-focused coping. Dysfunctional coping was linked to elevated mental health problems and emotion-focused coping was linked to less mental health problems. Dysfunctional coping and emotion-focused coping partially mediated the effects of specific COVID-19 stressors on mental health outcomes. Findings indicate that coping is one pathway through which the COVID-19 pandemic impacts mental health in pregnancy. Supports and interventions for pregnant women during the pandemic should focus on bolstering coping skills, in order to minimize the mental health consequences of COVID-19.

Exploring mothers' experiences of trauma and violence-informed cognitive behavioural therapy following intimate partner violence: a qualitative case analysis

PURPOSE

Intimate partner violence (IPV) is a pervasive public health issue impacting one in three women, worldwide. Broadly defined as any act of coercive control within the context of an intimate relationship, IPV often results in significant negative health outcomes. Cognitive Behavioral Therapy (CBT), a mainstay treatment for relational trauma, has particular relevance for women undergoing the many transformations associated with the perinatal period. The findings of this case analysis build upon existing literature supporting the positive impact of Trauma and Violence- Informed CBT (TVICBT) for women who have experienced IPV and are living with mental health challenges.

METHODS

As part of a larger mixed-methods study, three women who experienced IPV and received TVICBT during pregnancy participated in in-depth, semi-structured interviews to determine the perceived value and acceptability of this intervention.

FINDINGS

Insights gained herein, serve to enrich current evidence, suggesting that TVICBT provided during pregnancy may hold promise for the treatment of IPV-related mood and anxiety disorders.

CONCLUSIONS

Given that improved perinatal mental health has been linked to enhanced maternal resiliency and quality of life, greater maternal-infant attachment, and positive child health outcomes, this research has the potential to bridge the critical knowledge gap at the intersection of motherhood, trauma, and mental health.

Effectiveness and cost-effectiveness of an electronic mindfulness-based intervention (eMBI) on maternal mental health during pregnancy: the mindmom study protocol for a randomized controlled clinical trial

Background

Mental disorders are common during the peripartum period and may have far-reaching consequences for both mother and child. Unfortunately, most antenatal care systems do not provide any structured screening for maternal mental health. As a consequence, mental illnesses are often overlooked and not treated adequately. If correctly diagnosed, cognitive behavioral therapy is currently the treatment of choice for mental illnesses. In addition, mindfulness-based interventions (MBIs) seem to represent a promising treatment option for anxiety and depression during the peripartum period. Considering the internet’s increasing omnipresence, MBIs can also be offered electronically via a (tablet) computer or smartphone (electronically based MBI = eMBI).

Objective

The current study aims to examine the clinical effectiveness and cost-effectiveness of an eMBI (the mindmom application) developed by an interdisciplinary team of gynecologists, psychologists, and midwives, teaching pregnant women how to deal with stress, pregnancy-related anxiety, and depressive symptoms. The study sample consists of pregnant women in their third trimester who screened positive for emotional distress. The mindmom study is a bicentric prospective randomized controlled trial (RCT), which is currently conducted at the University women’s hospitals of Heidelberg and Tübingen, Germany.

Methods

Within the scope of the routine prenatal care, pregnant women attending routine pregnancy care in Baden-Wuerttemberg, Germany, are invited to participate in a screening for mental distress based on the Edinburgh Postnatal Depression Scale (EPDS). Women with an EPDS screening result > 9 will be referred to one of the mindmom coordinating study centers and are offered counseling either face-to-face or via videotelephony. After an initial psychological counseling, women are invited to participate in an eMBI in their last pregnancy trimester. The study will enroll N = 280 study participants (N = 140 per group), who are randomized 1:1 into the intervention (IG) or control group (treatment as usual = TAU).

All participants are requested to complete a total of 7 digital assessments (5 visits pre- and 2 follow-up visits postpartum), involving self-report questionnaires, sociodemographic and medical data, physiological measures, and morning cortisol profiles. The primary outcome will be depressive and anxiety symptoms, measured by the Edinburgh Postnatal Depression Scale, the State Trait Anxiety Questionnaire, and the Pregnancy-Related Anxiety Questionnaire. Secondary outcomes include mindfulness, satisfaction with birth, quality of life, fetal attachment, bonding, mode of delivery, and cost-effectiveness.

Discussion

This is the first German RCT to examine the (cost-)effectiveness of an eMBI on maternal mental health during pregnancy. If successful, the mindmom app represents a low-threshold and cost-effective help for psychologically distressed women during pregnancy, thereby reducing the negative impact on perinatal health outcome.

Trial registration

Deutsches Register Klinischer Studien, German Clinical Trials Register DRKS00017210. Registered on 13 January 2020. Retrospectively registered.

Supplementary information

The online version contains supplementary material available at 10.1186/s13063-020-04873-3.

Predicting Postpartum Depressive Symptoms from Pregnancy Biopsychosocial Factors: A Longitudinal Investigation Using Structural Equation Modeling

The prediction of postpartum depression (PPD) should be conceptualized from a biopsychosocial perspective. This study aims at exploring the longitudinal contribution of a set of biopsychosocial factors for PPD in perinatal women. A longitudinal study was conducted, assessment was made with a website and included biopsychosocial factors that were measured during pregnancy (n = 266, weeks 16–36), including age, affective ambivalence, personality characteristics, social support and depression. Depression was measured again at postpartum (n = 101, weeks 2–4). The analyses included bivariate associations and structural equation modeling (SEM). Age, affective ambivalence, neuroticism, positive, and negative affect at pregnancy were associated with concurrent depression during pregnancy (all p < 0.01). Age, affective ambivalence, positive affect, and depression at pregnancy correlated with PPD (all p < 0.05). Affective ambivalence (β = 1.97; p = 0.003) and positive (β = −0.29; p < 0.001) and negative affect (β = 0.22; p = 0.024) at pregnancy remained significant predictors of concurrent depression in the SEM, whereas only age (β = 0.27; p = 0.010) and depression (β = 0.37; p = 0.002) at pregnancy predicted PPD. Biopsychosocial factors are clearly associated with concurrent depression at pregnancy, but the stability of depression across time limits the prospective contribution of biopsychosocial factors. Depression should be screened early during pregnancy, as this is likely to persist after birth. The use of technology, as in the present investigation, might be a cost-effective option for this purpose.

Factors Affecting Women's Adjustment to Postpartum Changes: A Narrative Review

Background

Postpartum period is associated with stress and pressure, and the woman must adjust herself to these changes. This study aimed to review the factors affecting women's adjustment to postpartum changes in conducted studies.

Materials and Methods

This review was conducted by searching databases such as ISI Web of Science, Science Direct, Scopus, Cochrane, PubMed and Scientific Information Database (SID), Iranian Medical Articles Database (IranMedex), Iranian Research Institute for Information Science and Technology (IranDoc), and the Iranian Magazine Database (MagIran), as well as searching through Google Scholar (as a Web search engine) in December 2019. Publications from July 2004 to October 2019 were reviewed and limited to Persian and English. The keywords used included "Postpartum", "Women's needs", "Adjustment" and "Coping". After reviewing the articles, out of 60 original articles, 17 articles were selected for final evaluation.

Results

Factors affecting adjustment to postpartum changes were divided into personal and social factors. Personal factors included previous experiences, coping styles and strategies, personality traits, self-efficacy and awareness, and social factors included family and relatives, healthcare providers, cultural context, and laws and regulations.

Conclusions

Adjustment to postpartum changes depends on the personal and social factors that can interact with each other. Women's awareness enables them to use positive coping strategies in this critical situation. Educating women's spouse and family members can contribute to increase the women's social support. Additionally, the law support guarantees the implementation of many interventions in promoting the mother's health.

The Effect of COVID-19 on Youth Mental Health

The purposes of this study was to assess the youth mental health after the coronavirus disease 19 (COVID-19) occurred in China two weeks later, and to investigate factors of mental health among youth groups. A cross-sectional study was conducted two weeks after the occurrence of COVID-19 in China. A total of 584 youth enrolled in this study and completed the question about cognitive status of COVID-19, the General Health Questionnaire(GHQ-12), the PTSD Checklist-Civilian Version (PCL-C) and the Negative coping styles scale. Univariate analysis and univariate logistic regression were used to evaluate the effect of COVID-19 on youth mental health. The results of this cross-sectional study suggest that nearly 40.4% the sampled youth were found to be prone to psychological problems and 14.4% the sampled youth with Post-traumatic stress disorder (PTSD) symptoms. Univariate logistic regression revealed that youth mental health was significantly related to being less educated (OR = 8.71, 95%CI:1.97-38.43), being the enterprise employee (OR = 2.36, 95%CI:1.09-5.09), suffering from the PTSD symptom (OR = 1.05, 95%CI:1.03-1.07) and using negative coping styles (OR = 1.03, 95%CI:1.00-1.07). Results of this study suggest that nearly 40.4% of the youth group had a tendency to have psychological problems. Thus, this was a remarkable evidence that infectious diseases, such as COVID-19, may have an immense influence on youth mental health. Therefor, local governments should develop effective psychological interventions for youth groups, moreover, it is important to consider the educational level and occupation of the youth during the interventions.

Validation of the Italian version of the Revised Prenatal Coping Inventory (NuPCI) and its correlations with pregnancy-specific stress

Background

Pregnancy is a period of happiness but also of physical and psychological changes that can lead to distress. Functional coping strategies can reduce the pregnancy specific-stress. This study aimed to assess the psychometric properties of the Revised Prenatal Coping Inventory (NuPCI) in an Italian sample and to investigate how coping strategies were associated with pregnancy-specific stress.

Methods

In this cross-sectional study, low-risk pregnant women (N = 211) were assessed with NuPCI, NuPDQ (Revised-Prenatal Distress Questionnaire), Brief-COPE (Coping Orientation to the Problems Experienced), and STAI (State-Trait Anxiety Inventory). The reliability of NuPCI was evaluated by assessing its internal consistency and factor structure (with a Confirmatory Factor Analysis, CFA). The concurrent validity between NuPCI and Brief-COPE and NuPDQ and STAI was investigated. Lastly, the relationship between NuPCI and NuPDQ was analyzed, as well as the ability of these scales to predict Apgar score at birth.

Results

Internal consistency of NuPCI scales was good for Planning-Preparation (ɑ_C=0.84) and Spiritual-Positive Coping (ɑ_C=0.81) scales, acceptable for Avoidance (ɑ_C=0.76) scale. Moreover, the original three-factor structure was confirmed using a CFA with 29 of the 32 items (χ²₃₇₄ = 618.06; RMSEA = 0.056, 95% confidence interval: [0.048, 0.063]); CFI = 0.920; and TLI = 0.913). Statistically significant correlations between NuPCI scales and Brief-COPE subscales ranged between r = + 0.217 and r = + 0.624; also, NuPDQ score was positively correlated with STAI scales (State scale: r = + 0.539; Trait scale: r = + 0.462). Concurrent validity was confirmed reporting that NuPDQ score was predicted by NuPCI scores (R² = 0.423, p < 0.001), positively by Avoidance (β=+0.572) and Planning-Preparation (β=+0.215) and negatively by Spiritual-Positive Coping (β=-0.132). Finally, considering the stress, the effect of the Avoidance and Spiritual-Positive Coping scores respectively in decreasing (+ 155%) and increasing (+ 16%) the Apgar score became stronger.

Conclusions

Italian NuPCI has sound psychometric properties and it is a useful coping measure. NuPDQ showed also a good validity. Our results may suggest a significant role for coping strategies, particularly in modulating the condition of the newborn at birth.

Coping During Pregnancy Following Exposure to a Natural Disaster: The QF2011 Queensland Flood Study

INTRODUCTION

This study investigated how coping strategies moderated the impact of disaster-related objective hardship on subjective distress in pregnant women.

METHODS

The objective hardship (exposure severity), subjective distress (Peritraumatic Distress Inventory, Peritraumatic Dissociative Experiences Questionnaire and Impact of Event Scale-Revised) and coping styles (Brief COPE) of pregnant women (N = 226) exposed to the 2011 Queensland, Australia flood were assessed. Moderation analyses were used to assess how coping strategies moderated the relationship between objective hardship and subjective distress levels.

RESULTS

We found that the more severe the objective flood exposure, the greater the women's subjective distress. The moderation analyses were significant for the Brief COPE's three coping styles (i.e., problem-focused coping, emotion-focused coping, and dysfunctional coping). For women experiencing high levels of objective hardship, problem-focused (∆R² = 1.7%) and dysfunctional coping (∆R² = 1.5%) elevated subjective distress levels. For women experiencing low or moderate levels of objective hardship, emotion-focused coping reduced levels of subjective distress (∆R² = 1.3%). A three-way interaction between objective hardship, emotion-focused coping, and dysfunctional coping approached significance (∆R² = 1.0%), indicating a protective role of emotion-focused coping under high levels of objective hardship, for women who frequently use maladaptive coping strategies.

LIMITATIONS

Sample was generally high SES and no measure of social support was available.

CONCLUSION

Results suggest that both problem-focused and dysfunctional coping strategies were maladaptive for women with relatively high exposure levels. Overall, emotion-focused coping strategies were more likely than problem-focused or dysfunctional strategies to reduce pregnant women's subjective distress following the flood.

Psychological interventions to foster resilience in healthcare students

BACKGROUND

Resilience can be defined as maintaining or regaining mental health during or after significant adversities such as a potentially traumatising event, challenging life circumstances, a critical life transition or physical illness. Healthcare students, such as medical, nursing, psychology and social work students, are exposed to various study- and work-related stressors, the latter particularly during later phases of health professional education. They are at increased risk of developing symptoms of burnout or mental disorders. This population may benefit from resilience-promoting training programmes.

OBJECTIVES

To assess the effects of interventions to foster resilience in healthcare students, that is, students in training for health professions delivering direct medical care (e.g. medical, nursing, midwifery or paramedic students), and those in training for allied health professions, as distinct from medical care (e.g. psychology, physical therapy or social work students).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, 11 other databases and three trial registries from 1990 to June 2019. We checked reference lists and contacted researchers in the field. We updated this search in four key databases in June 2020, but we have not yet incorporated these results.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing any form of psychological intervention to foster resilience, hardiness or post-traumatic growth versus no intervention, waiting list, usual care, and active or attention control, in adults (18 years and older), who are healthcare students. Primary outcomes were resilience, anxiety, depression, stress or stress perception, and well-being or quality of life. Secondary outcomes were resilience factors.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data, assessed risks of bias, and rated the certainty of the evidence using the GRADE approach (at post-test only).

MAIN RESULTS

We included 30 RCTs, of which 24 were set in high-income countries and six in (upper- to lower-) middle-income countries. Twenty-two studies focused solely on healthcare students (1315 participants; number randomised not specified for two studies), including both students in health professions delivering direct medical care and those in allied health professions, such as psychology and physical therapy. Half of the studies were conducted in a university or school setting, including nursing/midwifery students or medical students. Eight studies investigated mixed samples (1365 participants), with healthcare students and participants outside of a health professional study field. Participants mainly included women (63.3% to 67.3% in mixed samples) from young adulthood (mean age range, if reported: 19.5 to 26.83 years; 19.35 to 38.14 years in mixed samples). Seventeen of the studies investigated group interventions of high training intensity (11 studies; > 12 hours/sessions), that were delivered face-to-face (17 studies). Of the included studies, eight compared a resilience training based on mindfulness versus unspecific comparators (e.g. wait-list). The studies were funded by different sources (e.g. universities, foundations), or a combination of various sources (four studies). Seven studies did not specify a potential funder, and three studies received no funding support. Risk of bias was high or unclear, with main flaws in performance, detection, attrition and reporting bias domains. At post-intervention, very-low certainty evidence indicated that, compared to controls, healthcare students receiving resilience training may report higher levels of resilience (standardised mean difference (SMD) 0.43, 95% confidence interval (CI) 0.07 to 0.78; 9 studies, 561 participants), lower levels of anxiety (SMD -0.45, 95% CI -0.84 to -0.06; 7 studies, 362 participants), and lower levels of stress or stress perception (SMD -0.28, 95% CI -0.48 to -0.09; 7 studies, 420 participants). Effect sizes varied between small and moderate. There was little or no evidence of any effect of resilience training on depression (SMD -0.20, 95% CI -0.52 to 0.11; 6 studies, 332 participants; very-low certainty evidence) or well-being or quality of life (SMD 0.15, 95% CI -0.14 to 0.43; 4 studies, 251 participants; very-low certainty evidence). Adverse effects were measured in four studies, but data were only reported for three of them. None of the three studies reported any adverse events occurring during the study (very-low certainty of evidence).

AUTHORS' CONCLUSIONS

For healthcare students, there is very-low certainty evidence for the effect of resilience training on resilience, anxiety, and stress or stress perception at post-intervention. The heterogeneous interventions, the paucity of short-, medium- or long-term data, and the geographical distribution restricted to high-income countries limit the generalisability of results. Conclusions should therefore be drawn cautiously. Since the findings suggest positive effects of resilience training for healthcare students with very-low certainty evidence, high-quality replications and improved study designs (e.g. a consensus on the definition of resilience, the assessment of individual stressor exposure, more attention controls, and longer follow-up periods) are clearly needed.

Psychological interventions to foster resilience in healthcare professionals

BACKGROUND

Resilience can be defined as the maintenance or quick recovery of mental health during or after periods of stressor exposure, which may result from a potentially traumatising event, challenging life circumstances, a critical life transition phase, or physical illness. Healthcare professionals, such as nurses, physicians, psychologists and social workers, are exposed to various work-related stressors (e.g. patient care, time pressure, administration) and are at increased risk of developing mental disorders. This population may benefit from resilience-promoting training programmes.

OBJECTIVES

To assess the effects of interventions to foster resilience in healthcare professionals, that is, healthcare staff delivering direct medical care (e.g. nurses, physicians, hospital personnel) and allied healthcare staff (e.g. social workers, psychologists).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, 11 other databases and three trial registries from 1990 to June 2019. We checked reference lists and contacted researchers in the field. We updated this search in four key databases in June 2020, but we have not yet incorporated these results.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in adults aged 18 years and older who are employed as healthcare professionals, comparing any form of psychological intervention to foster resilience, hardiness or post-traumatic growth versus no intervention, wait-list, usual care, active or attention control. Primary outcomes were resilience, anxiety, depression, stress or stress perception and well-being or quality of life. Secondary outcomes were resilience factors.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data, assessed risks of bias, and rated the certainty of the evidence using the GRADE approach (at post-test only).

MAIN RESULTS

We included 44 RCTs (high-income countries: 36). Thirty-nine studies solely focused on healthcare professionals (6892 participants), including both healthcare staff delivering direct medical care and allied healthcare staff. Four studies investigated mixed samples (1000 participants) with healthcare professionals and participants working outside of the healthcare sector, and one study evaluated training for emergency personnel in general population volunteers (82 participants). The included studies were mainly conducted in a hospital setting and included physicians, nurses and different hospital personnel (37/44 studies). Participants mainly included women (68%) from young to middle adulthood (mean age range: 27 to 52.4 years). Most studies investigated group interventions (30 studies) of high training intensity (18 studies; > 12 hours/sessions), that were delivered face-to-face (29 studies). Of the included studies, 19 compared a resilience training based on combined theoretical foundation (e.g. mindfulness and cognitive-behavioural therapy) versus unspecific comparators (e.g. wait-list). The studies were funded by different sources (e.g. hospitals, universities), or a combination of different sources. Fifteen studies did not specify the source of their funding, and one study received no funding support. Risk of bias was high or unclear for most studies in performance, detection, and attrition bias domains. At post-intervention, very-low certainty evidence indicated that, compared to controls, healthcare professionals receiving resilience training may report higher levels of resilience (standardised mean difference (SMD) 0.45, 95% confidence interval (CI) 0.25 to 0.65; 12 studies, 690 participants), lower levels of depression (SMD -0.29, 95% CI -0.50 to -0.09; 14 studies, 788 participants), and lower levels of stress or stress perception (SMD -0.61, 95% CI -1.07 to -0.15; 17 studies, 997 participants). There was little or no evidence of any effect of resilience training on anxiety (SMD -0.06, 95% CI -0.35 to 0.23; 5 studies, 231 participants; very-low certainty evidence) or well-being or quality of life (SMD 0.14, 95% CI -0.01 to 0.30; 13 studies, 1494 participants; very-low certainty evidence). Effect sizes were small except for resilience and stress reduction (moderate). Data on adverse effects were available for three studies, with none reporting any adverse effects occurring during the study (very-low certainty evidence).

AUTHORS' CONCLUSIONS

For healthcare professionals, there is very-low certainty evidence that, compared to control, resilience training may result in higher levels of resilience, lower levels of depression, stress or stress perception, and higher levels of certain resilience factors at post-intervention. The paucity of medium- or long-term data, heterogeneous interventions and restricted geographical distribution limit the generalisability of our results. Conclusions should therefore be drawn cautiously. The findings suggest positive effects of resilience training for healthcare professionals, but the evidence is very uncertain. There is a clear need for high-quality replications and improved study designs.