“Stop, pause and take a break”: a mixed methods study of the longer-term outcomes of digital emotional wellbeing training for perinatal women | BMC Pregnancy and Childbirth

Comparison group

There were no significant differences between the intervention and comparison groups’ demographics, including age, socio-economic status and number of children (see Table 1).

Psychological distress

We compared the baseline psychological distress of participants in the MMM intervention groups, versus those who received no wellbeing intervention (i.e., the comparison ORIGINS group). Table 2 includes DASS-21 scores as subsets for anxiety, depression and stress, and total scores.

We compared baseline antenatal psychological distress scores using the DASS-21 self-report questionnaire in participants who enrolled in the MMM study compared to those who did not over the same time period. Those in the LKCT intervention group (n = 28) and those in the MT group (n = 26) had significantly higher total summative DASS scores (p = 0.013). Median (IQR): LKCT group = 20 (8–24), MT group = 16 (10–30), ORIGINS’ comparison group = 12 (6–20). Additionally, the stress subset DASS median scores were statistically significant in the MMM groups (p = 0.016) and the depression sub-group (p = 0.047) compared to the comparison group.

Interview group: qualitative analysis

Analysis of the interviews with participants identified four main themes from their reflections on long-term engagement and enactment of learnt skills: (1) Motivation to use skills; (2) Taking time for oneself; (3) Emotional support; and (4) Improving wellbeing. Within each theme there were sub-themes, some of which were identified by the research team as enablers or barriers to engagement in the training programs. The themes and sub-themes are presented in Fig. 2, along with exemplar quotes. Each theme is described in more detail below and elaborated through direct participant quotes.

Themes, subthemes and example quotes

Theme 1: Motivation to use skills

This theme describes how participants applied learnt skills in everyday life and used them either in their interactions with their baby or to their own actions.

1a: Connection and interaction with baby

Many of the women who participated in either the LKCT or MT training continued to use the skills regularly in their connection and interaction with their babies from pregnancy through to the first year of infancy.

“I think there was one meditation that focused on …. like connecting with the baby while you were still pregnant and kind of imagining that relationship and that sort of thing. But I think sometimes when I was feeling a little bit low, in myself, … I felt a little bit disconnected, I suppose, to my daughter. So when I had those feelings, I could reassure myself, I suppose, that I’m not actually disconnected, like it’s – you know maybe I’m just distracted and that sort of thing, and we do have a bond in the relationship and that helped to give me some reassurance.” (MMM50-LKCT)

“If we go to the park and he really enjoys – I don’t know, he just enjoys sitting there, touching stones and throwing things up in the air and whatever else, I think just not needing to find something to do and just letting him explore.” (MMM24-MT)

1b: Increased self-awareness and being present

Most mothers mentioned increased self-awareness and being present in the moment. There was a common theme of being present and connection to nature, as indicated in the following participant quotes.

“I also really enjoy getting out in nature and being in the moment and kind of being mindful of my environment.” (MMM50- LKCT)

“I probably don’t do anything for myself but definitely getting outdoors with her is big a thing and just walking.” (MMM43- LKCT)

“I make an effort to be, you know, present and – especially if we’re outside to… at least listen to things around us.” (MMM24-MT)

1c: Breathing and relaxation

Up to 12 months post-intervention, participants described how the training has continued to enable regular relaxation, predominantly through breathing exercises and visualisaations.

“But now, I know sometimes I go to bed and it’s just like trying to find that switch off, so I might now put the lights on, you know, do some breathing exercises, go to a happy place, do the visualisations or the techniques, definitely makes the difference.” (MMM43- LKCT)

Theme 2: Taking time for oneself

This theme describes time as both an enabler and barrier to practicing skills learnt in the training programs.

2a: Time for oneself

Overwhelmingly, participants acknowledged that time for oneself was important, even if it was fleeting, the program reinforced the benefit of fostering personal time. They described this as supporting emotion regulation through having time to focus on themselves and using breathing as a calming strategy to soothe themselves.

“I definitely do need a little bit of time to myself to focus on my mental health, because I think that when you have a newborn, you’re so focused on them.” (MMM2-LKCT)

“I try to spare, at least, 5–10 minutes every day for myself to, you know, reorganise my thoughts and feelings and – and give me some time to – to digest and settle and stuff like that, mentally” (MMM38-LKCT)

“I think it’s more allowed me to focus on me a bit more, like it’s okay to go actually, no, I need to step away for 15 minutes. I just need to take a breath and get myself back together.” (MMM32-LKCT)

2b: Habit and regular reminders

Participants often reflected that the greatest enabler to practice was regularity, in the form of setting aside a routine time, place or setting. Practice therefore becomes a habit, and it was emphasised that establishing this habit before birth helped to sustain it afterwards.

“You build that habit before birth and then just continue it afterwards (MMM1-LKCT)

“So, I think having a set time in the day, even though it wasn’t a specific time, it was just before bed… was helpful.” (MMM50-LKCT)

There were recommendations that the MMM program could be enhanced with more frequent prompts and affirmations, “maybe some text messages or some affirmation you’re doing a good job just to give you that little bit of a boost maybe if you’re having a bad day.” (MMM37-MT).

2c: Too busy

New mothers are extremely busy, and many participants simply did not reflect on the program, “So I was just like all consumed with baby stuff for the first eight months.” (MMM54-LKCT). Frequently, participants said that they were just too tired, too busy with the baby or too sleep deprived to continue with the practice.

“It’s just I don’t think about it. I’m rushing around, doing things most of the time, working at home, looking after the family.” (MMM3-MT)

While some participants had every intention of continuing with the practice, it was not as high a priority as other activities, “I think I had every intention on going back and looking at them when I had time, but when I have time, all I wanna do is sit down and do nothing, so I never ended up going back and doing them.” (MMM51-MT)

Theme 3: Emotional support

This theme reflects on the emotional wellbeing postnatal support needs of the participants from the time they completed the antenatal program until the follow-up interview.

31a: Need for postnatal program

All participants saw the benefits of providing the training program postnatally, although they differed in their suggested timeframes, some recommending it was immediately available post-birth while others believed they were not ready until after the first three months, or longer. Invariably they saw the need for both an antenatal and postnatal program.

“I definitely feel quite passionate about giving women the support early on, you know, like straight after… delivery as well.” (MMM37-MT)

3b: Support network in person or virtual

Simply having a support network post birth was fundamentally important to many women. Some women were uncertain where to go for specific support, and conveyed frustration with lack of access to timely help.

“It can be one month, two months, three months, whenever or just weeks, days, maybe but there should be… a place that’s open and accessible for everyone and they have to know about it, and they can reach out for help.” (MMM38-LKCT)

Participants valued the care of their partners, particularly in supporting their mental health needs, “My husband keeps saying…, “You need to look after yourself to look after her” or have that timeout because I don’t have any time away from her, so just having a break.” (MMM43- LKCT)

There were mixed opinions on preferences for in-person or virtual training programs, with most interested in both options. In terms of postnatal services, there was a more consistent leaning towards in person, particularly for breastfeeding advice or baby assessments.

“I think, that’s a really bad shift by a lot of health professionals now just thinking that they can monitor mums and babies via telehealth. (MMM33-MT)

3c: Isolation and loneliness

Several women mentioned their isolation and loneliness in the first few months after giving birth and projected a sense of disconnection. This was more acute for those without local family support.

“Talking more or solely about those very early days when you’re completely lost. Mostly when you don’t have like a mum around or another help…, because all our parents are back in Europe, so we were completely on our own and sometimes we felt lost.” (MMM38- LKCT)

I found since having [the baby] it to be more isolating than I’ve ever found before. (MMM43- LKCT)

“I felt like after I’d left hospital, I was kind of like left to it. There wasn’t really any follow up support after that. I was just… left.” (MMM3-MT)

3d: Needs not met by the training program

Some participants reflected that support was indeed needed, but that they felt the digital format was inappropriate for them (e.g., needing more intensive intervention, preference not to increase ‘screen time’ around baby). The training program did not feel relevant, appropriate, or suited to perception of their needs. One participant believed her mental health issues needed “deeper therapy” than the program could offer. Other reasons why participants did not continue with the practices included: forgetting about the program, the format of the program (I, myself, enjoy doing things like games and stuff, rather than… watching a video – I find reading as well much better than a video (MMM51-MT), and a general reluctance to use a digital device, “I don’t wanna be on my phone all the time in front of my daughter.” (MMM54- LKCT) These participants may be identified as requiring further support or support that takes a different format.

Theme 4: Improving wellbeing

This theme describes other common factors associated with emotional wellbeing during the first year post-birth.

4a: Aids sleep

Many participants considered the training played a role in aiding their sleep. One participant discussed her independent discovery of a bedtime sleep stories app that includes general meditations and ‘sleepcasts’ describing in detail a relaxing scene. She used them most nights to fall asleep.

4b: Anxiety and depression

A few of the participants discussed their struggles with anxiety and depression, including postnatal depression. Underlying issues were heightened because of COVID, “My anxiety has certainly increased since COVID times, like I think twice about where I’m gonna go and where I’m gonna take my kids. If there’s gonna be big crowds, I’d rather not. (MMM50-LKCT)

However, some women actively applied the training tools, such as mindfulness and relaxation techniques, from the program to alleviate their psychological distress,

“I had to actively do things that were going to bring my anxiety levels down because like every time I’d get sick or something could happen, automatically my mind goes to the absolute worst-case scenario. So, it was definitely al lot of self-awareness that like I would catch myself going like three anxious thoughts… and just go, “No, I need to go back to mindfulness, I need to go back to relaxation techniques”, or whatever it is and calm myself down.” (MMM2-LKCT)

4c: Impacts of COVID-19

Uniquely, this is a generation of women who experienced pregnancy and the postnatal period during the COVID-19 pandemic. Participants in this study underwent differing lockdown situations, with accessibility restrictions to healthcare, both for them and their child. Many of the women who were interviewed mentioned COVID, situational uncertainties and their heightened anxiety, “I thought COVID was probably the thing that threw a spanner most in the works for me personally.” (MMM17-LK).

COVID disrupted the provision of healthcare services, but many women found some level of support through digital platforms including telehealth. However, some participants found this more isolating,

“I mean if you look at all those Facebook groups, you would see there’s a lot of women looking for connection and it’s not online… people are looking for in-person.” (MMM33-MT)

4d: Unanticipated emotional impact of baby

There was a sense of misconception, even frustration, from some women about the unanticipated enormity of pregnancy, birth, and the postnatal period.

“One thing that I think women do is a disservice to each other is pretending that everything’s fluffy bunnies, roses and rainbows, when pregnancy is f* hard and, postnatally, it’s hard too…But I think a lot of people don’t talk about the challenges because it’s kind of taboo.” (MMM50-LKCT)

“I think just having a baby is just so overwhelming generally.” (MMM54- LKCT)

“I don’t think people realise how important [emotional wellbeing] really is during pregnancy, and especially that first year after giving birth. It’s a massive, massive undertaking, mentally and emotionally. So, anything that I could do to help that is, yeah, more than welcome.” (MMM32-LKCT)