Effect of mindfulness stress reduction combined with cognitive behavioral therapy on perinatal anxiety disorder and maternal-infant bonding

Abstract

BACKGROUND

Perinatal anxiety disorder is the main problem affecting mother-infant bonding. Though the impact of perinatal anxiety in primiparous women on the mother-infant relationship is well established, appropriate interventions need to be explored.

AIM

To explore the synergistic intervention effect of mindfulness-based stress reduction combined with cognitive behavioral therapy (CBT) on perinatal anxiety disorders and mother-infant bonding in primiparas.

METHODS

A total of 150 primiparas with perinatal anxiety disorders admitted to the hospital from January 2020 to October 2024 were selected and divided into two groups according to the random number method. The control group (n = 75) received CBT, and the observation group (n = 75) received mindfulness-based stress reduction combined with CBT. The anxiety and depressive emotions, as well as the mother-infant emotional bonding situation, were compared between the two groups.

RESULTS

After the intervention, the anxiety and depressive states in the observation group were lower than those in the control group (P < 0.05). The mother-infant bonding (sense of pleasure, recognition, understanding, and love) in the observation group was higher than that in the control group, and the role adaptation ability was also higher than in the control group (P < 0.05).

CONCLUSION

Mindfulness-based stress reduction combined with CBT can reduce perinatal anxiety disorders in primiparas, promote mother-infant bonding, and improve their ability to adapt to the mother role.

Key Words: Mindfulness stress reduction; Cognitive behavioral therapy; Primiparous women; Perinatal anxiety disorder; Mother-infant emotional bonding

Core Tip: Mindfulness-based stress reduction combined with cognitive behavioral therapy significantly reduces perinatal anxiety and depression in primiparas by enhancing self-regulation and correcting cognitive distortions. This synergistic approach strengthens mother-infant bonding through improved emotional recognition, role adaptation, and affectionate interactions, outperforming cognitive behavioral therapy alone. Prioritizing non-pharmacological interventions addresses perinatal mental health safely while promoting long-term maternal-infant relational health.

INTRODUCTION

Perinatal anxiety disorder refers to an anxiety disorder that occurs in pregnant and lying-in women from pregnancy to within one year after childbirth, including antenatal anxiety disorder and postpartum anxiety disorder[1]. According to incomplete statistics, the total prevalence rate of prenatal depression in both parents was 1.72%, the prevalence rate of early postpartum depression was 2.37%, and the prevalence rate of late postpartum depression was 3.18%[2]. Scholars such as Fairbrother et al[3] pointed out that perinatal anxiety disorder affects about 20% of pregnant and lying-in women, which not only affects the safety of pregnancy and lying-in women’s lives, but also has a certain negative impact on the development of the fetus and newborn. Currently, the causes of perinatal anxiety disorder have not been clearly defined and are believed to be related to factors such as hormonal changes, physical changes, and social psychology[4]. Drug treatment and psychological interventions are mainly used to treat perinatal anxiety disorders. Due to the particularity of pregnancy and the postpartum period, drugs may have potential impacts on both the mother and fetus. Therefore, psychological interventions have become the preferred method of addressing perinatal anxiety and depression.

Cognitive behavioral therapy (CBT) is a commonly used psychological treatment method that involves changing the wrong thinking and beliefs of patients to enable them to establish accurate cognition and healthy behaviors, thereby eliminating patients’ negative emotions[5]. However, when negative emotions dominate during the perinatal period, pregnant women are prone to escape behaviors, which affects the implementation of CBT. Therefore, it is advisable to combine other intervention methods to improve the effect of the intervention on perinatal anxiety disorders. Mindfulness-based stress reduction uses mindfulness meditation to address stress, pain, and illnesses. It guides patients to face the disease squarely, use their own internal strength to fight the disease, improve their physical and mental health, and cultivate mindfulness[6,7]. When CBT is administered to primiparas combined with mindfulness-based stress reduction, whether it can improve the intervention effect on perinatal anxiety disorders has high research significance. Therefore, this study analyzed the synergistic intervention effect of mindfulness-based stress reduction combined with CBT on perinatal anxiety disorder and mother-infant bonding in primiparas.

MATERIALS AND METHODS

Clinical data

A total of 150 primiparas with perinatal anxiety disorders admitted to the hospital between January 2020 and October 2024 were selected. Inclusion criteria: (1) Experiencing their first pregnancy and childbirth; (2) Singleton live birth; (3) Regular obstetric examinations in the research hospital; (4) Generalized anxiety disorder-7 (GAD-7)[8] self-rating scale score of ≥ 7 points, indicating the presence of anxiety symptoms; and (5) Informed about the study and have signed the consent form. The exclusion criteria were: (1) Miscarriage during the study period; (2) Pre-pregnancy mental diseases and cognitive impairments; (3) High-risk pregnancy or fetal malformations; (4) Lesions in important organs such as the heart, brain, liver, and kidneys; and (5) Dysfunctions in hematopoiesis, blood coagulation, and immunity. The patients were divided into two groups using the random number method: The control group (n = 75), aged 21 to 36 years old (27.81 ± 3.15), gestational age 30-38 weeks (35.14 ± 1.15), educational background: 21 cases with a high school education or below, and 54 cases with a junior college education or above; the observation group (n = 75), aged 20 to 38 years old (28.08 ± 3.27), gestational age 28 to 38 weeks (34.91 ± 1.28), educational background: 25 cases with a high school education or below, and 50 cases with a junior college education or above. There was no significant difference in the basic data of the primiparas between the two groups (P > 0.05), and they were comparable.

Methods

The control group received CBT: (1) Cognitive changes. After the primipara was admitted to the hospital, the nursing staff communicated reasonably with the primipara and established a WeChat group, inviting the primipara and her spouse to join. Knowledge about changes in pregnancy roles, breastfeeding, neonatal care, and emotional self-regulation was sent to the group. Knowledge lectures were carried out in the hospital, and each person was given a copy of the “Handbook of Knowledge on Healthy Pregnancy, Childbirth and Parenting”, which includes knowledge about breastfeeding, neonatal care, self-emotional regulation, diet/exercise after childbirth, and body shape restoration. Methods such as oral and video education were used to explain knowledge about pregnancy and childbirth, discuss the possible causes of anxiety and depression, provide self-intervention measures, and correct the patient’s wrong cognition; (2) Changing wrong beliefs. This included comprehensively understanding the information of the primipara and her family members, analyzing their psychological dynamics, encouraging the primipara to express her thoughts, listening carefully, analyzing the problems in her thoughts, and correcting her wrong cognition. Midwives and health experts jointly explained the manifestations and negative impacts of perinatal anxiety and successful intervention cases, and primiparas who have given birth safely shared their own rehabilitation experiences in person to change their wrong beliefs and establish accurate cognition; and (3) Behavioral change. The medical staff encouraged the primiparas to participate in recreational activities and divert their attention to activities such as gatherings with friends, watching movies, shopping, listening to music, and prenatal yoga. The primiparas were guided to master emotion regulation techniques, including progressive muscle and breathing relaxation techniques. When relaxing the muscles, the primipara would imagine what she wanted to do after childbirth. The imagined desensitization method was used to enable her to overcome the disease. For example, let the primipara imagine the most terrifying scene she wants to overcome, and use the imagination therapy to deal with and overcome the terrifying scene. Guide her to carry out intentional training, guide the primipara to recall bad events, experience the wrong beliefs of troubled emotions, make her aware of the problems brought about by the wrong beliefs, and transform unhealthy concepts into healthy ones, replacing wrong thinking with rational thinking. Postpartum behavioral norms were introduced to the primipara and her family members, and the relationship between the mother and the baby, as well as between relatives, was promoted through methods such as early mother-infant contact, breastfeeding, and joint parenting, so that she could adapt to the role change.

The observation group received mindfulness-based stress reduction combined with CBT. CBT was the same as that in the control group. Mindfulness-based stress reduction included the following: (1) Body scan. A relaxed, quiet, and comfortable environment was created, with soft and soothing music playing during this period. The primiparas were guided to assume a supine position, and family members cooperated beside them. The nursing staff instructed the primiparas to relax their bodies, empty their minds, maintain smooth breathing, gradually relax their bodies with music, concentrate their minds on their feet, gradually transfer the movement to their brain, feel the changes in various parts of their bodies, and experience the changes in their thoughts. Each session lasted 10-15 minutes, once a day; (2) Mindful breathing. The nursing staff guided the primiparas to assume a comfortable sitting position, keep their backs straight, let their shoulders hang naturally, concentrate their minds on their abdomen, keep their abdomen bulging when inhaling, and let their abdomen sink when exhaling. The primiparas were asked to try to concentrate their attention on breathing. If their attention was distracted, they were to think about the things that distracted them and return their attention to breathing. Each session lasted for 10 minutes, once a day; (3) Sitting meditation. The primiparas were asked to relax their bodies, take a supine position, close their eyes, and carry out deep breathing and meditation in soothing music, imagining comfortable and pleasant scenes and contents, making them experience the changes in the scenes and promoting the release of their emotions. The primiparas were encouraged to listen to and feel the feelings brought about by the music with an accepting attitude, keep their attention focused, and note that, at this stage, it is awareness rather than sound. Each session lasted for 10 minutes, once a day; (4) Mindful practice of the five senses. The primiparas were guided to feel things around her from the aspects of vision, touch, hearing, taste, and smell, without analysis and criticism, without being affected by the outside world. They were guided to accept the environment they were in and gradually release pressure. Each session lasted for 5 minutes, once a day; and (5) Awakening. After the mindfulness training was completed, the nurse awakened the primiparas’ consciousness, asked them to move their limbs, and discussed and shared the problems and feelings encountered during meditation training.

Both groups underwent continuous intervention until discharge. Interventions for both groups of mothers were conducted by the same team. Before performing the interventions, all instructors received the same training to ensure they knew the intervention terms and how to perform the procedures. Additionally, we observed the physical and mental conditions of the participants during the intervention process and adjusted the intensity of the intervention in a timely manner according to their health status.

Observation indicators

Observation indicators include: (1) Anxiety state: The GAD-7 scale was used to evaluate anxiety before and after the intervention. It comprises seven items in total, each scored from 0 to 3 points, with a total score of 21 points. A score exceeding 7 points indicates the presence of anxiety symptoms, and the score increases with the aggravation of the anxiety degree; (2) Depressive state: The Patient Health Questionnaire-9[9] was used to evaluate the depressive state. It comprises nine items in total, each scored from 0 to 3 points, with a total score of 27 points. The score increases with the aggravation of the depressive degree; (3) Mother-infant bonding: The Chinese version of the Mother-Infant Attachment Inventory[10] was used to evaluate the mother-infant bonding before and after the intervention. It includes four dimensions: Sense of pleasure, recognition, understanding, and love, with 6, 13, 3, and 4 items, respectively, for a total of 26 items. Each item is scored from 1 to 4 points, with a total score of 104 points. Higher scores indicate better mother-infant bonding; and (4) Role adaptation status: The Mother Role Adaptation Scale[11] was used to evaluate the role adaptation status before and after the intervention. It comprises 16 items, each scored from 1 to 4 points, with a total score of 80 points. The score increases with an improved degree of role adaptation.

Statistical analysis

Statistical analyses were performed using IBM SPSS Statistics for Windows, version 26.0. Measurement data that conform to the normal distribution are expressed as mean ± SD, and the t-test was used; enumeration data are expressed as rates (%), and the χ² test was used; P < 0.05 indicated that the difference was statistically significant.

RESULTS

Anxiety state

There was no significant difference in the anxiety state between the two groups before the intervention (P > 0.05). After the intervention, the anxiety state in both groups was alleviated, and anxiety relief in the observation group was more obvious (P < 0.05; Table 1).

Table 1 Comparison of anxiety status between the two groups (score, mean ± SD).

Group	Before	After	t	P value
Observation (n = 75)	13.04 ± 1.86	5.48 ± 1.01	30.933	< 0.001
Control (n = 75)	12.86 ± 2.15	6.76 ± 1.08	21.953	< 0.001
t	0.548	7.497
P value	0.584	< 0.001

Depressive state

There was no significant difference in depressive state between the two groups before the intervention (P > 0.05). After the intervention, the depressive state in both groups was alleviated, with the alleviation being more pronounced in the observation group (P < 0.05; Table 2).

Table 2 Comparison of depression status between the two groups (score, mean ± SD).

Group	Before	After	t	P value
Observation (n = 75)	15.10 ± 3.05	6.81 ± 1.15	22.025	< 0.001
Control (n = 75)	14.94 ± 3.14	8.09 ± 1.24	17.572	< 0.001
t	0.317	6.555
P value	0.752	< 0.001

Mother-infant bonding

There was no significant difference in the mother-infant bonding state between the two groups before the intervention (P > 0.05). After the intervention, the mother-infant bonding level in both groups improved, and the improvement in the observation group was more obvious (P < 0.05; Table 3).

Table 3 Comparison of maternal and infant bonding status between the two groups (score, mean ± SD).

Group	A sense of joy		Discriminate		Understand		Love
	Before	After	Before	After	Before	After	Before	After
Observation (n = 75)	12.18 ± 2.04	18.64 ± 1.52a	28.64 ± 3.15	41.75 ± 3.62a	6.50 ± 1.75	9.14 ± 1.03a	7.26 ± 1.61	11.20 ± 1.14a
Control (n = 75)	12.73 ± 2.12	15.08 ± 1.81a	29.07 ± 3.27	35.08 ± 3.50a	6.84 ± 1.81	8.08 ± 1.05a	7.67 ± 1.72	8.94 ± 1.17a
t	1.619	13.044	0.820	11.472	1.170	6.241	1.507	11.981
P value	0.108	< 0.001	0.413	< 0.001	0.244	< 0.001	0.134	< 0.001

^aP < 0.05 vs the pre-intervention of the same group.

Role adaptation

There was no significant difference in the role adaptation ability between the two groups before the intervention (P > 0.05). After the intervention, the role-adaptation ability of both groups improved, and the improvement in the observation group was more obvious (P < 0.05; Table 4).

Table 4 Comparison of role adaptability between the two groups (score, mean ± SD).

Group	Before	After	t	P value
Observation (n = 75)	48.86 ± 4.28	65.40 ± 3.15	26.954	< 0.001
Control (n = 75)	49.67 ± 4.31	58.84 ± 3.27	14.679	< 0.001
t	1.155	12.512
P value	0.250	< 0.001

DISCUSSION

Perinatal anxiety disorder is more common in the early and late stages of pregnancy and is a high-risk factor for postpartum depression in parturients. If not treated timely, it will continue into the postpartum period, seriously affecting the quality of life of pregnant and lying-in women, while also affecting the normal development of infants and young children. Suicidal or infanticidal behaviors may occur in severe cases[12]. Especially for primiparas, fear of any negative information about childbirth, worry about the pain of childbirth, safety of the childbirth method, and excessive worry about the fetus will all cause them to develop perinatal anxiety disorders[13]. Since the transformation of the “biological-psychological-social” medical model, the influence of social, psychological, and other factors on perinatal anxiety disorders has received significant attention in clinical practice. The adoption of reasonable and effective psychological intervention measures is of great significance for the treatment of perinatal anxiety disorders.

CBT eliminates patients’ negative emotions and wrong behaviors by changing their wrong beliefs and thinking, and correcting their wrong cognitions[14]. Using CBT for primiparas can solve the problems encountered by parturients during the perinatal period, increase the knowledge of childbirth during the perinatal period and postnatal parenting for primiparas, and is of great significance for improving the psychological state of parturients. However, since primiparas experience physiological, psychological, and other functional transformations during pregnancy and childbirth, their psychological stress responses are obvious, and their negative emotions are significant. As such, it is difficult to achieve ideal results by only using CBT.

Mindfulness-based stress reduction is a scientifically effective psychological intervention. It can change the focus of attention and help face the present moment through methods such as body scanning, observing breath, and observing awareness, thereby relieving negative emotions[15]. This study showed that after the intervention, the anxiety and depressive states of the observation group were lower than those of the control group (P < 0.05). This indicates that a combination of mindfulness-based stress reduction and CBT can relieve anxiety and depressive emotions in primiparas. By using CBT for primiparas, understanding the problems existing in primiparas during pregnancy and childbirth, and conducting health education on knowledge such as breastfeeding, neonatal care, emotional self-regulation, and diet/exercise after childbirth, it can meet the health knowledge needs of primiparas and their families, change their wrong cognitions and beliefs, and eliminate negative emotions. At the same time, paying attention to joint parenting intervention enables primiparas and their spouses to jointly learn neonatal care skills, so that primiparas can obtain social support, thereby relieving their negative emotions[16]. Combined with mindfulness-based stress reduction, this method emphasizes focusing on the present moment, encourages parturients to consciously accept and perceive the present moment, can guide individuals to cultivate mindfulness, and uses their own potential to maintain their health to relax physical and mental stress and reduce the influence of anxiety and depressive emotions[17]. Simultaneously, during the process of mindfulness-based stress reduction, methods such as mindful meditation, body scanning, and mindful breathing can help parturients eliminate distracting thoughts and achieve soothing of the body, mind, and self-healing. In addition, mindful meditation can gradually awaken the parturient’s “selfless” nature, experience the feelings and experiences brought by different scenes, enable her to face and accept negative emotions, relieve her own uncertainties and wrong beliefs, and establish positive and optimistic emotions[18]. Therefore, the combination of mindfulness-based stress reduction and CBT plays a synergistic role in establishing positive beliefs and relieving negative emotions.

Perinatal anxiety disorder is the main problem affecting mother-infant bonding. Factors such as physical changes during pregnancy in primiparas, concerns about the safety of the fetus, fear of childbirth pain, and the burden of taking care of the newborn increase the occurrence of anxiety. It is difficult for them to adapt to the changes in their roles. In severe cases, they cannot face the newborn, and malignant events, such as harming or killing the baby, may occur, hindering mother-infant breastfeeding, affecting the mother-infant bond, and reducing the level of mother-infant bonding. Simultaneously, the generation of negative emotions in the mother potentially affects the subsequent physical and mental development of the child, which is not conducive to the establishment of a secure attachment relationship[19,20]. This study showed that after the intervention, mother-infant bonding (sense of pleasure, recognition, understanding, and love) and role adaptation ability were higher in the observation group than in the control group (P < 0.05). Mindfulness-based stress reduction and CBT combined can help primiparas smoothly adapt to role changes, promote mother-infant bonding, and form secure and attached relationships. CBT pays attention to correcting the wrong beliefs and cognitions of primiparas, enabling them to master the implementation of breastfeeding, neonatal care, etc., relieving their fear of childbirth. Successful cases are used as examples to increase the parturient’s confidence in childbirth. Simultaneously, parturients are encouraged to participate in more recreational activities and gradually relax their emotions through progressive muscle and breathing relaxation. The imagined desensitization method enables primiparas to gradually adapt to terrifying scenes, thereby relieving their negative emotions and accepting their own role changes. Moreover, early mother-infant contact and breastfeeding can further promote the establishment of the mother-infant attachment relationship and improve mother-infant bonding[21]. At the same time, combined with mindfulness-based stress reduction therapy, it can prompt primiparas to observe, pay attention to and accept the current situation, gradually expand individual awareness, stimulate their positive and optimistic emotions, correct self-cognitive biases, improve their somatization symptoms, enable them to accept the role of “mother”, welcome the future, and is conducive to the establishment of the mother-infant attachment relationship and the improvement of the mother-infant bonding level[22,23].

This study had several limitations that should be acknowledged when interpreting its findings. First, the follow-up period was restricted to the duration of hospitalization, with no longitudinal assessment of maternal mental health or mother-infant bonding after discharge. Consequently, the durability of the observed therapeutic effects, such as the risk of anxiety relapse or the stability of attachment outcomes at six weeks or three months postpartum, remains unknown. Future studies should incorporate extended follow-up intervals to evaluate the persistence of benefits. Second, the study did not stratify the outcomes according to baseline anxiety severity. Participants with mild (GAD-7 scores of 7-10) vs moderate (11-14) perinatal anxiety were pooled for analysis, potentially masking differential responses to the combined mindfulness-CBT intervention. Subgroup analyses or stratified randomization would clarify whether this approach is equally efficacious across the spectrum of anxiety severity. Third, while the study demonstrated efficacy relative to CBT alone, it lacked an economic evaluation of alternative low-intensity interventions (e.g., supportive psychotherapy or music therapy). Without cost-effectiveness data, the scalability and real-world feasibility of integrating mindfulness-CBT into perinatal care remain uncertain. Comparative health-economic analyses are warranted to position this intervention within existing resource-constrained settings.

CONCLUSION

In conclusion, the application of mindfulness-based stress reduction combined with CBT can reduce the degree of perinatal anxiety disorder in primiparas, relieve their depressive emotions, improve the level of mother-infant bonding, promote the establishment of the mother-infant attachment relationship, and improve their ability to adapt to their mother’s role, which is worthy of clinical application.