Remotely Delivered Interventions to Support Women With Symptoms of Anxiety in Pregnancy: Mixed Methods Systematic Review and Meta-analysis

Current state and practical recommendations on reproductive mental health: a narrative review

Emotional disorders (EDs) are highly prevalent during the reproductive period, including pregnancy, postpartum, and women undergoing fertility treatments. International guidelines are increasingly suggesting the need to evaluate, prevent, and treat EDs in those women. The main aim of this narrative review is to summarize current practice in the field of EDs management during fertility treatments, pregnancy, and the postpartum and to propose a new technology-based model of care that helps to provide psychological care to all women who are in these periods. Four different databases (Pubmed, Scopus, Science Direct, Web of Science) were consulted. Selected keywords were related with infertility, pregnancy, postpartum, EDs, assessment, prevention, treatment, and technologies. We identified 1603 studies and 43 were included in this review. According to these studies, different face-to-face protocols already exist to manage EDs in women undergoing fertility treatments, pregnant or at the postpartum. We noticed an increased interest in developing technology-based solutions to overcome the limitations of traditional mental healthcare services. However, we also detected some issues in the use of technologies (i.e. increased attention to the postpartum or the lack of transdiagnostic approaches). Our results evidenced that there is still a need to develop modern, well-designed, and conceptually-relevant ICT-based programs to be used in women undergoing fertility treatments, pregnant or at the postpartum.

Impact of a private sector residential early parenting program on clinically significant postnatal depressive symptoms experienced by women: Audit of routinely collected data

INTRODUCTION

Early parenting services in Australia offer brief structured residential programs to address moderate to severe non-psychotic mental health problems among women and unsettled infant/toddler behaviours. The aims were to (1) estimate the immediate and medium-term impact of a five-night psychoeducational residential early parenting program on postpartum depressive symptoms and (2) identify the factors associated with improvement or worsening of postpartum depressive symptoms after completing the program and six weeks post-discharge.

METHODS

Audit of routinely collected medical record data from pre-admission, pre-discharge and post-discharge assessments of a consecutive cohort of women admitted, with their infants/toddlers in a 15-month period to Masada Private Hospital Early Parenting Centre. Data included structured questions assessing: demographic characteristics, access to family and social support, past and current mental health problems, reproductive and obstetric health, chronic health conditions, breastfeeding problems, coincidental major life events, health risk behaviours and infant/toddler feeding, sleeping and crying behaviours. Standardised instruments included the Partner Interaction after Birth Scale (PIBS), the MacLean Screening Instrument for Borderline Personality Disorder (MSI-BPD), Modified Fatigue Assessment Scale (FAS) and selected items from the Karitane Parenting Confidence Scale. The primary outcomes were Edinburgh Postnatal Depression Scale scores at pre-discharge and follow up assessments. Data were analysed using multinomial logistic regression models in which individual and psychosocial characteristics at pre-admission were included as predictors of the likelihood of the changes of the outcomes from pre-admission to pre-discharge and follow up.

RESULTS

Complete data from 1220 of 1290 (95%) eligible women were available to assess pre-admission to pre-discharge and from 559 (45.8%) to assess pre-discharge to six-week follow-up changes. The mean pre-admission EPDS score was 11.7 (95% CI: 11.5; 12.0), pre-discharge it was 7.1 (95% CI: 6.9; 7.4) and at six-week follow up it was 5.7 (95% CI: 5.3; 6.1). We found that almost all women experienced a clinically meaningful and rapid improvement in depressive symptoms of at least this magnitude (reduction in mean EPDS scores of 4.6 points from pre-admission to pre-discharge (five nights) and a further reduction of 1.2 points pre-discharge to follow up) (six weeks) and we identified an interpretable set of risk factors for symptoms that did not improve or worsened. The adverse outcomes were associated with having symptoms of borderline personality disorder, a partner experienced as lacking kindness and care, coincidental adverse events and having a child younger than six months.

CONCLUSION

Residential early parenting programs, which take a psycho-educational approach to strengthening caregiving skills, maximising agency, and reducing helplessness, have a rapid beneficial effect on women's postpartum depressive symptoms. These programs provide a valuable and effective component of comprehensive mental health services. Long-term dialectical behaviour therapy is indicated for women with borderline personality disorder traits for whom early parenting programs alone are insufficient to improve depressive symptoms.

Peer support and mobile health for perinatal mental health: A scoping review

BACKGROUND

Up to one in five women experience perinatal depression and/or anxiety with profound negative consequences for mothers and families. Peer support interventions have the potential to effectively prevent perinatal mental health conditions. Meanwhile, mobile health has gained popularity and plays a significant role in enhancing maternal health services. However, little is known about the availability of mobile health combined with peer support for supporting perinatal mental health. This scoping review aimed to map the relevant literature and gain insights into the available evidence on mobile health and peer support for perinatal mental health, to identify gaps and inform opportunities for future research.

METHODS

A scoping review of the literature was conducted. The search strategy included five databases: CIANHL, Scopus, PsycInfo, PubMed, and ScienceDirect for the period from 2007 to 2022.

RESULTS

Eight studies met the inclusion criteria, including features of online support strategies, effectiveness, and attitudes of women about peer support with mobile health. The results showed decreased depressive scores and provided a positive experience for women. Strong satisfaction with accessibility and flexibility of mobile health was found when combined with the peer support features. Additional emotional support tools (e.g., mindfulness-based activities) were likely to be acceptable to women and beneficial to mobile health.

CONCLUSIONS

Understanding the context of peer support and mobile health informs the potential to support perinatal mental health. Further research in this growing area is needed to test the effectiveness of peer support in combination with mobile health intervention for supporting perinatal mental health.

Evaluation of a web-based intervention to optimize perinatal emotional wellbeing: A nested case-control study

Background/Objective

WazzUp Mama© is a remotely delivered web-based tailored intervention to prevent and reduce perinatal emotional distress, originally developed in the Netherlands. The current study aimed to evaluate the adapted WazzUp Mama© intervention in a Flemish (Dutch-speaking part of Belgium) perinatal population.

Methods

A 1:3 nested case-control study was performed. A data set including 676 participants (169 cases/507 controls) was composed based on core characteristics. Using independent t-test and chi-square, the two groups were compared for mean depression, self and perceived stigma, depression literacy scores, and for positive Whooley items and heightened depression scores. The primary analysis was adjusted for covariates.

Results

The number of positive Whooley items, the above cut-off depression scores, mean depression, perceived stigma, and depression literacy scores showed statistically significant differences between cases and controls, in favor of the intervention group. When adjusting for the covariates, the statistically significant differences between cases and controls remained for depression, perceived stigma, and depression literacy, for the positive Whooley items and for above cut-off depression scores.

Conclusion

WazzUp Mama© indicates to have a moderate to large positive effect on optimizing perinatal emotional wellbeing, to positively change perceived stigma and to increase depression literacy.

The effect of an mHealth application based on continuous support and education on fear of childbirth, self-efficacy, and birth mode in primiparous women: A randomized controlled trial

BACKGROUND

The Fear of Childbirth (FOC) is associated with several adverse health outcomes for children and women. This study aimed to evaluate the effectiveness of an interactive mobile health application named Tele-midwifery with an emphasis on continuous care and education, on FOC, self-efficacy, and childbirth mode in primiparous women.

METHODS

Seventy primiparous women attending the prenatal clinic of Baharlou Hospital in Tehran, Iran, were randomly assigned to two parallel intervention and control groups with 35 participants each. Women in the intervention group received Tele-midwifery for eight weeks, whereas women in the control group only received routine care. The Wijma delivery expectancy/experience questionnaire and the Childbirth Self-Efficacy Inventory were used to measure the FOC and self-efficacy at baseline and eight weeks after the intervention. The FOC and birth mode were also measured after birth.

RESULTS

There was a significant decrease in FOC among women in the intervention group compared to control groups after eight weeks of intervention (- 20.9 [95% Confidence Interval,-24.01 to-17.83], p < 0.001), and after birth (- 30.8, [95% CI-33.8 to-27.97], p < 0.001). After eight weeks, the mean self-efficacy score in the intervention group was significantly higher than the control group (p < 0.001). Compared to the control group, the intervention group had a lower C-Section (CS) rate (p = 0.03).

CONCLUSIONS

Tele-midwifery intervention reduced FOC, increased women's self-efficacy in childbirth, and decreased the number of CS in a group of first-time mothers. Healthcare providers can use the mHealth approach to support pregnant women with FOC.

TRIAL REGISTRATION

Registration number: IRCT20200122046227N1, Registered on 27 January 2020.

Non-pharmacological interventions for the management of perinatal anxiety in primary care: a meta-review of systematic reviews

BACKGROUND

Perinatal anxiety (PNA), anxiety that occurs during pregnancy and/or up to 12 months postpartum, is estimated to affect up to 21% of women, and may impact negatively on mothers, children, and their families. The National Institute for Health and Care Excellence (NICE) has called for further research around non-pharmacological interventions in primary care for PNA.

AIM

To summarise the available international evidence on non-pharmacological interventions for women with PNA in a primary care population.

DESIGN & SETTING

A meta-review of systematic reviews (SRs) with narrative synthesis was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance.

METHOD

Systematic literature searches were conducted in 11 health-related databases up to June 2022. Titles, abstracts, and full-text articles were dual-screened against pre-defined eligibility criteria. A variety of study designs were included. Data were extracted about study participants, intervention design, and context. Quality appraisal was performed using the AMSTAR 2 tool (A MeaSurement Tool to Assess systematic Reviews). A patient and public involvement group informed and contributed towards this meta-review.

RESULTS

Twenty-four SRs were included in the meta-review. Interventions were grouped into the following six categories for analysis purposes: psychological therapies; mind-body activities; emotional support from healthcare professionals (HCPs); peer support; educational activities; and alternative or complementary therapies.

CONCLUSION

In addition to pharmacological and psychological therapies, this meta-review has demonstrated that there are many more options available for women to choose from that might be effective to manage their PNA. Evidence gaps are present in several intervention categories. Primary care clinicians and commissioners should endeavour to provide patients with a choice of these management options, promoting individual choice and patient-centred care.

Utilization of digital prenatal services and management of depression and anxiety during pregnancy: A retrospective observational study

Introduction

We examined how utilization of Maven, a digital healthcare platform that provides virtual prenatal services, is associated with improvements in perceived management of anxiety and depression during pregnancy, and how medical knowledge and support may influence this association.

Materials and Methods

In this retrospective study we used adjusted logistic regression to examine the relationship between digital platform use in pregnancy and perceived mental health management, and how perceived management of mental health is affected by user-reported improvements in medical knowledge and feeling supported by the platform. Effects were evaluated separately among users with and without a mental health condition. Demographics, medical history, and mental health management were self-reported.

Results

Of 5,659 users, 705 (12.5%) reported that Maven helped them manage anxiety and/or depression in the prenatal period. In adjusted models, users who read more articles, sent more messages to care advocates, or had more appointments with providers were more likely to report improved management of mental health in a dose-response manner (e.g., articles read: Q2 aOR 1.31 (95% CI 1.01–1.70), Q3 aOR 1.68 (95% CI 1.30–2.17), Q4 1.99 (95% CI 1.54–2.59)). Improvements in medical knowledge and high perceived support were both associated with better perceived mental health management. Results were similar in users with and without a mental health condition.

Discussion

These results suggest that access to a diverse set of digital resources provides multiple pathways to managing depression and anxiety during pregnancy for those with and without a diagnosed mental health condition.

Telemedicine Interventions as an Attempt to Improve the Mental Health of Populations during the COVID-19 Pandemic-A Narrative Review

Published reports indicate the need for psychological interventions and the integration of psychiatric care into crisis management plans in people with mental health issues caused by the COVID-19 pandemic. It seems crucial to identify the root causes of the health-social-economic crisis and identify potential opportunities for widely implemented psychological assistance. This narrative literature review aims to identify the types of interventions deployed as telemedicine-based mental health support and their effectiveness. The PubMed and Web of Science electronic databases were searched. From a total of 48 articles, 46 were analysed after removing duplicates. From these, thirty-seven records were excluded according to the inclusion criteria and nine (eight RCT and one cross-over) were assessed as full texts. The included publications were randomised clinical trials or cross-over studies focused on remote mental support interventions. In all studies, participants represented both sexes and had an average age range of 6-64. Studies included participants from seven countries and the overall number of participants in the included studies was 687. The content of these intervention programmes includes both established psychotherapeutic programmes, as well as new interventions. Remote support was implemented through three approaches: phone/video calls, mobile applications, and internet-based programs. The results of the included studies indicate a higher or equal efficacy of telemedicine interventions compared to traditional forms. The review also revealed a relatively wide range of targeted research groups: from children with social anxiety through to their caregivers; adolescents with neurological disorders; and from college students to adults with psychiatric or orthopaedic disorders. Analysis of the included papers found that telemedicine interventions show promising results as an attempt to improve population mental health during the COVID-19 pandemic.

RAPID-2 study protocol: a cluster randomised feasibility trial of a midwife facilitated intervention for pregnant women with symptoms of mild to moderate anxiety

INTRODUCTION

Many women experience symptoms during pregnancy. Elevated and prolonged anxiety can have negative effects on the woman and baby. The RAPID intervention aims to provide suitable, timely support for women with mild-moderate anxiety. The RAPID intervention is based on social support, relational continuity, psychological and relaxation response theory, and comprises midwife facilitated group discussions, one-to-one support and directed self-help materials.

METHODS AND ANALYSIS

Four National Health Service Trusts in England that provide maternity care will be cluster randomised to the RAPID intervention plus usual care or usual care. At each intervention site, two midwives and two maternity support workers will facilitate the intervention over a 12-week period. Eligibility includes nulliparous women at 16-20 weeks of pregnancy (n=50) with self-report symptoms of mild-moderate anxiety. Community midwives will signpost women to the study. The aim of the study is to establish the feasibility of conducting a definitive trial to examine the effectiveness of the RAPID intervention in addition to usual care. The objectives are to assess recruitment and completion rates, and a qualitative assessment of women's and facilitators' experiences of participation. An estimation of change in the seven-item Generalised Anxiety Disorder scale will inform the sample size for a definitive cluster trial.

ETHICS AND DISSEMINATION

Ethical approval was given by East Midlands-Derby Research Ethics Committee 14 March 2022 (REC Reference: 22/EM/0018). Findings will be made available through publication in peer-reviewed journals, conferences and to participants. A final report will be submitted to HEE/NIHR ICA awards committee for publication.

TRIAL REGISTRATION NUMBER

ISRCTN12834758.

Unclear Insomnia Concept in Randomized Controlled Trials and Systematic Reviews: A Meta-Epidemiological Study

There are two possible ways to conceptualize the term "insomnia": insomnia disorder and insomnia symptoms, which are often poorly reported. The purpose of this study was to examine the proportion of randomized controlled trials (RCTs) and systematic reviews (SRs) that mention insomnia in their abstracts and cannot distinguish between insomnia disorder and insomnia symptoms from the abstract. We included RCT and SR articles that included the word "insomnia" in the methods or results sections of their structured abstracts, published after 2010. We searched PubMed using English language restrictions on 10 March 2022. From 1580 PubMed articles, we obtained 100 random samples each for eligible RCTs and SRs. The unclear insomnia concept accounted for 88% of the RCT abstracts and 94% of the SR abstracts. Among the RCT and SR abstracts with unclearness, the concept of insomnia was unclear in 27% of RCTs and 57% of SRs after investigating the full text. The concept of insomnia has been unclear in many RCTs and SRs abstracts. The authors of RCTs and SRs are recommended to state "insomnia disorder" or "insomnia symptoms" in the methods and results sections of their abstracts.

Developing a training programme for midwives and maternity support workers facilitating a novel intervention to support women with anxiety in pregnancy

BACKGROUND

The RAPID-2 intervention has been developed to support women with symptoms of mild-to-moderate anxiety in pregnancy. The intervention consists of supportive discussions with midwives, facilitated discussion groups and access to self-management materials. This paper reports the development of a training programme to prepare midwives and maternity support workers to facilitate the intervention.

METHODS

Kern's six-step approach for curriculum development was used to identify midwives and maternity support workers training needs to help support pregnant women with anxiety and facilitate a supportive intervention. The stages of development included feedback from a preliminary study, stakeholder engagement, a review of the literature surrounding midwives' learning and support needs and identifying and supporting the essential process and functions of the RAPID intervention.

RESULTS

Midwives' reported training needs were mapped against perinatal mental health competency frameworks to identify areas of skills and training needed to facilitate specific intervention mechanisms and components. A training plan was developed which considered the need to provide training with minimal additional resources and within midwives' scope of practice. The training plan consists of two workshop teaching sessions and a training manual.

CONCLUSION

Future implementation is planned to include a post-training evaluation of the skills and competencies required to fully evaluate the comprehensive programme and deliver the RAPID-2 intervention as planned. In addition, the RAPID-2 study protocol includes a qualitative evaluation of facilitators' views of the usefulness of the training programme.

Review of Mobile Apps for Women With Anxiety in Pregnancy: Maternity Care Professionals' Guide to Locating and Assessing Anxiety Apps

Background

Mental health and pregnancy apps are widely available and have the potential to improve health outcomes and enhance women’s experience of pregnancy. Women frequently access digital information throughout their pregnancy. However, health care providers and women have little information to guide them toward potentially helpful or effective apps.

Objective

This review aimed to evaluate a methodology for systematically searching and reviewing commercially available apps that support pregnant women with symptoms of anxiety in order to assist maternity care professionals in identifying resources that they could recommend for these women.

Methods

A stepwise systematic approach was used to identify, select, describe, and assess the most popular and highly user-rated apps available in the United Kingdom from January to March 2021. This included developing a script-based search strategy and search process, writing evaluation criteria, and conducting a narrative description and evaluation of the selected apps.

Results

Useful search terms were identified, which included nonclinical, aspirational, and problem-based phrases. There were 39 apps selected for inclusion in the review. No apps specifically targeted women with anxiety in pregnancy. Of the 39 apps included in the review, 33 (85%) focused solely on mind-body techniques to promote relaxation, stress reduction, and psychological well-being. Only 8 of the 39 (21%) apps included in the review reported that health care professionals had contributed to app development and only 1/39 (3%) provided empirical evidence on the effectiveness and acceptability of the app. The top 12/39 (31%) apps were evaluated by 2 independent reviewers using the developed criteria and scores. There was a small negative correlation between the reviewers’ scores and app user rating scores, with higher user rating scores associated with lower reviewer scores.

Conclusions

App developers, publishers, and maternity care professionals should seek advice from women with lived experience of anxiety symptoms in pregnancy to locate, promote, and optimize the visibility of apps for pregnant women. There is a lack of resources that provide coping strategies based on current evidence for the treatment of anxiety in pregnancy. Maternity care providers are limited in their ability to locate and recommend acceptable and trustworthy apps because of the lack of information on the evidence base, development, and testing of apps. Maternity care professionals and women need access to libraries of trusted apps that have been evaluated against relevant and established criteria.