|
 
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| REVIEW ARTICLE |
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| Year : 2023 | Volume
: 11
| Issue : 2 | Page : 98-105 |
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Effect of Mindfulness-based Interventions on Mental Health of Women with Infertility: A Narrative Review
Smarika Dalal
Department of Applied Psychology, Guru Jambheshwar University of Science and Technology, Hisar, Haryana, India
| Date of Submission | 19-Apr-2023 |
| Date of Acceptance | 18-Jul-2023 |
| Date of Web Publication | 29-Aug-2023 |
Correspondence Address:
Ms. Smarika Dalal
House No. 168, Sector 15A, Hisar - 125 001, Haryana
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jacs.jacs_37_23
Background: By instinct, human beings have desire to propagate their genes. Infertility can be very painful for the individuals. The men and women with this medical condition are not just battling physiological problems but also dealing with psychological, emotional, and social battles, including low self-esteem, stress, depression, frustration, hopelessness, anxiety, feeling of guilt and worthlessness, insecurity in marital relationship, marital discords and lesser marital satisfaction. Women population is more vulnerable to the psycho-social consequences of infertility. Though many research studies have been conducted to investigate the psycho-social impact of infertility on women, the research literature on the combative role of mindfulness-based interventions on mental health of women have been limited. Mindfulness as a psycho-therapeutic intervention has been shown to be effective in chronic conditions like cancer, diabetes, anxiety, depression and pain. The mindfulness-based interventions in individuals with chronic conditions can assist them to accept the condition and overcome the psychological issues that arise due to the physical health conditions. Infertility is a physical health condition that has strong psychological consequences. Thus, there is a need to study the impact of these interventions on women population suffering from infertility. The purpose of the present study is to explore the effect of mindfulness-based interventions on the mental health of the women with infertility. Objective: In light of the foregoing history, the current review's research question is “Are mindfulness-based interventions effective in improving mental health of women with infertility?” Methods: This is a narrative review guided by systematic approach to searching. Prominent research databases were used to locate empirical articles reporting on the efficacy of mindfulness-based therapies on mental health of infertile women between 2000 and 2020. There were no restrictions on participant demographics including age, sex, geography, socioeconomic status, or year of publication. Only empirical studies which investigated mindfulness-based interventions on mental health (anxiety, stress, depression, quality of life and psychological well-being) of infertile women were included in the review. Results: Seventeen papers were considered in the review which involved 983 females. Depression, anxiety, stress, quality of life and psychological well-being were taken as measures of mental health of infertile women. The studies have confirmed that the mindfulness-based interventions are highly helpful for women with infertility. The interventions have successfully reduced stress, anxiety and depressive symptoms among the participants as well as enhanced their quality of life and psychological well-being.
Keywords: Anxiety, depression, infertility, mental health, mindfulness, psychological well-being, quality of life, stress
How to cite this article:
Dalal S. Effect of Mindfulness-based Interventions on Mental Health of Women with Infertility: A Narrative Review. J Appl Conscious Stud 2023;11:98-105 |
How to cite this URL:
Dalal S. Effect of Mindfulness-based Interventions on Mental Health of Women with Infertility: A Narrative Review. J Appl Conscious Stud [serial online] 2023 [cited 2023 Dec 9];11:98-105. Available from: http://www.jacsonline.in/text.asp?2023/11/2/98/384454 |
| Introduction | |  |
Infertility, a life crisis, affects individuals all over the world. Infertile patients have a considerable degree of psychological distress as a result of their condition. For patients who are infertile, there is a substantial risk of depression, anxiety, and stress. Infertility is a painful psychological experience that affects women's quality of life and psychological well-being more as the social and cultural norms expect women to play the role of mothers. In case of their inability to do so, women suffer from a multitude of psychological issues.
Infertility is a medical condition which is defined as the “disease of the male or female reproductive system defined by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse” (WHO, 2018). There are two types of infertility: primary and secondary. Primary infertility is when a person has never been able to conceive, while secondary infertility is when at least one past pregnancy has been achieved.
Parenthood is considered to be one of the very important transitional phases in the individual's life as well as the life of a couple. When an individual or a couple fails to conceive naturally, one goes through a sense of loss which is further aggravated by the societal pressure. In many of the studies, it has been found that when a couple suffers from infertility, it is the woman who is blamed and shamed, even when the male counterpart may have been infertile. More so, women are the ones who suffer more in terms of social and psychological aspects and more frequently experience violence, divorce, stress, depression, anxiety and low self-esteem. Kaufman (1969) has argued that infertility leads to a strain in the marriage. Menning (1975) has remarked that infertility is “psychologically threatening and emotionally stressful.”
Infertility poses more problems because the cause of infertility may not always be somatic or immunological (Podolska and Bidzan, 2011). This makes the management and treatment of infertility problems difficult and ambiguous. It has also been pointed out in various studies that the relationship between infertility and psychological problems is not just unidirectional rather it is bidirectional. Infertility issues can cause stress but at the same time many studies have indicated that stress can also lead to infertility (Cwikel et al., 2004, Edelmann and Connolly, 1986; Noyes and Chapnick, 1964). To understand infertility, it is imperative to understand the familial, cultural, religious/spiritual, social and other psychological and emotional dimensions of the individuals involved.
Infertility is not a single event, rather it is a process that unfolds (Dunkel-Schetter and Lobel, 1991). Studies have noted that emotional adjustment in infertility-affected couples is challenging since they must deal with issues such as diagnosed infertility causes stress; identity crisis related to infertility; managing continued infertility treatment; high likelihood of treatment cycles failing; selecting a course of therapy; consecutive cycle outcomes that are uncertain; unfavourable outcomes. Prior to or concurrent with the fertility therapy procedure, a stress assessment is done. Along with the various treatments and medical procedures, psychotherapies are employed as an adjunct therapy. Likewise, the psychological and social consequences which begin as a threat to the individual, after some time change into a feeling of loss (Lazarus, 1966; Lazarus and Launier, 1978; Lazarus and Folkman, 1984). There has been a limited research on the effectiveness of psychological therapies for people or couples for whom infertility is a confirmed diagnosis or when medical treatments have failed despite spending a lot of time on them.
Most often associated with mindfulness, which has its origins in Eastern contemplative traditions, is the formal practice of mindfulness meditation. In fact, it has been said that the “heart” of Buddhist meditation is “mindfulness” (Kabat-Zinn, 2003; Thera, 1962). But mindfulness is more than just meditation. It has “awareness inherent in it.” This entails paying attention to one's present-moment experience mindfully (Brown and Ryan, 2003). Both theoretically and experimentally, mindfulness and psychological health have been related. The mindfulness practices of awareness and nonjudgmental acceptance of one's present-moment experience are regarded to be effective in treating ruminating, anxiety, stress, fear, rage, and other common psychological distress. According to Davidson et al. (2012), a variety of practice modalities (such as contemplative practices), can foster states of mindfulness. Contemplative practices are “structured and socially scaffolded activities that train skills by placing some constraint or imposing some discipline on a normally unregulated mental or physical habit” (Davidson et al., 2012, p. 147). Practices like yoga, tai chi etc., are included in contemplative practices. Through awareness of the breath, thoughts, and emotions, contemplative practices have been shown to aid in the development of mindfulness of thoughts and feelings in infertile individuals.
The maladaptive inclinations to ignore, suppress, or over-engage with one's upsetting thoughts and feelings are a common component of psychological distress symptoms (Hayes and Feldman, 2004; Kabat-Zinn, 1990). Many of these symptoms of psychological distress (anxiety, stress etc.) overlap with the ones found in infertile women. Although it has been discovered that mindfulness is a powerful protective element in managing life's stresses, its beneficial impacts and protective mechanisms for infertile women undergoing in vitro fertilization (IVF) have not yet been fully investigated and are subject to some limitations. The current study focuses on adding to the literature that studies the efficacy of mindfulness-based therapy for infertile women.
| Methodology | | |
Search strategy
The Boolean expression to find papers reporting on the effectiveness of mindfulness-based interventions and therapy was created. The databases PubMed, PsycNET, Google scholar, and DOAJ were searched. The terms (”mindfulness-based cognitive therapy,” OR “mindfulness-based interventions,” OR “mindfulness-based stress reduction therapy,” OR “mindfulness-based therapy,” OR “MBCT,” OR “MBSR,” OR “MBI”) AND (”infertility and mindfulness,” OR “infertility and body-mind therapy,” OR “infertility and psychological interventions”) were all used in searches. A quality ranking system was used to analyze studies. The dates selected were from 2000 to 2020.
Eligibility
For the current study, in terms of participants, interventions, comparisons, outcomes and study designs the criteria were: Participants: The sample included only women who had been medically diagnosed with infertility, and/or if the sample included couples, then males and females have been studied separately and data for them is available separately; Interventions: The interventions used had to be mindfulness-based interventions; Comparison: The included research studies may or may not have control/comparison groups; Outcome: Studies where the criterion variable, that is, the variable on which effectiveness of mindfulness-based intervention studied were stress, anxiety, depression, quality of life and psychological well-being; Study design: Any empirical study that featured data collection.
Theme identification
Although it is a broad topic, “mental health” lacks a generally recognized definition. The World Health Organization (WHO) defines mental health as a “state of well-being in which the individual realizes his or her own abilities, can cope with the typical stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.” An individual's mental health can be determined not only by the absence of mental diseases but also by the presence of positive mental health markers. In the current study, the outcome variables have been divided into two broad umbrella categories: Firstly, the effect of mindfulness-based interventions in alleviating negative mental health markers like stress, anxiety and depression and secondly, the effect of mindfulness-based interventions in alleviating positive mental health markers the psychological well-being and quality of life.
Data extraction
- Phase 1: 76 studies were identified from the various sources. Titles and abstracts were screened by the author for potential inclusion. The studies were excluded if (a) they were nonintervention studies or the psycho-therapeutic intervention was not based on mindfulness; (b) the topics were out of the scope of paper; (c) the full length papers were not available; (d) papers were not in English language
- Phase 2: 30 studies were available for examination post Phase 1. Studies were excluded if: (a) the studies did not involve data collection; or (b) there was no separate data for females available.
Seventeen papers met the inclusion criteria and were included in the narrative review [Figure 1]. A total of 1067 females participated in these studies. The largest sample size in a study was recorded to be 174 (Bai et al., 2019) and the smallest sample size included was 24 (Rahmani et al., 2018). The studies were from various countries and the participants belonged to a wide range of ethnicity.
| Summary | | |
The Mindfulness-based interventions that were improvised in the included studies were mindfulness-based cognitive therapy (MBCT), mindfulness-based stress reduction (MBSR) therapy, mindfulness-based intervention for IVF women (MBII), mindfulness-based programs (MBPs), brief mindfulness therapy, mindfulness-based group counselling, mindfulness-based cognitive infertility stress therapy, and recognition therapy based on mindfulness.
MBCT was used in three out of the seventeen studies (Rahmani et al., 2018; Moein et al., 2018; Sherratt and Lunn, 2013). In two other studies, parts of MBCT were used as therapy for infertile women (Shargh et al., 2016; Varghese and Fathima, 2022). There was significant reduction in the stress and anxiety symptoms among the women (Varghese and Fathima, 2022). The quality of life significantly improved (Rahmani et al., 2018; Moein et al., 2018). Mental health and marital satisfaction (Shargh et al., 2016) also showed significant improvements and an increase was observed in all sub scales of well-being except functioning and risk (Sherratt and Lunn, 2013).
Another mindfulness-based intervention used was MBSR therapy. MBSR therapy was used in four out of seventeen of the studies that were included in the review. The stress, anxiety and depression symptoms considerable reduced (Mousavi et al., 2020) after MBSR therapy was improvised on the female with fertility problems. Similar results were seen in another study where a significant reduction was reported by the authors in depression and anxiety symptoms (Arani et al., 2022). MBSR therapy was also associated with increase in quality of life (Hosseini et al., 2020) and psychological well-being (Paiva et al., 2015).
MBII was used to study the effect of mindfulness-based intervention programs on women with fertility problems. There were two studies among those cited here where MBII was conducted and their results showed a considerable and significant improvement in quality of life scores. The participants reported better self-compassion and improved emotional regulation (Li et al., 2019). In another study all the participants reported feeling better and thinking clearer (Li et al., 2016). Twenty-nine of the participants reported that MBII helped them to deal better with physical pain and other discomforts; thirty-five reported improvements in sleep; twenty-nine reported increase in closeness with partner and and increase in marital satisfaction; thirty reported better social connections and reduction in feeling of inferiority; twenty-eight reported reduction in stress; twenty-six reported greater concentration and thirty-eight reported enhanced awareness with bodies (Li et al., 2016).
Two studies were based on MBPs where a significant reduction was reported in symptoms of chronic stress in the previous month as and when study was conducted (Nery et al., 2019). General well-being, in this study, was reported to improve. Depressive symptoms were reported to have reduced in the study while in another study similar significant reduction in depressive symptoms was also indicated (Galhardo et al., 2013). A 7-year follow up study on the original forty-six out of the fifty-five participants showed that there was a significant time effect reported in various facets including depressive symptoms (Galhardo et al., 2019). Also, effect of MBP on anxiety was maintained over the years (Galhardo et al., 2019).
Other studies conducted proved that Brief mindfulness therapy showed significant reduction in depressive symptoms while the results for anxiety and stress were not significant (Bai et al., 2019). Mindfulness-based group counselling was also effective in significantly bringing down the depressive symptoms (Kalhori et al., 2020). Mindfulness-based cognitive infertility stress therapy applied on the infertile female participants led to a significant increase in all six aspects of psychological well-being (Fard et al., 2018). Recognition therapy based on mindfulness when applied on infertile females showed that there was an increase in mental health and marital satisfaction reported by the participants (Shargh et al., 2015). [Table 1] presents a brief summary of the studies that have been included in the review paper. | Table 1: Summary of all the studies that have been included in the study
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| Discussion | | |
A review of the present literature
Our searches of research databases turned up seventy-six studies, of which we included seventeen in our study. We discovered a wide range of mindfulness programs, variation in the tools used to assess results, and a dearth of follow-up to ensure effectiveness of interventions in the research. Women who are infertile or who are receiving treatment for infertility benefited from mindfulness therapies for stress, anxiety, and depression. Their quality of life and psychological well-being also improved. There were evidence of improvement when looking at emotional regulation and degree of mindfulness, but additional research is required. Our analysis offers details on current mindfulness initiatives, a synopsis of the outcomes of mindfulness therapies, an outline of the metrics so far, and suggestions for creating high-caliber mindfulness protocols for infertile women.
The key findings from the body of literature currently available are that the MBIs help infertile women feel better and have a higher quality of life by lowering their levels of stress, anxiety, despair, and anger. These may be principally due to an improvement in attentional capacity, the elimination of avoidance coping, self-awareness and nonjudgemental acceptance of the reality, which enables a detached engagement with unpleasant feelings and thoughts. By replacing our automatic and mindless thinking with a curious, detached, and nonreactive perspective, mindfulness techniques aim to strengthen our potential to adopt an attitude of openness or acceptance (Creswell, 2017). This process of focusing awareness and attention on the present moment experience, including the events that may happen internally or externally, thoughts, and emotions, infertile women may anticipate experiencing a decrease in their focus on and involvement with their infertility problem as well as a decrease in their level of self-criticism (Galhardo et al., 2013; Creswell, 2017).
The seventeen research studies that were considered for the current study reviewed effect of mindfulness-based intervention on five outcome variables namely, stress, anxiety, depression, quality of life and psychological well-being. The conclusions derived from these reviews were consistent. The empirical studies unanimously pointed out towards the significant reduction in stress, anxiety and depression and significant improvement in quality of life and psychological well-being. According to research by Tran et al. (2014), dispositional mindfulness has been linked to reduced perceptions of stress, decreased depressed and anxiety symptoms, and increased acceptance of pain. The studies that have been included in the review have unanimously indicated that the mindfulness-based interventions can be very helpful in women who suffer from infertility. The infertility, in most cases, is a physical problem which has mental and psychological effects. The psychological effects are, but not limited to, low self-esteem, poor social relationships, stress, depression, anxiety, reduced quality of life, lowered intimacy with spouse, lesser marital satisfaction. The findings show that mindfulness-based therapies are meaning-based, which distinguishes them from their problem-or emotion-centered rivals (Covington, 2015; Schmidt et al., 2005; Boivin, 2003). Expanding compassionate acceptance and cognitive de-centering from stressful thoughts are the main focuses of mindfulness-based interventions, which also provide the individual control over how to react to pressures, as well as the surrounding thoughts and emotions. By moving from “self as content” to “self as context,” there is a change in how we view ourselves and the world around us (Peterson and Eifert, 2011). Change can be achieved through mindfulness-based therapy in two different ways. First, the vicious cycles of depressive thoughts linked with infertility are further stopped by the improvement of cognitive capacities, excessive autonomic arousal, and emotional regulation. Second, exercising mindfulness entails addressing infertility-related stressors in a manner that is specific to the condition (Alsubaie et al., 2017).
A critical overview of the present literature
The scarcity of randomized controlled trials, which is a substantial barrier to the results' generalization, is one of the present literature's key gaps. Second, there aren't many research comparing the experimental group to the control group, and there aren't many studies comparing mindfulness-based interventions to alternative therapies. The studies lack follow-up data that may help determine if the interventions were beneficial. The majority of research concentrate on preintervention and postintervention design, but the interventions' long-term efficacy cannot be assessed. The performance bias cannot be ruled out in the studies since there was no blinding of the participants during the therapy. Attrition rates and their causes need to be investigated further. Though the efficacy of mindfulness-based interventions have been successful to an extent, it is quite early to say whether they can act as stand-alone therapies. The mindfulness-based interventions act via certain mechanisms and an understanding of these mechanism can aid practitioners to understand and refine the mindfulness-based practices to more specific psychological targets and yield better results (Malinowski, 2013). In the present literature, a major drawback is the lack of a universal definition of the mindfulness-based interventions which makes it challenging to separately study the effects of various interventions (Mindfulness Meditation, MBCT, Mindfulness-based stress reduction therapy etc.) that fall under the umbrella term of “Mindfulness-based Interventions.”
Limitations
The current narrative review had some limitations: (a) The number of studies included is very small. (b) Mental health is a vast term that encompasses more than the five outcome variables that have been considered in the present study. The number of outcome variables can be increased to make the study more generalizable. (c) The current study only included empirical studies to maintain consistency of research design. Meta-analytic studies and systematic reviews could have been included. (d) The review only considered the female population as its sample. The male population and the couples could be further included to make the study more generalizable.
Scope for future research
Despite the limitations, the preliminary research indicates that the women who are struggling with mental health issues associated to infertility may benefit from mindfulness-based therapy. There is a need to undertake methodologically sound and large sample studies to show the efficacy of such interventions as a stand-alone or adjunct or supportive intervention given their great potential. Mindfulness techniques are quite cost effective as they do not require specialized trainers and can be easily practiced at home without much guidance. More researches can be conducted in the field of uncommon psychological symptoms of this condition. Also, more studies can be conducted to understand the effect of infertility of spouse on the individual. The studies on effectiveness of the mindfulness-based interventions on “infertile males/men” and “infertile couples” are few. Thus, these neglected areas can also be studied further to reach a definitive conclusion.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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