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

Abstract

Background: Symptoms of anxiety are common in pregnancy, with severe symptoms associated with negative outcomes for women and babies. Low-level psychological therapy is recommended for women with mild to moderate anxiety, with the aim of preventing an escalation of symptoms and providing coping strategies. Remotely delivered interventions have been suggested to improve access to treatment and support and provide a cost-effective, flexible, and timely solution.

Objective: This study identifies and evaluates remotely delivered, digital, or web-based interventions to support women with symptoms of anxiety during pregnancy.

Methods: This mixed methods systematic review followed a convergent segregated approach to synthesize qualitative and quantitative data. The ACM Digital Library, Allied and Complementary Medicine Database, Applied Social Sciences Index and Abstracts, Centre for Reviews and Dissemination database, the Cochrane Central Register of Controlled Trials, the Cochrane Library, CINAHL, Embase, Health Technology Assessment Library, IEEE Xplore, Joanna Briggs Institute, Maternity and Infant Care, MEDLINE, PsycINFO, and the Social Science Citation Index were searched in October 2020. Quantitative or qualitative primary research that included pregnant women and evaluated remotely delivered interventions reporting measures of anxiety, fear, stress, distress, women's views, and opinions were included.

Results: Overall, 3 qualitative studies and 14 quantitative studies were included. Populations included a general antenatal population and pregnant women having anxiety and depression, fear of childbirth, insomnia, and preterm labor. Interventions included cognitive behavioral therapy, problem solving, mindfulness, and educational designs. Most interventions were delivered via web-based platforms, and 62% (8/13) included direct contact from trained therapists or coaches. A meta-analysis of the quantitative data found internet-based cognitive behavioral therapy and facilitated interventions showed a beneficial effect in relation to the reduction of anxiety scores (standardized mean difference -0.49, 95% CI -0.75 to -0.22; standardized mean difference -0.48, 95% CI -0.75 to -0.22). Due to limitations in the amount of available data and study quality, the findings should be interpreted with caution. Synthesized findings found some evidence to suggest that interventions are more effective when women maintain regular participation which may be enhanced by providing regular contact with therapists or peer support, appropriate targeting of interventions involving components of relaxation and cognitive-based skills, and providing sufficient sessions to develop new skills without being too time consuming.

Conclusions: There is limited evidence to suggest that women who are pregnant may benefit from remotely delivered interventions. Components of interventions that may improve the effectiveness and acceptability of remotely delivered interventions included providing web-based contact with a therapist, health care professional, or peer community. Women may be more motivated to complete interventions that are perceived as relevant or tailored to their needs. Remote interventions may also provide women with greater anonymity to help them feel more confident in disclosing their symptoms.

Keywords: CBT; antenatal; anxiety; digital interventions; distress; eHealth; electronic health; fear; mobile phone; parenting; pregnancy; remote delivery; remote interventions; systematic review; therapy.

Figure 1

PRISMA (Preferred Reporting Item for Systematic Reviews and Meta-Analyses) diagram, remotely delivered interventions for anxiety in pregnancy.

Figure 2

Risk of bias table with assessments of the experimental studies [16,17,38-41,43-47,49-52,62].

Figure 3

Risk of bias summary of the quantitative experimental selected studies.

Figure 4

Studies reporting digitally delivered interventions for intervention and control groups (anxiety outcomes) [17,40,41,43,45,46,49,50,53].

Figure 5

Studies reporting digitally delivered cognitive behavioral therapy interventions for intervention and control groups (anxiety outcomes) [17,40,41,45,52].

Figure 6

Studies reporting digitally delivered interventions with facilitator or therapist support for intervention and control groups (anxiety outcomes) [17,40,41,43,46,50].