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Department of Obstetrics and Gynecology, Pamukkale University School of Medicine, Denizli, Turkey
Laboratory of Reproductive Endocrinology, Brigham and Women0 s Hospital, Harvard Medical School, Boston, MA 02115, USA
c
Department of Obstetrics and Gynecology, Turgut Ozal University School of Medicine, Ankara, Turkey
b
art ic l e i nf o
a b s t r a c t
Article history:
Received 5 October 2013
Received in revised form
16 December 2013
Accepted 16 December 2013
Available online 28 December 2013
Background: Childbirth is an important experience in a woman0 s life, and unfavorable birth experiences
have been shown to negatively impact postpartum maternal health. Aim of this study was to evaluate the
effects of music therapy on postpartum pain, anxiety level, satisfaction and early pospartum
depression rate.
Methods: Totally 161 primiparous women were recruited and randomized either music group (n 80) or
a control group (n 81). Women in the music group listened to self-selected music during labor.
Postpartum pain intensity, anxiety level and satisfaction rate were measured using the visual analog
scale (VAS), postpartum depression rate was assessed with Edinburg Postpartum Depression Scale
(EPDS) at postpartum day one and day eight.
Results: Mothers in the music therapy group had a lower level of postpartum pain and anxiety than the
control group and it was statistically signicant at all time intervals (1, 4, 8, 16 and 24 h, po 0.001). A
signicant difference was observed between the two groups in terms of satisfaction rate (p o0.001) and
postpartum depression rate at postpartum day one and day eight (po 0.05).
Limitations: We only measured the effect of music therapy on early postpartum depression rate. Effect of
music on late postpartum depression rate should be investigated in future.
Conclusions: Using music therapy during labor decreased postpartum anxiety and pain, increased the
satisfaction with childbirth and reduced early postpartum depression rate. Music therapy can be
clinically recommended as an alternative, safe, easy and enjoyable nonpharmacological method for
postpartum well-being.
Published by Elsevier B.V.
Keywords:
Postpartum pain
Anxiety
Satisfaction
Music therapy
Pospartum depression
1. Introduction
Women are more exposed to psychiatric illness during the
postnatal period. The rate of psychiatric admission is increased
postnatally, mostly because of the raised risk of psychosis and
depressive illnesses in the rst three month after labor (Kendell
et al., 1976). Many women experience considerable stress when
confronted with the physiological and psychological changes
which occur during pregnancy and childbirth (Matas, 1997;
Turner et al., 2004). Childbirth is an important experience in a
woman0 s life, and the grade of this experience has short and long
terms effects. Unfavorable birth experiences have been shown to
negatively impact postpartum psychiatric symptoms, sexual
n
Corresponding at: Laboratory of Reproductive Endocrinology, Brigham and
Women0 s Hospital, Harvard Medical School, Boston, MA 02115, USA.
Tel.: 1 857 222 1836; fax: 1 617 264 5275.
E-mail address: serapsimavli@yahoo.com (S. Simavli).
195
the study protocol and signed informed consent was obtained from
all patients before the randomisation.
Inclusion criteria were women between 18 and 35 years,
primiparous with a 3741 weeks of gestation and were singleton
pregnant with babies of cephalic presentation and normal birthweight, expected to have normal spontaneous delivery. Women
who had any of the followings were excluded; maternal hypertensive disorders, diabetes mellitus, evidence of intrauterine
growth restriction, postdates, premature rupture of membranes
for longer than 20 h, multiple pregnancies, desired cesarian, receiving analgesic or antipsychotic medications, mothers with hearing difculties, chronic pain problems, severe dysmenorrhea,
inability to understand visual annolog scale or EPDS, fetal death
in utero, known fetal anomaly. Data for age, height, weight,
gestational week, educational level, occupation, family class were
recorded on a data sheet.
1. Patients in the music group will have signicantly less postpartum pain than those in the control group.
2. Patients in the music group will have signicantly less anxiety
than those in the control group.
3. Patients in the music group will have signicantly high satisfaction level with the childbirth experiance than those in the
control group.
4. Patients in the music group will have signicantly less postpartum depression than those in the control group both in
postpartum day one and day eighty.
2. Methods
2.1. Study population
This randomised controlled trial was conducted between September 2011 and September 2012. Overall, 161 primiparous women
who are at 36 weeks of gestational age, coming to Obstetry and
Gynecology Department for their antenatal care, were asked to
participate in a trial which investigates the effect of music therapy
on postpartum maternal health. The study was approved by the
Turgut Ozal University Human Ethical Committee and complied
with the Helsinki Declaration including current revisions and Good
Clinical Practice guidelines. Eligible patients were informed about
2.2. Randomization
Randomization was completed using a computerized minimization program to assign participant women to either music group
or control group by our clinical secretary at 36 weeks of gestation.
Randomisation was stratied according to maternal age, gestational week, education and family class. In this way, external
variables were controlled and minimized of group differences.
Calculation of the required sample size was performed with
respect to postpartum depression rate. According to the literature,
a standard deviation of EPDS 3.7 was expected, and the analysis
was carried out with respect to detecting a difference of at least 1.5
(40%) for this parameter. With a power of 90% and level of 0.05, a
sample size for each group of at least 64 patients was calculated as
being appropriate. Sixteen patients (25% of calculated sample size)
were also added to each group to replace possible missing data for
all potential causes.
2.3. Procedures
196
total scores ranged from 0 to 30. The scale has been validated for
use postnatally and during pregnancy and focuses on the cognitive
and affective features of depression. Although the scale cannot in
itself conrm a diagnosis of depression, score of Z 10 suggests
minor depressive symptoms and Z 13 suggests probable major
depression. The EPDS was found to have satisfactory sensitivity
and specicity, and was also sensitive to change in the severity of
depression over time (Cox et al., 1987). They were instructed about
the importance of describing their feelings in the previous seven
days and not only on the day they were completing the questionnaire. Depression rates were assessed at three time points: at
36 weeks of gestation, postpartum day one before being discharged, and postpartum day eight with using EPDS.
2.5. Statistical analysis
Continuous variables were rst inspected for normality of
statistical distribution graphically and by ShapiroWilk test. Data
are presented as mean 7standard deviation (SD) or median with
interquartile range (IQRs), as appropriate. For descriptive statistics,
numbers and percentages were used for categorical variables.
Baseline characteristics and outcome measures of the two groups
were analyzed with Student0 s t-test or MannWhitney test for
continuous data and chi-square test for the comparison of categorical variables. For paired datas Friedman and Wilcoxon signed
ranks tests were used. All the comparisons were two-tailed.
p values r0.05 were considered statistically signicant. Statistical
analysis was performed with SPSS version 17.0 software (SPSS Inc.,
Chicago, IL).
3. Results
Women in the music therapy and control groups completed the
study, as shown in the ow diagram of randomization presented as
Fig. 1. Twenty women dropped out because of one of the following
reasons: Received unplanned caesarean section for prolonged labour
Excluded (n=9)
-Performed caesarean (n=4)
-Forget group assigment (n=2)
-Cervical dilatation>3 cm (n=3)
Excluded (n=11)
-Performed caesarean (n=7)
-Forget group assigment (n=4)
Analysed (n=71)
Analysed (n=70)
Fig. 1. Flow diagram of subject progress through the phases of the trial.
Table 1
Demographic characteristics of groups.
Table 2
Antenatal and postnatal Edinburgh Postnatal Depression Score.
Variables
Control group
(n 70)
Maternal age
(years)
BMI (kg/m2)
Gravidity
Gestational age
(days)
Education
Primary school
High school
University
Family class
Low
Middle
High
Employment
situation
Full time
Part time
House wife
Antenatal EPDS
24.177 3.22
23.39 7 3.88
0.19n
Variables
27.20 72.53
1.00 (0.00)
270.527 5.39
26.78 7 2.38
1.00 (1.00)
271.977 5.81
0.32
0.01nn
0.13n
25 (35.2%)
21 (29.6%)
25 (35.2%)
30 (42.9%)
17 (24.3%)
23 (32.8%)
0.56
16 (22.5%)
44 (62%)
11 (15.5%)
16 (22.9%)
43 (61.4%)
11 (15.7%)
40.99
15 (21.1%)
13 (18.3%)
43 (60.6%)
8.047 2.76
15 (21.4%)
16 (22.9%)
39 (55.7%)
8.497 2.58
0.78
0.33n
(n 11), did not inform the researchers when they went to the
maternity unit for labor (n 5) and had cervix dilation of more than
3 cm (n4). Although 161 pregnant women were enrolled in the
groups, 141 participants were included in the nal analysis. Seventyone women were in the music therapy group, and 70 women were in
the control group.
The demographic characteristics of music therapy and control
groups were shown in Table 1. The music therapy and control
groups were found similar with respect to maternal age, BMI,
gestational age, family class, education level, employment situation and antenatal depression rate (p 40.05). The type and
percentage of music chosen by women were classical music,
11.3% (n 8); light music, 14% (n 10); popular music, 18.3%
(n 13); Turkish art music 21.2% (n 15); Turkish folk music
15.5% (n 11) and Turkish su music 19.7% (n 14).
The music therapy group0 s antenatal minor depression rate
(EPDS Z10) was 25.4% and control group0 s was 30.0% (p 0.54).
Groups0 antenatal major depression rates (EPDS Z13) were 11.3%
and 12.9%, respectively (p 0.77). Although antenatal depression
rate was not different, in the postpartum period there were
statistically signicant difference for minor and major depression
rate between music therapy and control group both in the
postpartum day one and day eight (p o0.05) (Table 2). Not only
minor but also major postpartum depression rates were signicantly lower in the music therapy group than in the control group
at both postnatal day one and day eight (all po 0.05) (Table 2).
In the music therapy group, antenatal and postnatal depression
rates were different. At antenatal, postnatal day one and postnatal
day eight, minor depression rates were 25.4%, 15.5%, 12.7%, and
major depression rates was 11.3%, 5.6%, 5.6%, respectively. In the
music therapy group, while postnatal minor depression rate was
statistically signicantly lower than antenatal depression rate
(p 0.03), there were no statistically signicant differences
between antenatal and postpartum periods for major depression
rate (p 0.23). In the control group, minor depression rate was
30.0%, 31.4%, 35.7%, and major depression rate was 12.9%, 17.1%,
18.6% at antenatal, postpartum rst day and eight day, respectively. Additionally, while not signicantly different, postnatal
Control group
(n 70)
8.047 2.76
18 (25.4%)
8 (11.3%)
8.497 2.58
21 (30.0%)
9 (12.9%)
0.33n
0.54
0.77
7.31 72.35
11 (15.5%)
4 (5.6%)
8.277 2.76
22 (31.4%)
12 (17.1%)
0.03n
0.03
0.03
7.14 72.13
9 (12.7%)
4 (5.6%)
8.59 72.85
25 (35.7%)
13 (18.6%)
0.001n
0.01
0.02
Data are means 7 standard deviation (SD). Abrevations: EPDS; Edinburg Postpartum Depression Scale.
nn
Antenatal depression
Mean (SD) score
EPDS Z 10
EPDS Z 13
Postnatal depression
day one
Mean (SD) score
EPDS Z 10
EPDS Z 13
Postnatal depression
day eight
Mean (SD) score
EPDS Z 10
EPDS Z 13
Data are means7 standard deviation (SD) or median (IQR). Abrevations: BMI; body
mass index, EPDS; Edinburg Postpartum Depression Scale.
n
197
VAS-A (1 h)
VAS-A (4 h)
VAS-A (8 h)
VAS-A (16 h)
VAS-A (24 h)
VAS-P (1 h)
VAS-P (4 h)
VAS-P (8 h)
VAS-P (16 h)
VAS-P (24 h)
VAS-S (2 h)
VAS-S (12 h)
VAS-S (24 h)
3.30 7 0.46
2.747 0.38
2.28 7 0.29
1.65 7 0.31
0.88 7 0.57
3.29 7 0.44
3.107 0.38
2.747 0.38
2.337 0.31
2.177 0.23
8.32 7 0.78
8.75 7 0.56
9.69 7 0.27
4.89 7 0.93
4.247 0.77
3.317 0.46
2.75 7 0.38
2.30 7 0.29
5.42 7 0.93
4.58 7 0.91
4.22 7 0.76
3.39 7 0.49
3.30 7 0.46
5.677 0.91
6.127 0.95
6.777 1.05
o 0.001n
o 0.001n
o 0.001n
o 0.001n
o 0.001n
o 0.001n
o 0.001n
o 0.001n
o 0.001n
o 0.001n
o 0.001n
o 0.001n
o 0.001n
4. Discussion
Music, which in everyday life is used for pleasure and its moodchanging effects can be used for therapeutic benet. Music therapy
is widely used in the treatment of mental health. In the present
198
Conict of interest
None.
Acknowledgements
None.
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