The transition to parenthood for men is commonly described as both stressful and challenging (Genesoni and Tallandini, 2009; Leach et al, 2016). While the traditional view of fathers as breadwinners and disciplinarians has transformed in recent decades to that of a more engaged and involved parental role, there is scant research on the impact on men's emotional wellbeing, the increased roles and responsibilities and how to support men during this time (Genesoni and Tallandini, 2009; Leach et al, 2016).
A literature review examining men's psychological transition during the perinatal period (Genesoni and Tallandini, 2009) revealed that the most stressful time for men during the perinatal period was while their partner was pregnant. During this time, men are thought to undergo a psychological re-organisation of the self (Genesoni and Tallandini, 2009). Leach et al (2016) suggested that male psychological distress in the antenatal period may be related to issues such as poor relationship satisfaction, financial burdens, and poor job quality, which intensify during pregnancy. The distress experienced by men could have detrimental effects on their pregnant partners, with women being twice as likely to experience anxiety and depressive disorders if their male partners have an anxiety-related disorder (Leach et al, 2016).
Research indicates that men entering fatherhood encounter multiple emotional risk factors, with fathers shown to be as vulnerable to depression and emotional issues as mothers (Wilkes et al, 2012). Perinatal mental health disorders affects 1 in 7 pregnant women and 1 in 20 men, according to Deloitte Access Economics (2012). Pregnancy is therefore a risk factor for the onset or exacerbation of depressive and/or anxiety disorders for both women and men. Additionally, there is a significant correlation between younger age and higher risk factors for depression and stress (Bergström, 2013). Recommendations from the millennium cohort study on the fathers' involvement and effect on family mental health outlined the need for better engagement with men, with the emphasis on providing tailored information (Genesoni and Tallandini, 2009).
Although the introduction of male parental leave entitlements across Europe over the past decade have been observed as a way to support men to support their pregnant partners, no significant long term programmes for men have been established (Twamley et al, 2013). NHS online information offers no support programmes and/or screening for mental health issues for fathers during the perinatal period (NHS Choices, 2017). In Australia, although the Department of Health has mandated routine screening for depression, and referral to mental health services, for women during the perinatal period (Rowe et al, 2013), there are no similar services for the partners. Childbirth education also provides mental health interventions, including stress reduction and emotional management skills, for pregnant women but fails to include expectant fathers.
Mindfulness
Mindfulness as a therapeutic practice has been developed from the philosophical and theoretical concepts of Buddhism. It is a process of awareness and acceptance of the present moment, including thoughts, feelings, sensations, environment and physical wellbeing. Mindfulness involves using a state of relaxation that emphasises detatchment from emotional reactions and feelings to events through techniques that allow the regulation of emotional reactivity, and fast recovery from negative or unpleasant experiences (Kabat-Zinn, 2003).
Studies in mindfulness
Mindfulness has been used in various forms for women in the perinatal period with various levels of effectiveness. A small pilot study (n=31) to reduce prenatal stress and improve mood through an 8-week mindfulness intervention demonstrated significant reduction in anxiety (Vieten and Astin, 2008). Similar findings were also demonstrated with a pilot study (n=27) that incorporated mindfulness into childbirth and parenting programmes, which demonstrated statistically significant pre-to post-test increases (P<0.05) in mindfulness and reductions in anxiety and depression (Duncan and Bardacke, 2010). Additionally, Goodman et al (2014) found similar interventions feasible and acceptable in reducing anxiety and depression during the perinatal period, while increasing compassion and mindfulness. Although this was a small study (n=23), 82% of participants demonstrated improvements post-intervention, compared to base measurements, and 69.6% showed an improvement in levels of depression. More recently, randomised control study (n=30) by Duncan et al (2017) incorporated a short, time intensive, 2.5-day mindfulness childbirth programme, with participants recording greater childbirth self-efficacy and mind-body awareness. Mindfulness for women has and continues to foster positive outcomes, with authors universally recommending larger, long-term trials on mindfulness for women in the perinatal period (Vieten et al, 2008; Duncan and Bardacke, 2010; Goodman et al, 2014; Duncan et al, 2017).
Mindfulness interventions
The introduction of mindfulness-based interventions initiated clinical research, which led to the development of the therapeutic intervention now known as mindfulness-based stress reduction (MBSR) (Kabat-Zinn, 1982; 1994). Hybrid forms of mindfulness interventions were developed and the research literature on mindfulness-based interventions increased substantially (McCown, 2013). MBSR interventions are being used increasingly for health problems that were not previously considered amenable to psychologically focused treatments (Majumdar et al, 2002; Byrne et al, 2014). MBSR interventions are well established as a treatment option for a wide range of psychological health issues, and are recognised for their potential to reduce stress and increase the person's psychological functioning skills (Grossman et al, 2004; Monshat et al, 2013; Sharma et al, 2014). In the past decade, clinical improvements have been attributed to the use of MBSR in a range of mental health problems, including anxiety, depression suicidal ideation and perinatal mental health (Dunn et al, 2012; Serpa et al, 2014). Mindfulness techniques have also been shown to be beneficial in treating individuals with alcohol and other drug disorders, reducing relapse and increasing the efficacy of adjunct treatments (Hsu et al, 2013; Witkiewitz et al, 2014).
While the use of MBSR during the perinatal period has shown efficacy for men, almost all programmes during the perinatal period are aimed at women (Gambrel and Piercy, 2015a; 2015b).
Literature review
Aim
The aim of this integrative review was to synthesise literature regarding the effectiveness of mindfulness-based interventions used for men during the perinatal period.
Methodology
An integrative review of existing literature was undertaken to identify and analyse research-based literature about the benefits of MBSR in reducing stress in men during the perinatal period. An integrative literature review was chosen as the most appropriate methodology because it is considered to be instrumental in providing a more comprehensive understanding of concepts and health care issues, using a wide range of methodologies and research designs, and affording the potential for new perspectives and conceptualisation of a topic (Whittemore and Knafl, 2005). Souza et al (2010) list five essential stages of knowledge integration required to develop a more complete understanding of a topic. The stages, problem identification, literature search, data collection, data analysis, and discussion are described in Table 1. Although combining research from diverse designs can become complex and challenging (Souza et al, 2010), a systematic and rigorous approach such as the five-step process will reduce bias and error. Whittemore et al (2005) support this approach, and add that rigorous integrative reviews allow various perspectives of a given subject to be examined, forming new knowledge bases from which new clinical practices are developed (Whittemore et al, 2005; Souza et al, 2010).
| Stage | Processes undertaken |
|---|---|
| 1. Preparing the guiding question | The reviewer(s) clearly define the participants, the intervention to be evaluated and the results to be measured |
| 2. Searching or sampling the literature | The processes undertaken to search for literature, the databases included and other search strategies and the application of inclusion and exclusion criteria, are outlined |
| 3. Data collection | The means of data collection is described, including the selected critical appraisal checklist and appraisal tools. The reviewer also demonstrates the appropriateness of the tools (Critical Appraisal Skills Programme (CASP), 2014) |
| 4. Critical analysis of the studies included | This phase includes the grouping of studies to weigh rigour, validity of methods and results to determine usefulness, with hierarchical organisation based on the design of the research and levels of evidence |
| 5. Discussion of results | The reviewer provides the reader(s) with an interpretation and synthesis of results, identifying gaps in knowledge and priorities for further research |
This review used the five stages as outlined by Souza et al (2010) as the basis for identifying and reviewing literature on the use of MBSR interventions for men with pregnant partners.
Problem identification
The emotional wellbeing of men with pregnant partners is central to supporting both the woman and the child (Bergström, 2013; Wynter et al, 2013). There is substantive evidence to show that high levels of stress are as prevalent for men as women in the perinatal period (Letourneau et al, 2012; Bergström, 2013; Wynter et al, 2013). Stress experienced by men is more likely to be displayed as anger and violence, and for women, stress is likely to be displayed as anxiety and depression (Beddoe et al, 2009). Research (Genesoni and Tallandini, 2009) has established the perinatal period as one of the most demanding periods in life for men, in terms of change in psychological reorganisation of the self. The authors report that the experience of becoming a father is one of the most inter-and intra-personally challenging times for men (Genesoni and Tallandini, 2009). Maternity care provides routine screening for mental health and referral to mental health services for women during pregnancy (Rowe et al, 2013); however, there are no mental health screening or interventions targeted specifically to men with pregnant partners (Jones et al, 2014).
Literature search
A search was completed using the following electronic databases: CINAHL, Maternity and Infant Care Database (MIDIRS), Medline, and Excerpta Medica Database (Embase). A combination of 14 key terms (mindfulness, MBSR, insight meditation, stress reduction, mindful meditation, stress reduction, mindful meditation, emotional wellbeing, fathers, perinatal, pregnancy, dad, men, and male) were used, in addition to manual searching of reference lists. All retrieved literature was imported into a reference management software programme. No date restrictions were applied.
Inclusion and exclusion criteria
The inclusion and exclusion criteria for this integrated review were guided by the question ‘Can mindfulness based stress reduction reduce stress for men with pregnant partners during the perinatal period?’ to ensure a focused selection of literature. The criteria are shown in Table 2.
| Inclusion criteria | Exclusion criteria |
|---|---|
| English and non-English studies translated to English | Non-English studies where translation was unavailable |
| Mindfulness-based stress reduction interventions used for men during the perinatal period | Non mindfulness-based stress reduction interventions |
| Mindfulness-based programmes for women in the perinatal period | |
| Mindfulness-based programmes used during the perinatal period, with mixed populations, where the data for male participants was not able to be clearly identified and analysed separately. |
The initial search resulted in 157 articles, from which 32 duplicates were excluded. Titles and abstracts were reviewed for relevance, with 58 articles remaining. These 58 articles underwent assessment for relevance to the inclusion and exclusion criteria. Of these 56 articles were excluded; 30 on the basis of population and timing (studies conducted with both men and women, just women, or just men but not in the perinatal period) and 26 due to the use of interventions other than MBSR. Two remaining articles were evaluated for methodological quality using the appropriate Critical Appraisal Skills Program (CASP) tool.
Critical analysis of the studies included
CASP tools are considered an effective way to critically appraise research evidence (Nadelson and Nadelson, 2014). Specific checklists have been developed for randomised controlled trials, systematic reviews, qualitative and quantitative research (CASP, 2014).
Applying the CASP tool to the remaining two articles resulted in both articles receiving a CASP-approved score greater than 8. A CASP score of greater than 8 is sufficient to achieve methodological rigour (CASP, 2014). The first article (Gambrel and Piercy, 2015a) was evaluated using the CASP tool for randomized control trials and scored scoring a 9 out of 11, thereby meeting the inclusion threshold. The second article (Gambrel and Piercy, 2015b) was appraised using the CASP tool for qualitative research and scored 10 out of 10, thereby also meeting the inclusion threshold.
Following the approach suggested by Souza et al (2010), thematic analysis was undertaken on the included articles, with the findings being compared to the theoretical reference literature on MBSR. This allows for identification of gaps in the knowledge, and priorities for future studies (Souza et al, 2010).
Study characteristics
The two articles included in this review are from the same study, involving the same team of authors (Gambrel and Piercy, 2015a; 2015b). The first article (Gambrel and Piercy, 2015a) reported on the quantitative results of a mixed methods randomised controlled trial undertaken in the USA. The second article reported on the qualitative findings from the same project. Participants were couples (n=33) expecting their first child. Of these, 16 couples were assigned to a 4-week MBSR programme (treatment group) and 17 couples to a wait list (control group) (Gambrel and Piercy, 2015b). This design is considered to be the gold standard in research trials (Creswell, 2014). The use of mixed methods designs is said to allow studies to transcend false dichotomies between the two methods. Pragmatically, the two methodological approaches complemented each other in answering the research question (Creswell and Plano Clark, 2011).
Results from this review are presented as themes drawn from the two included studies and considered in the context of other relevant theoretical and research literature (Souza et al, 2010). Five themes were identified: variations in mindfulness-based stress reduction, essential ingredients of mindfulness, engagement of participants in mindfulness, measuring mindfulness, and mindfulness study limitations. This article will discuss the first three themes, while the latter themes will be discussed in Part II of this series.
Variations in mindfulness based stress reduction
From the emergence of MBSR in the early 1970s, variations on the standard MBSR model have been the subject of much debate. Jon Kabat-Zinn, a pioneer in the development of MBSR, introduced what is now considered to be the standard programme model at the University of Massachusetts in 1979 (White, 2014). The programme consisted of 2.5 hour sessions each week for 8 weeks, as well as a 1-day silent retreat and a commitment from participants to practise mindfulness for 45 minutes per day, 6 days a week (White, 2014). Once the standard framework for an 8-week MBSR programme was developed, hybrid forms of the intervention, including a 10-week programme, were then developed and evaluated for the treatment of chronic pain (Kabat-Zinn, 1982). Bergen-Cico et al (2013) and have challenged the view that MBSR must be rigidly applied using the standard model, with a range of MBSR programmes developed based on the needs of participants and resource availability.
MBSR programmes in clinical populations are as varied as the psychological and physical illnesses affecting these populations. In relation to the clinical treatment of mental health problems, a meta-analysis of MBSR by Grossman et al (2004) indicated that the intervention provided via a structured programme of 8–10 weeks duration improved quality of life, coping, depression and anxiety outcomes, using standardised measures. A meta-analysis conducted by Klainin-Yobas et al (2012) indicated that the effects of MBSR were significantly associated with the duration of the programme. Other studies have, however, indicated the effectiveness of MBSR for mental health problems when delivered through less intense programmes of shorter duration (Zeidan et al, 2010a; Bergen-Cico et al, 2013) Research Zeidan et al (2010b) suggests the efficacy of MBSR programmes in which the duration is as short as 4 days, as measured through improved visual-spatial processing, working memory and executive functioning, and decreased stress; benefits normally associated with standard 8–10 week MBSR programmes. In a study evaluating a brief, 5-week MBSR programme, Bergen-Cico et al (2013) demonstrated the ability of the intervention to reduce anxiety, while increasing psychological wellbeing. The findings of the two articles included in the review were consistent with these studies (Gambrel and Piercy, 2015a; 2015b); that is, brief MBSR interventions, similar to programmes between 8–10 weeks' duration can reduce anxiety and improve psychological wellbeing. The availability of brief versions of MBSR, with established effectiveness has important implications for increasing access to an evidence-based intervention within the resource limitations typically experienced by mental health service providers (Zeidan et al, 2010b).
Essential ingredients of MBSR interventions
This theme addresses the components of MBSR, and whether there is evidence that some components are more important than others in contributing to the impact of the intervention. Kabat-Zinn (2002) draws attention to two key theoretical aspects of mindfulness. First, mindfulness involves a purposeful deep attention that allows a non-conceptual awareness; this removes the automaticity and habitual unawareness of everyday moments. Second is the practice of focusing on those things we rarely pay attention to, such as breathing. Being mindful of and focusing on breathing, letting the act of breathing occur naturally but watching it attentively, provides opportunities for the mind to wander, and to be brought back to attending to our breathing (Kabat-Zinn, 2002). Attending mindfully to breathing allows the participant to ‘drop in’ on the present moment. This approach of paying attention (being mindful) to one primary focus (breathing), while allowing thoughts to come and go without judgment, are the main ingredients of MBSR interventions (Kabat-Zinn, 2002).
The MBSR intervention evaluated in the two articles involved in the review (Gambrel and Piercy, 2015a; 2015b) used mindfulness techniques that were consistent with those developed by Kabat-Zinn (1996) to improve presence and awareness in participants. Formal mindfulness practices used in the MBSR sessions to improve participants' presence and awareness included the mindfulness of breathing, and open awareness. While Dobkin and Zhao (2011) suggest a link between the reduction of depressive symptoms, stress, and medical symptoms using MBSR interventions, they were not able to demonstrate a relationship between any one particular MBSR practice and outcomes. This raises questions, not only regarding the duration of meditation practices needed to accrue benefits, but also as to whether the benefits gained rely on any particular mindfulness activity and/or the active engagement of the participant in MBSR interventions.
Gambrel and Piercy (2015a; 2015b) demonstrate the capacity of MBSR interventions to be condensed with no apparent reduction in efficacy in non-clinical populations. The efficacy of condensed MBSR interventions also appears to have similar results in clinical populations (Boggs et al, 2014). While the key mindfulness ingredients cannot be extrapolated, similarities can be inferred; namely that mindfulness is about a purposeful, deep attention, focusing on automatic processes (Bergen et al, 2014; Zeidan et al, 2010b). According to Kabat-Zinn (2011), the emphasis of mindfulness has always been on awareness of the present and acceptance of things as they are from moment to moment.
Engagement of participants in mindfulness
The male participants involved in Gambrel and Piercy's mixed method randomised controlled trial reported that the social support that women may experience during pregnancy (mother support groups, friends and family excited about the pregnancy) is different to men's experience of support (Gambrel and Piercy, 2015a; 2015b). Support during the perinatal period, such as antenatal education classes and visits to maternity clinics, are primarily woman-focused, which may have contributed to men's deeper engagement in the mindfulness programme, resulting in greater benefits as recorded in the study outcomes (Gambrel and Piercy, 2015a; 2015b).
Furthermore, Gambrel and Piercy suggest that while it is unclear as to which specific activities resulted in improved mindfulness in men, the key appears to be engagement. The authors suggest that high-functioning couples could benefit from access to self-guided programmes (Gambrel and Piercy, 2015a; 2015b). High-functioning couples were defined as those with high socioeconomic and educational status, strong and happy relationships, and scores of more than 70 on the Couple Satisfaction Index. Promoting access to mindfulness programmes through online delivery and self-study options may increase accessibility and ease of use, thus resulting in meaningful engagement (Gambrel and Piercy, 2015a; 2015b).
Development of web-and app-based technologies, and their widespread use is changing the attitudes and help-seeking behaviours of people with mental health problems. Christensen and Hickie (2010) suggest that web-based psychoeducation provides earlier and better management of mental health problems. A recent randomised controlled trial (Morledge et al, 2013) examined the feasibility of an online mindfulness programme to reduce stress. Participants were recruited using flyers and advertising in clinics and health care facilities. Participants (n=551) undertook a 12-week internet stress management (ISM) programme, in which email contact details were automatically randomised into three groups: control (n=184), ISM (n=183) and ‘ISM+’ (ISM with message board support) (n=184), with the control group receiving ISM after the completion of the trial (Morledge et al, 2013). No significant differences were observed between the ISM and ISM+ groups, and the authors concluded that the ISM programme was effective in reducing perceived stress and improving mindfulness. Regardless of engagement, ISM or ISM+ demonstrated a reduction in stress with continued mindfulness improvements, correlating with other MBSR programmes. No research has evaluated online programmes versus face-to-face delivery of MBSR for men in the perinatal period.
Discussion
Mindfulness interventions have become increasingly accepted in the treatment of a wide range of health issues. This integrative review identified two articles reporting outcomes from a single study of the use of MBSR for men in the perinatal period; one article reporting quantitative findings and the other reporting qualitative findings (Gambrel and Piercy, 2015a; 2015b). The two sets of findings were then examined in light of the growing body of literature investigating the use of mindfulness interventions in both clinical and non-clinical populations. The themes emerged were: variations in mindfulness-based stress reduction, essential ingredients of MSBR, engagement of participants in mindfulness and measuring mindfulness with both quantitative and qualitative methodologies. This article has discussed the first three themes, with discussion of the latter themes to follow in Part II.
Variations in mindfulness-based stress reduction programmes were evident, with differences in delivery (face-to-face sessions, group-based sessions and online), suggesting that mindfulness interventions can be delivered according to the needs of intended participants and resource availability. Being able to deliver brief versions of MBSR through online delivery may address resource limitations that would otherwise restrict the accessibility and/or delivery of MBSR.
Regardless of length of mindfulness intervention or mode of delivery, the essential ingredients in all MBSR programmes involve purposeful deep attention and a deliberate focusing on automatic processes, such as breathing, which is confirmed by the included studies. While it is often stated that specific mindfulness practices or ingredients cannot be signalled out as being more effective than others, all require the basic framework of deep purposeful attention and breathing.
The widespread use of web-and app-based technologies are gaining in popularity, changing the ways in which people engage with mindfulness and other forms of psychological interventions. As a result of being able to design and deliver mindfulness programmes online, it is possible that the participant engagement issues often seen in face-to-face mindfulness may be reduced; however, studies (Boggs et al, 2014; Andersson, 2016) have shown that providing mindfulness therapies online are consistent with reported qualitative accounts from face-to-face mindfulness sessions, and that guided psychological treatments, including mindfulness programmes, can be as effective as face-to-face delivery. Trends in mindfulness interventions suggest varying methods and timeframes for delivery, with no single method being validated as superior to another.
Conclusion
As yet, there is no consensus on what ought to be included in a mindfulness intervention, although studies evaluating the outcomes of MBSR have tended to stay close to the intervention model developed by Kabat-Zinn (1982). A number of studies have reported using 8-week programme, comprising 2-3 hourly sessions per week; however, other research has involved the use of mindfulness interventions of shorter duration.