HEAD TRASH CLEARANCE 1
HEAD TRASH CLEARANCE AND PERINATAL MENTAL HEALTH
A preliminary study on the efficacy of Head Trash Clearance in reducing perinatal anxiety and
depression.
Barnard, M.Pa., & Leachman, A.
aSchool of Psychology, University of Nottingham, University Park, Nottingham, UK NG7 2RD.
Email: [email protected] (M. Barnard), [email protected] (A.
Leachman) HEAD TRASH CLEARANCE 2
Abstract
There is an increased prevalence of tokophobia and fear of childbirth (FOC) reported within current research. However, studies on the efficacy of tokophobia and FOC specific interventions are limited, let alone those in online settings. The current study aimed to assess the effectiveness of the Fearless Birthing Programme, an online intervention which aims to specifically reduce levels of pregnancy and childbirth anxiety using the Head Trash Clearance method. Over the course of three months in trimester two, pregnant participants completed a series of questionnaires on perinatal anxiety and depression; at some point during those three months, access to the Fearless Birthing Programme was also provided, with the aim of measuring changes in anxiety and depression as a consequence of programme access. Analyses suggested that there were only marginal reductions in anxiety and depression over time, regardless of when programme access was granted. However, participants enjoyed the programme and found it as useful as other pregnancy and birth preparation activities they were part of. A discussion of the challenges faced when conducting perinatal mental health intervention research is provided, and it is argued that research into factors affecting attrition rates and self-discipline would be useful to the field as a whole. Further RCT research into the Head Trash Clearance Method as a general therapeutic tool would be of benefit.
Lay summary
More women than ever now say they have a fear of giving birth, with some even reporting a fear of childbirth, also known as tokophobia. It is important for these women to have access to scientifically tested interventions to help reduce these fears. However, not many studies exist that test such interventions. This study aimed to test the effectiveness of the Fearless Birthing HEAD TRASH CLEARANCE 3
Programme, an online programme which aims to clear a person’s fears of childbirth using a technique called Head Trash Clearance. During trimester 2 of their pregnancy, people took part in a study where they were given access to the programme, and their levels of pregnancy specific anxiety and depression were recorded before and after using this programme. The results of the study suggest that levels of anxiety and depression did not dramatically reduce as a result of using the programme. However, people also said that they found the programme helpful and useful. We suggest that the programme could still be a helpful tool for pregnant women, there are several things scientists can do to improve the quality of tokophobia and FOC research as a whole. These improvements, as well as more research into Head Trash Clearance, would help us understand what techniques work for people who are anxious during pregnancy.
Keywords
Fearless Birthing programme, Head Trash Clearance, Reflective Repatterning, tokophobia, anxiety, depression. HEAD TRASH CLEARANCE 4
A preliminary study on the efficacy of Head Trash Clearance in reducing perinatal anxiety and
depression.
Introduction
Concerns about anxiety during pregnancy have resulted in an increasing amount of research focus in recent years. It has been suggested that it has a significant prevalence within the pregnant population; reviews of studies into pregnancy anxiety have reported a worldwide prevalence of tokophobia and non-phobic fear of childbirth (FOC) of between 6.3% to 14.8%
(Nilsson et al., 2018; O’Connell et al., 2017). Studies into pregnancy anxiety without tokophobia have reported similar prevalences such as 15.6% in a Swedish sample (Rubertsson et al., 2014), and over 90% of pregnant women have reported at least moderate pregnancy anxiety within an
Indian sample in trimesters 1 and 3 (Madhavanprabhakaran et al., 2015).
The consequences of pregnancy anxiety are also of concern. Not only is it associated with an increased risk of postnatal depression (Heron et al., 2004), it can also lead to an increased frequency of unhealthy behaviours during pregnancy such as smoking and increased caffeine consumption (Lobel et al., 2008). It is also associated with changes in pregnancy duration, with studies showing both increases in pregnancy duration (Qiao et al., 2012) and increased risk of early delivery (Lobel et al., 2008; Rini et al., 1999). Due to its occurrence and consequences, it is important to understand the ways in which pregnancy anxiety can be reduced in expectant mothers. HEAD TRASH CLEARANCE 5
Intervention methods have been suggested as a way of reducing pregnancy anxiety. For example, research comparing intensive therapy methods, defined as a combination of routine antenatal checks and cognitive therapy, have been shown to reduce pregnancy anxiety and increase the proportion of women choosing vaginal delivery as opposed to caesarean (Saisto et al., 2001). However, these interventions are often conducted face-to-face, and this presents practical challenges within today’s society. Due to the challenges of the COVID pandemic, medical facilities now try to schedule virtual appointments and therapy sessions wherever possible. Additionally, for those with concerns with their mental health during pregnancy, they may wish to seek help from less formal and flexible sources such as the internet (Ashford et al.,
2016). Thus there has been a significant increase in recent years in evaluating the efficacy of internet based therapies to treat antenatal mental health.
Some interventions have focused on simply increasing the amount of information available to pregnant women (Tsai et al., 2018). However, a large proportion of intervention studies on antenatal mental health share the common factor of being grounded within cognitive behavioural therapy (CBT) or mindfulness methods. These methods include exercises or modules to try and challenge negative thoughts and apply learned strategies to written assignments which then receive feedback from a trained therapist or apply self-compassion techniques to everyday tasks.
Such techniques have been applied to specific pregnancy issues and mental health issues with positive findings. For example, a CBT based intervention for pregnancy loss resulted in reduced symptoms of PTSD, grief, anxiety, and depression (Kersting et al., 2013). Studies into general wellbeing interventions have found reduced levels of negative affect (Haga et al., 2020) and increases in self-compassion up to six weeks post-intervention (Gammer et al., 2020). Finally, HEAD TRASH CLEARANCE 6 studies into pregnancy-related depression interventions have found lower antenatal depression scores (Forsell et al., 2017) and postnatal depression scores and the frequency of automatic negative thoughts (Solness et al., 2020) post-intervention. Taken together, this suggests that internet-based interventions for antenatal and postnatal mental health are promising methods for improving the wellbeing of pregnant women with a wide variety of mental health concerns.
Similar interventions can be found for those women who have a FOC, albeit the amount of available research is limited. Pregnant women who have taken part in online FOC interventions have reported that they feel that the exercises help relax them and worry less about the antenatal and postnatal periods (Baylis et al., 2020) Whilst some still feel some doubts, they feel less hopeless than before and feel that they would be able to use active coping methods in labour
(Nieminen et al., 2015). However, findings from empirical and randomised controlled trials
(RCTs) are more mixed. For example, an online intervention comprising of psycho-education, cognitive restructuring, and in vivo exposure methods saw a decrease in FOC with what the authors argue was a large effect size (Nieminen et al., 2016); large effect sizes were also reported for anxiety symptom severity reduction following enrolment on the ‘MUMentum’ program
(Loughnan et al., 2019). Another method combining text, audio, photos, and assignments saw no changes in FOC immediately post-intervention, but instead lower levels of FOC one year postpartum (Rondung et al., 2018). Another intervention targeting Iranian women found that not only did an online CBT intervention reduce FOC, but it also increased the rate of women subsequently choosing a vaginal birth as opposed to a caesarean birth (Shahsavan et al., 2020), which is similar to Saisto et al.’s (2001) findings regarding face-to-face intervention. Taken together, this suggests that whilst the benefits of internet interventions for FOC are appreciated HEAD TRASH CLEARANCE 7 by pregnant women, findings from research are mixed and more research needs to be conducted in order to rigorously assess their efficacy.
One approach that has gained an increased in interest and popularity over recent years is called Fearless Birthing. Developed by Alexia Leachman, its principles and techniques are based primarily within the field of Reflective Repatterning (Leachman, 2018b). Reflective
Repatterning is a technique that uses the law of opposites to create neutrality; negative emotions on a subject are made more positive and vice versa, thus balancing the feelings one has towards something and removing the emotional nature of the trigger (Milbank, 2017). From this,
Leachman developed the ‘Head Trash Clearance’ (HTC) method, which aims to clear one’s fear and anxieties about pregnancy and childbirth in a quick and easy manner. It requires participants to identify the things that are concerning them, or their ‘Head Trash’, and gain some perspective on the mental and physical symptoms that fear gives. The participant then uses the Tapas
Acupunture Technique (Fleming, 2007) hand position whilst repeating ten mantras, one of which will be an opposite of another mantra in the list. For example, if one is a fear of pain, one mantra on the list might state that ‘pain is a wonderful thing’ whilst another will state that a ‘pain is a terrible thing’. The participant will then re-evaluate their anxiety levels before finally repeating the HTC method with the opposite concept. For example, if one has just completed mantras on pain, they would then complete mantras focused on pleasure. Since the inception of the Fearless
Birthing programme the HTC method is now used in a wider context. It is now being applied to fears and anxieties in other aspects of life such as OCD, COVID anxiety, general anxiety, lack of confidence and self-esteem (Leachman, 2018c, 2018a). However, its main focus to date has been within the context of FOC and tokophobia. The Fearless Birthing programme aims to help HEAD TRASH CLEARANCE 8 women take control of their anxiety and equip them with the tools necessary to give birth in as little pain and stress as possible. The online version of the programme teaches participants the
HTC method using videos, worksheets, fear clearance audio tracks, and audio podcasts, and does so in the context of specific pregnancy-based anxieties.
The programme is advantageous in that it allows flexibility in learning for participants and how quickly it can be used, to the point where it can even be used in between contractions during labor (Leachman, 2018d). However, its efficacy has not yet been tested within an empirical setting. The aim of this study was to assess the efficacy of the online Fearless Birthing programme using a sample of pregnant women in their second trimester. Over a three-month period, participants were given access at some point to the online version of the Fearless Birthing programme, and once a month a series of demographic and survey responses were recorded.
Survey responses covered feelings of current pregnancy anxiety, depression, and feelings towards the programme as well as any other pregnancy-related activities participants had taken part in. Based on the previous literature, it was predicted that after the online intervention had been delivered to participants, levels of anxiety and depression would reduce compared to baseline measures.
Methods
Participants
Participants were recruited using methods such as Call for Participants, social media posts, and publicity events such as radio interviews and online interviews with the programme leader to advertise for participants. Those interested in taking part were then invited to contact the lead HEAD TRASH CLEARANCE 9 researcher, who then provided them with additional details and the link to the first survey if they were still interested in taking part. A total of 20 pregnant females took part in the study, and their mean age was 32.15 (sd= 5.77). At the beginning of the study, they had been pregnant for an average time of 13.45 weeks (sd= 2.28 weeks). At the time of the study, fourteen of these females reported that they were married, three reported cohabiting with another person, and three reported that they single. Fourteen participants also reported that this was not their first pregnancy, whilst the remaining six were experiencing their first pregnancy. All participants gave informed consent before taking part in the research and were given a £10 online shopping voucher once the study had been completed as a means of inconvenience allowance. Ethical approval was obtained from a University School Ethics Committee.
Design
The study used a 3x4 mixed design, with the month in which access to the Fearless
Birthing programme was granted as a between -subjects factor (three levels) and time of self- report as a within-subjects factor (four levels). For context, the study took place over the course of three months. For the between subjects factor, participants were granted access to the Fearless
Birthing programme either at the beginning of these three months, at the end of the first month, or at the end of the second month. This means that by the end of the study the first group had access to the programme for three months, the second group had access for two months, and the final group had access for one month. Assignment to these groups was conducted randomly.
Self-report measures were then taken four times over the course of three months. The first set of questionnaires were completed at the beginning of the three months, and the second, third, HEAD TRASH CLEARANCE 10 and fourth sets of questionnaires were completed and the end of the first, second, and third months of the study respectively.
Research has shown that levels of anxiety differ significantly between the three trimesters of pregnancy, with higher levels of pregnancy anxiety in trimesters one and three compared to trimester two (Da Costa et al., 1999; Madhavanprabhakaran et al., 2015; Teixeira et al., 2009).
Therefore, in order to control for individual differences in gestation time, only participants who were in the second trimester of their pregnancy were selected for the study. In order to ensure that they were in the second trimester throughout the study’s duration, participants were required to be 12-16 weeks pregnant at the beginning of their participation.
Materials and Stimuli
All questionnaires and data were collected online using Qualtrics, a platform designed for questionnaire administration and data collection.
State Trait Inventory for Cognitive and Somatic Anxiety
The first questionnaire administered was the State-Trait Inventory for Cognitive and
Somatic Anxiety (Grös et al., 2007). This inventory was chosen on the basis that it is argued to act as a purer measure of anxiety over other more commonly used measures of anxiety such as the State Trait Anxiety Inventory (Gros et al., 2007; Spielberger, 1983). The STICSA comprises of two 21-item questionnaires assessing the cognitive (10 items) and somatic (11 items) symptoms of anxiety. Items are administered on a 4 point Likert scale ranging from 1-4; a score of 1 indicates a participant does not experience a symptom ‘at all’ whilst a score of 4 indicates a HEAD TRASH CLEARANCE 11 participants experiences a symptom ‘very much’. Scores for cognitive, somatic, and overall anxiety range from 10-40, 11-44, and 21-84 respectively. In all cases, a higher score indicates a greater presence of anxiety. For the current study, the trait part of the inventory was only completed at the beginning of the study, whilst the state part was completed on all four occasions.
Pregnancy Related Thoughts Questionnaire
Participants were also administered the Pregnancy Related Thoughts Questionnaire (PRT-
Rini, Dunkel-Schetter, Wadhwa, & Sandman, 1999). The PRT is a 10-item measure that looks at a woman’s worry or concern about issues during pregnancy. Item scores range from 1 to 4, with a score of 1 indicating a concern is ‘Never’ experienced, and a score of 4 indicating a concern is experienced ‘Very much’. Total scores range from 10-40, and higher scores indicate a greater presence of pregnancy-specific anxiety.
Edinburgh Postnatal Depression Scale
The Edinburgh Postnatal Depression Scale (Cox et al., 1987) was also administered. Whilst the aim of the Fearless Birthing programme is to reduce levels of pregnancy anxiety, it is important to note that excessive anxiety in pregnancy is associated with an increased risk in postnatal depression (Evans et al., 2015). Additionally, it has been established in research that anxiety and depression share a common component of general negative affect (Clark & Watson,
1991). Thus extending the project to assess levels of depression was felt to be a suitable addition to assessing the programme’s efficacy. The EPDS is a 10-item question assessing the degree of depression a woman may have experienced over the past 7 days. For each item, scores of HEAD TRASH CLEARANCE 12 between 0 and 3 are administered depending on whether a woman has not experienced symptoms at all, or whether she has constantly experienced them, respectively. Total scores on this scale therefore range from 0-30, with higher scores indicating higher levels of postnatal depression.
Additional measures
As well as the STICSA, PRT, and EPDS, additional questions regarding the frequency of use, enjoyment, perceived benefit, and intention to continue using the Fearless Birthing
Programme were asked. These questions were only administered to participants once they had been given access to the Fearless Birthing programme for at least one month. All participants at the end of months one, two, and three were asked to also rate the frequency, enjoyment, perceived benefit, and intention to continue with other activities that could be related to pregnancy. These included attending GP or midwife appointments, antenatal appointments, using other online resources, attending pregnancy-related social events, practising self-care, and making preparations for the birth of their child. Questions on perceived enjoyment, benefit, and intention to continue with the activity were administered on a five-point Likert scale, with ‘1’ indicating a participant strongly disagreed with the statement, and ‘5’ indicating that they strongly agreed with it. HEAD TRASH CLEARANCE 13
Online Fearless Birthing Programme
At some point during the study, depending on group allocation, participants were given online access to the Fearless Birthing programme. The Fearless Birthing programme’s site contains videos, audio podcasts, worksheets, and fear clearance tracks that participants could access when they wanted to. All of these were created by the programme leader with the aim of reducing the fears women might have surrounding pregnancy and childbirth and enable them to feel more confident about the process. These resources focused on effective use of Head Trash
Clearance, as well as specific areas of pregnancy and childbirth that may induce anxiety, such as a fear of needles, fear or losing dignity during labour, and fear of pregnancy loss. Participants were encouraged to use the online course as and when they wanted to; they were not required put a minimum amount of time into using the programme.
Procedure
Once participants gave consent to take part in the study, they were presented with each of the surveys outlined above. Once this had been completed, participants were asked to either continue with their pregnancy as normal, or they were told that they would now be given access to the Fearless Birthing Programme. Email details at this point were passed on to the programme leader, who then provided them with access to online Fearless Birthing resources. One, two, and three months after the initial set of surveys had been completed, participants were asked to complete all of the surveys again, with the exception of the trait component of the STICSA. HEAD TRASH CLEARANCE 14
Once the final survey had been completed, participants were mailed a shopping voucher as a means of inconvenience allowance.
Results
A total of 10 participants either did not complete all of the required surveys for analysis or reported not using the programme despite being given access to it. Their data were therefore discarded from the final analysis. Additionally, one participant who was randomly allocated into the group who were given access to the programme after completing the baseline survey did not use the programme until the second month of the study; thus their data were analysed as part of the group who received access to the programme at the end of the first month of the study.
Mixed Design ANOVAs
Missing data from the remaining participants were accounted for by using mean item replacement. This is a technique that has been used in previous research (Barnard & Chapman,
2018), and was felt to be appropriate given that no more than two items were missing in each case. State cognitive anxiety, state somatic anxiety, state anxiety overall, pregnancy anxiety, and depression levels were then analysed through a series of 3x4 mixed design ANOVAs (month that programme was administered x time at which surveys were conducted). These ANOVAs were conducted in JASP v.0.13.1. Violations of sphericity were accounted for using Greenhouse
Geiser corrections. HEAD TRASH CLEARANCE 15
These ANOVAs revealed no significant main effects of month that the programme was delivered or time at which survey was conducted, nor any interactions. Between these two variables, on any of the measures of anxiety and depression taken (all ps> .05). Details on exact p values can be found in Appendix ‘A’. Reported values of post-hoc power were calculated using
G*Power (Faul et al., 2007).
Descriptive Analysis
Participants’ opinions on the Fearless Birthing Programme, as well as opinions on any other services they were using at the time, were put through a descriptive analysis. Means and standard deviations were collated for each questionnaire item and can be found in Tables 1-3. HEAD TRASH CLEARANCE 1
Table 1
Mean scores for the questionnaire items “I have enjoyed using the activities provided as part of the Fearless Birthing Programme” and “I have enjoyed the other activities I have taken part in during my pregnancy”. Standard deviations are in brackets.
Fearless Birthing Programme Other services used
Month 1 Month 2 Month 3 Month 1 Month 2 Month 3
Group 1 4.25 (0.25) 4.33 (0.29) 4 (0.71) 4.5 (0.5) 4 (0.41) 4 (0)
Group 2 3.5 (0.5) 3.67 (0.29) 4.33 (0.29) 3.5 (0.5) 3.33 (0.58)
Group 3 4.33 (0.67) 4 (0) 4.33 (0.33) 4 (0.58) HEAD TRASH CLEARANCE 1
Table 2
Mean scores for the questionnaire items “I have found the resources provided as part of the Fearless Birthing Programme to be beneficial” and “I have found the other activities I have taken part in during my pregnancy to be beneficial”. Standard deviations are in brackets.
Fearless Birthing Programme Other services used
Month 1 Month 2 Month 3 Month 1 Month 2 Month 3
Group 1 4.25 (0.48) 4.25 (0.25) 4.33 (0.29) 4.5 (0.29) 4.25 (0.25) 4.33 (0.29)
Group 2 3.5 (0.5) 3.33 (0.57) 4.33 (0.29) 3.75 (0.63) 3 (0.5)
Group 3 3.67 (0.88) 3.33 (0.67) 4 (0) 4 (0.58) HEAD TRASH CLEARANCE 2
Table 3
Mean scores for the questionnaire items “I intend to continue using the Fearless Birthing resources in the future” and “I intend to continue my other pregnancy-related activities in the future”. Standard deviations are in brackets.
Fearless Birthing Programme Other services used
Month 1 Month 2 Month 3 Month 1 Month 2 Month 3
Group 1 4.25 (0.48) 4.25 (0.47) 3.5 (0.35) 4.75 (0.25) 4 (0.41) 4 (0.5)
Group 2 4 (0.7) 3 (0.87) 4.67 (0.29) 4 (0.41) 3 (0.5)
Group 3 4 (1) 3.67 (0.33) 4 (0.58) 3.33 (1.2) HEAD TRASH CLEARANCE 1
With regards to perceptions of enjoyment, benefit, and future intention to use the Fearless
Birthing programme, participants were positive overall about the programme; all scores were either 3 out of 5 or above. All participants enjoyed the programme and found it to be beneficial.
In particular, the group who were given access to the programme in the first month of the study had average scores of 4 or above throughout their study participation. Another pattern emerging from this data is the decrease in intention scores in the final month of the study for groups who were given access to the programme in months 1 and 2 of the study. This could suggest that participants had gained the benefits they needed from the online programme by the time the study ended.
What should also be noted here are the enjoyment, benefit, and intention scores for the other services participants used throughout their second trimester. As with scores for the Fearless
Birthing programme, all items scored a 3 or above, meaning that participants were generally positive about the other experiences they had also taken part in.
Discussion
The aim of the current study was to evaluate the effects of Head Trash Clearance, a technique based on the principles of reflective repatterning, on levels of general anxiety, pregnancy-related anxiety, and depression in pregnant women. Results suggested that whilst participants reported high levels of satisfaction with the programme, only marginal effects were found for decreasing levels of state anxiety and depression over time, regardless of intervention HEAD TRASH CLEARANCE 2 group. Thus, the findings did not support the original hypothesis that specific and significant reductions in anxiety and depression would occur in the intervention group.
Main findings and methodological considerations
This, however, does not necessarily mean that Head Trash Clearance is ineffective at alleviating pregnancy anxiety. There are several reasons, mainly methodological, as to why the data collected did not support the original hypothesis. One reason could be potential issues with power levels due to attrition rates and engagement rates. The table presented in Appendix ‘A’ indicates a wide range of power levels; whilst some of these meet and exceed 0.8, which is the minimum level of acceptable power, several tests did not meet this level of power. This is particularly true for between-subjects tests, meaning that any differences between intervention groups that could explain the current findings would not have been easily detectable. Ten participants reported not engaging with the programme despite completing all surveys, and a further two participants did not complete all of the anxiety and depression questionnaires, meaning that 60% of the data had to be discarded prior to conducting ANOVAs. Whilst this seems like a large attrition rate, this reflects the current state of pregnancy intervention research both in terms of participant numbers and attrition rates. For example, a recent systematic review of internet-based interventions reported that attrition rates ranged from 13.2-60.9% and sample sizes of between 12-910 (Ashford et al., 2016). Whilst it would have been ideal to analyse more data, practical and financial constraints with the current study did not make this possible. The current study, despite a lack of significant findings, does add to previous research reporting issues with both power and attrition (Kersting et al., 2013; Loughnan et al., 2019). It could be argued therefore that an important focus for pregnancy intervention research would be to HEAD TRASH CLEARANCE 3 understand the factors that impact attrition rate in internet interventions, as well as discover how attrition rates can be lowered in a practical and ethical manner. However, it is also acknowledged that the specificity in the inclusion criteria, whilst put in place to ensure that data were as controlled as possible, could have also contributed towards lower responses to initial study adverts. Widening the participation criteria could alleviate this issue, but due to differences in perinatal mental health across trimesters this approach should be taken with caution.
The internet also contains a vast array of information, which can vary in levels of bias and accuracy. In the current study, we asked participants what additional activities they were taking part in other than the Fearless Birthing Programme but did not ask whether participants were looking at additional mental health interventions either online or otherwise. This is important as research has previously highlighted the downsides of internet interventions for perinatal mental health. Qualitative findings have suggested that whilst some types of forum are perceived as helpful, the internet is also perceived by expectant mothers as anxiety provoking due to the high levels of extreme or conflicting information that are readily available (Harrsion et al., 2020). In our study, it is possible that some participants were accessing other information online that fit into the category of extreme information, or even conflicted with the information provided as part of the Fearless Birthing programme. This might explain why reductions in anxiety and depression were not significant once women had received access to the programme.
Additionally, it is important to note that internet interventions come with additional challenges such as programme relevance, managing to fit programme completion within already busy daily schedules, and having the self-discipline to apply interventions to everyday practise (Baylis et al., 2020). We argue that not only is it important for future research to understand the barriers for HEAD TRASH CLEARANCE 4 pregnant women wishing to access internet interventions, but to also understand the types of online information that could act as a barrier towards the efficacy of the main intervention being studied.
Despite the lack of significant evidence for the reduction of anxiety and depression as a result of the intervention, descriptive analyses yielded positive findings about the programme’s use. When asked about how much they enjoyed and found the Fearless Birthing programme to be useful, scores provided by participants were high, with little variation. Scores also indicated that participants intended to use the programme in future. These scores were not only consistent across time but were also evident regardless of the time at which the programme was introduced to the participant. This suggests that no matter when the programme is introduced to pregnant women at least in the second trimester, they feel that it is beneficial to them to the point that they would still use it in future. It also suggests that pregnant women found it useful across a long period of time; this is evident from the fact that scores of enjoyment, usefulness, and intention to continue using the programme, were consistent across all three months for those women who were given access to the programme at the beginning of the study. This could provide evidence to support the claim that Head Trash Clearance would be useful at more crucial stages of pregnancy, such as between contractions (Leachman, 2018d). It is also worth noting that levels of usefulness of the programme were comparable to other pregnancy-related activities people were taking part in during the study, such as antenatal classes and general birth preparations.
Future research may benefit from conducting regression research into whether these activities are felt to reduce anxiety and depression in pregnant women, and whether internet interventions such HEAD TRASH CLEARANCE 5 as the Fearless Birthing Programme have additional benefits on mental health after these additional activities have been considered.
Practical implications and suggestions for future research
Due to the recent COVID-19 pandemic, the need for remote technology and services has become even more crucial for society, thus investigations into the efficacy of online interventions are also more important for research and practice. Whilst HTC and the Fearless
Birthing programme are already available online, the perceived enjoyment and usefulness of the programme in the current study suggests there may be benefit in exploring additional technological versions of the programme, such as an app. This would fit in with the zeitgeist of healthcare provision during the pandemic, whilst also allowing people to access a wider variety of services that not only have the potential to alleviate perinatal mental issues but are also enjoyable. This could even be used in tandem with pre-established treatments, such as psychotherapeutic options provided by the NHS. However, caution must be exerted with this practical application. Whilst the literature argues that patient choice between publicly funded and private options would empower patients in their healthcare provision, choice increase could lead to the closure of specific localised NHS services which would negatively affect public opinions on private healthcare choices within the NHS (Timmins, 2005). There are also some NHS trusts where there is a struggle to train up psychotherapists, so NHS services are struggling to provide core provision let alone offer patient choice that a HTC app would provide (Valsraj & Gardner,
2007). HEAD TRASH CLEARANCE 6
The pandemic has also produced new challenges to perinatal mental health that could be benefitted by remote services. Data into the mental health of pregnant women has found that levels of severe anxiety and depression are higher than they were before the COVID-19 pandemic, and that these levels are independent of other factors such as pregnancy complications and previous mental health history (Ceulemans et al., 2020; Farrell et al., 2020). Specifically,
COVID-19 anxiety has been reported as an indirect predictor of poor mental health in pregnancy
(Salehi et al., 2020), and new anxieties for pregnant women include the cessation of face-to-face visits, fear of infection during pregnancy, and having an essential worker within the household; again these findings are independent of demographic factors or previous mental health and pregnancy history (Moyer et al., 2020). As interventions such as the Fearless Birthing
Programme aim to tackle specific fears of pregnancy and childbirth, there is potential scope for such interventions to use cognitive or reflective repatterning techniques to tackle COVID-19 specific anxieties, and findings on their efficacy in reducing these new anxieties may be of interest for research and practice.
It would also be of both interest and importance to assess the effects of reflective repatterning as a general therapeutic technique, as opposed to targeting pregnancy anxiety as a specific technique. Whilst anecdotal evidence exists regarding the usefulness of the technique
(Milbank, 2018), to our knowledge there is no empirical evidence to support these claims. RCT research into reflective repatterning as a therapeutical method could help us to understand its usefulness as well as the exact components of it that make the HTC method useful and beneficial to others, including pregnant women. Furthermore, understanding how the Fearless Birthing programme and the HTC method complement or contrast from existing interventions within the HEAD TRASH CLEARANCE 7 context of medical implications would be particularly useful. For example, we know that perinatal mental health interventions contribute towards an increase rate of vaginal as opposed to elective caesarean births (Saisto et al., 2001; Shahsavan et al., 2020). It would be interesting to know whether the Fearless Birthing programme makes a similar contribution towards birth outcomes, and whether this is due to an improved mental and emotional state during pregnancy.
Additionally, research into specific therapeutic interventions for tokophobia is limited or non- existent. A recent consensus statement highlighted that, as well as operational and measurement issues, tokophobia research in general is challenged by a lack of empirical evidence into phobia- specific interventions. Whilst cognitive and behavioural methods exist, these have only been assessed in a general context (Jomeen et al., 2021). What would be useful is for research to investigate the effects of interventions on reducing symptoms of tokophobia, starting with interventions such as the Fearless Birthing Programme which aim to clear this phobia specifically.
Conclusion
Head Trash Clearance and the Fearless Birthing Programme are promising techniques and interventions that aim to reduce levels of pregnancy anxiety and tokophobia. Whilst the current study did not find significant reductions in anxiety and depression as a result of the programme, this by no means implies that it is not effective. Various changes to experimental methodology such as increased participation and the use of a more robust RCT method could provide us with different findings that advance our knowledge and understanding of the HTC programme and reflective repatterning as a therapeutic technique. This in turn would have important implications for research into therapeutic interventions for perinatal anxiety, and implications for the HEAD TRASH CLEARANCE 8 provision of online interventions. Participants also enjoyed the programme and understanding from a qualitative perspective what was enjoyable and useful would deepen our understanding of programme’s effectiveness. There are a vast range of unanswered questions that can still be explored regarding the Fearless Birthing programme
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Appendix ‘A’: Results for the mixed design ANOVAs conducted on STICSA anxiety, pregnancy anxiety, and depression levels
2 Measure Analysis F df p np Achieved
power State cognitive Main effect- 1.97 2,6 .22 0.397 0.46
anxiety month programme
access given Main effect- 2.99 3,18 .058 0.333 0.99
time at which survey
was completed Interaction 2.11 6,18 .1 0.413 0.99 State somatic anxiety Main effect- 0.94 2,6 .44 0.239 0.25
month programme
access given HEAD TRASH CLEARANCE 2
Main effect- 0.42 1.88,11.27 .66 0.065 0.31
time at which survey
was completed
Interaction 1.002 3.76,11.27 .44 0.25 0.82
State anxiety total Main effect- 1.35 2,6 .33 0.311 0.34
month programme
access given
Main effect- 1.36 3,18 .29 0.185 0.81
time at which survey
was completed
Interaction 1.5 6,18 .23 0.333 0.95
Pregnancy anxiety Main effect- 0.41 2,6 .68 0.12 0.13
month programme
access given HEAD TRASH CLEARANCE 3
Main effect- 3.87 1.22,7.34 .084 0.392 0.99
time at which survey
was completed
Interaction 0.93 2.45,7.34 .46 0.236 0.79
Depression Main effect- 0.55 2,6 .6 0.156 0.16
month programme
access given
Main effect- 2.85 3,18 .067 0.322 0.98
time at which survey
was completed Interaction 1.35 6,18 .31 0.31 0.93