Effects of listening to music on postpartum stress exploring the prevalence and correlates of maternal

and anxiety levels postpartum anxiety before hospital discharge among

422 mothers revealed that moderate maternal
Ying-Fen Tseng, Chung-Hey Chen and ChihChen S Lee
anxiety is
Aim. This Taiwan study investigated what effect
common prior to perinatal hospital discharge
listening to specially selected, relaxing music at
(Britton 2005). Postpartum anxiety may also have
home, on a self-regulated basis, had on the
the potential to influence child outcomes, either
perceived stress and state anxiety of postpartum
directly or indirectly. High postpartum maternal
women. Background. Listening to music has been
anxiety has been associated with a reduced ability to
increasingly used in the perinatal period, but few
cope (Barnett & Parker 1986), feeling less able to
studies have been undertaken to provide evidence
provide effective parenting (Teti & Gelfand 1991,
of its effectiveness. Design. A randomised clinical
Gondoli & Silverberg 1997, Porter & Hsu 2003) and
trial. Methods. Seventy-seven postpartum women
decreased maternal reactivity or sensitivity,
were randomly assigned to an experimental group (n
especially when infants display highly negative
= 37) and a control group (n = 40). The experimental
emotions (Mertesacker et al. 2004). There are many
group listened to music at home for at least 30
potential causes for high postpartum maternal
minutes a day over two weeks and received regular
anxiety, including cultural beliefs and practices
postpartum care. The women in the control group
received regular postpartum care only. The Authors: Ying-Fen Tseng, RN, PhD Candidate,
Perceived Stress Scale and State Anxiety Inventory Associate Professor, Department of Nursing, Chung
were used to measure outcomes. Results. After Hwa University of Medical Technology; Chung-Hey
controlling the pretest scores and educational level Chen, PhD, RN, Professor, Institute of Allied Health
of mothers, which was a significant covariate, there Sciences & Department of Nursing, College of
were no significant differences in the posttest levels Medicine, National Cheng Kung University, Tainan,
of perceived stress and state anxiety between the Taiwan; ChihChen S Lee, PhD, MT-BC, Associate
two groups. Conclusions. This study does not provide Professor, Director of Music Therapy, Music
evidence that preselected designer music reduced Department, Southwestern Oklahoma State
stress and anxiety levels among postpartum women. University, Weatherford, OK, USA
Relevance to clinical practice. Despite the absence of
Correspondence: Chung-Hey Chen, Professor,
significant findings, there are lessons that
Institute of Allied Health Sciences & Department of
professionals may find useful. It is recommended
Nursing, National Cheng Kung University, 1
that future studies take more account of the stress
University Road, Tainan 70101, Taiwan. Telephone:
factors that postpartum women are unable to
+886 6 2353535 ext. 5846. E-mail:
control when they are listening to music at home.
chunghey@mail.ncku.edu.tw
Key words: anxiety, music, nurses, nursing,
postpartum, stress
surrounding the postpartum period (Kim-Godwin
Accepted for publication: 4 April 2009
2003). For example, Taiwanese women believe rest
Introduction is essential after childbirth. During the customary 30-
day postpartum confinement, female relatives or
Childbearing can change a woman’s body image, life-
live-in helpers perform household activities for the
style and socialroles(Tseng
new mother. The new mother is confined to her
etal.1994).Highmaternalstress oranxiety during the
home during this period and is expected to perform
immediate postpartum period may have a potent
a variety of avoidance rituals. According to the
influence on a woman’s subsequent adaptation and
Taiwanese custom of zuo yue zi (‘doing the month’),
has been associated with unfavourable outcomes
the new mother should not go out, walk about, read,
such as postpartum depression or child behaviour
cry, bathe, wash her hair or touch cold water
problems (Teissedre & Chabol 2003). A study
(Holroyd et al. 1997). Four leading stressors
associated with the practice of these rituals were
identified in Leung’s study (2005), environmental
constraints, difficulties in following prescribed
rituals, conflicts between all the parties involved and
attaining the maternal role. Although some studies
challenged whether ‘doing the month’ rituals are
necessarily protective and supportive of postpartum
women (Heh 2001, Leung 2005), women who adhere
to the practice experience less severe physical
symptoms and lower levels of postpartum
depression (Chien 2006). Showing cultural sensitivity
during postpartum care is essential for nurses
working in 21st century healthcare. As well as
educating women about the benefits of
contemporary postpartum care, identifying
appropriate complementary interventions that help
them adapt to this potentially stressful period will
maximise the effect of the ‘doing the month’ rituals,
both psychologically and physically, without the side
effects associated with conventional pharmaceutical
treatments. This is of particular benefit to women
who are breastfeeding.
Original article
sessions and music therapy during labour were
significantly more relaxed in the three hours before
delivery than those in the control group, according
to the Trippet Muscle Relaxation Inventory. The self-
reported questionnaires also showed that women in
the music therapy group felt they had significantly
more personal control during their labour than those
in the control group. Chang and Chen (2005) found
that Taiwanese women who took part in an
experimental group – where they chose from
relaxing, anxiety-reducing Western classical, new age
or Chinese religious music – reported significantly
lower anxiety and a higher level of satisfaction with
their caesarean experience than the control group.
Chang et al. (2008) randomly assigned 116
Taiwanese pregnant women to a music group and
120 to a control group. After two weeks the music
group showed significant reductions in stress,
anxiety and depression using three established
measurement scales. In comparison, the control
group showed a much smaller reduction in stress,
while their anxiety and depression scores showed
little or no improvement. Women in the music group
also expressed preferences for the type of music
they listened to, with lullabies, nature and crystal
sounds proving more popular than classical music.
Although music therapy is gaining broader
acceptance, no studies have been undertaken to
examine its efficacy in the postpartum period. The
purpose of this study was to undertake a
randomised trial to evaluate the effects that listening
to music had on perceived stress and state anxiety
during this period. We hypothesised that when the
women listened to relaxing music – chosen from
preselected designer music collections, at home and
on a self-regulated basis for at least 30 minutes a
day for two weeks – this would decrease their
perceived stress and anxiety.
Methods
A pretest, posttest randomised control group design
was implemented to examine the effects of music
listening on postpartum women’s perceived stress
and state anxiety.
Participants
We recruited participants through the postnatal
wards at two teaching hospitals in Kaohsiung,
Taiwan, between January– July 2004. The inclusion
criteria were as follows: (1) at least 18 years old and
married; (2) delivery of a mature and normal
newborn and (3) consent to participate. Postnatal
women who had apparent postpartum
complications or an illness requiring prescription
medication were excluded from study. Ninety-two
women who met the inclusion criteria returned their
consent documents and were randomly
assigned via lot to either the experimental or control
group. A total of 77 participants who completed the
two period assessments, 37 in the experimental and
40 control group, constituted the final valid samples
for analysis.
Measures
In addition to the survey on demographic data (age,
education, occupation and socio-economic status),
obstetric variables (parity, type of delivery, sex of
neonate and type of infant feeding) and average
frequency of music listening in the past, the
Perceived Stress Scale (PSS) and State Anxiety
Inventory (S-STAI) were employed to measure the
experimental outcomes. The PSS was designed to
measure the degree to which respondents find their
lives unpredictable, uncontrollable or overloaded
(Cohen et al. 1983). The 10 items on the scale focus
on feelings and thoughts experienced during the
past month and are rated by the subject on a
fourpoint scale representing the frequency with
which each item occurs. Higher scores indicate
greater stress. The Chinese version of the PSS has
shown adequate internal consistency, test–retest
reliability and construct validity (Chen et al. 1994).
The PSS had adequate two-week test–retest
reliability (correlation coefficient = 0Æ61) and
internal consistency (coefficient a =0 Æ84) in our
study. The STAI was developed by Spielberger et al.
(1970). It provides a reliable, relatively brief, self-
reported measure of both state and trait anxiety. It
consists of a state version, which measures a
transitory condition of perceived tension and a trait
version, which measures a relatively stable condition
of anxiety proneness. The STAI consists of 40 brief
descriptors – 20 to assess ‘how you feel right now’
and 20 to assess ‘how you generally feel’. Each
descriptor measures the intensity of anxiety on a
scale of one to four, with a higher score indicating
more anxiety. This was translated and revised into a
Chinese version by Chung and Long. The Chinese
STAI was reported to have reasonably good
reliability and validity in a study of Taiwanese junior
high school students (Chung & Long 1984). For the
purpose of our study, only the state version was
used. In our study population, the S-STAI was found
to have adequate twoweek test–retest reliability
(correlation coefficient = 0Æ59) and internal
consistency (coefficient a =0 Æ93).
Procedure
The study was approved by the appropriate
institutional review boards. Participants randomly
assigned to the experimental and control groups
received a written description of the purpose of the
research and completed a consent form
Data analysis
The demographic and obstetric data were
summarised with descriptive statistics such as
frequencies, percentages and means. One-way
analysis of covariance (ANCOVA ANCOVA) was used
to test the effects of groups on the PSS and S-STAI.
The accepted level of significance for all analyses
was p < 0Æ05. Data analyses were carried out using
SAS SAS Version 8.0.
Conclusions
The postpartum care practice known as zuo yue zi
(‘doing the month’) has its significance in Taiwanese
culture. To maximise both the psychological and
physiological benefits of practicing the rituals
without the associated stress, the effect of
complementary or mind-body approaches, such as
listening to music, was investigated. According to
this study, when postpartum women listened to
relaxing music chosen from preselected designer
music collections on a selfregulated basis in their
own home, it did not result in a significant difference
in their perceived stress and state anxiety levels.
Future studies in this subject may compare the
effects of listening to music when participants select
their own music or have it selected for them by the
researchers. They may also take more account of
what participants are doing when they are listening
to music and the stress factors that they are unable
to control when they are listening to music at home.
Acknowledgements
This study was supported by grant NSC 92-2314-B-
037-005 from the National Science Council, Taipei,
Taiwan. The authors wish to thank the women who
participated in the trial.
Contributions
Study design: CHC; data collection and analysis: CHC,
YFT and manuscript preparation: YFT, CHC, CCSL.
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