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.

a
School of Psychology, University of Nottingham, University Park, Nottingham, UK NG7 2RD.

Email: megan.barnard1@nottingham.ac.uk (M. Barnard), alexia.leachman@me.com (A.

Leachman)
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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
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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.
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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.
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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,

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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
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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
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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
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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,
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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
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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
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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.

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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.
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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.
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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.
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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)

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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)

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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)

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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
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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
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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
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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
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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).
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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

References

Ashford, M. T., Olander, E. K., & Ayers, S. (2016). Computer- or web-based interventions for

perinatalmental health: A systematic review. Journal of Affective Disorders, 197, 134–146.

https://doi.org/10.1016/j.jad.2016.02.057

Barnard, M. P., & Chapman, P. (2018). The moderating effect of trait anxiety on anxiety-related

thoughts and actions whilst driving. Personality and Individual Differences, 135, 207–211.

https://doi.org/10.1016/j.paid.2018.07.027

Baylis, R., Ekdahl, J., Haines, H., & Rubertsson, C. (2020). Women’s experiences of internet-

delivered Cognitive Behaviour Therapy (iCBT) for Fear of Birth. Women and Birth, 33(3),

e227–e233. https://doi.org/10.1016/j.wombi.2019.05.006

Ceulemans, M., Hompes, T., & Foulon, V. (2020). Mental health status of pregnant and

breastfeeding women during the COVID‐19 pandemic: A call for action. Obstetrics, 151(1),

146–147. https://doi.org/10.1002/ijgo.13295

Clark, L. A., & Watson, D. (1991). Tripartite model of anxiety and depression: psychometric

evidence and taxonomic implications. Journal of Abnormal Psychology, 100(3), 316–336.

Cox, J. L., Holdenand, J. M., & Sagovsky, R. (1987). Detection of Postnatal Depression

Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of

 HEAD TRASH CLEARANCE 9

Psychiatry, 150, 782–786.

Da Costa, D., Larouche, J., Dritsa, M., & Brender, W. (1999). VARIATIONS IN STRESS

LEVELS OVER THE COURSE OF PREGNANCY: FACTORS ASSOCIATED WITH

ELEVATED HASSLES, STATE ANXIETY AND PREGNANCY-SPECIFIC STRESS.

Journal of Psychosomatic Research, 47(6), 609–621.

Evans, K., Spiby, H., & Morrell, C. J. (2015). A psychometric systematic review of self-report

instruments to identify anxiety in pregnancy. Journal of Advanced Nursing, 71(9), 1986–

2001. https://doi.org/10.1111/jan.12649

Farrell, T., Reagu, S., Mohan, S., Elmidany, R., Qaddoura, F., Ahmed, E. E., Corbett, G.,

Lindow, S., Abuyaqoub, S. M., & Alabdulla, M. A. (2020). The impact of the COVID-19

pandemic on the perinatal mental health of women. Journal of Perinatal Medicine, 48(9),

971–976. https://doi.org/10.1515/jpm-2020-0415

Faul, F., Erdfelder, E., Lang, A. G., & Buchner, A. (2007). G*Power 3: A flexible statistical

power analysis program for the social, behavioral, and biomedical sciences. Behavior

Research Methods, 39, 175–191.

Fleming, T. (2007). TAT Professionals’ Manual. TAT International.

Forsell, E., Bendix, M., Hollandare, F., von Schultz, B. S., Nasiell, J., Blomdahl-Wetterholm,

M., Eriksson, C., Kvarned, K., van der Linden, J. L., Soderberg, E., Jokinen, J., Wide, K., &

Kaldo, V. (2017). Internet delivered cognitive behavior therapy for antenatal depression: A

randomised controlled trial. Journal of Affective Disorders, 221, 56–64.

https://doi.org/10.1016/j.jad.2017.06.013

Gammer, I., Hartley-Jones, C., & Jones, F. W. (2020). A Randomized Controlled Trial of an

Online, Compassion-Based Intervention for Maternal Psychological Well-Being in the First

 HEAD TRASH CLEARANCE 10

Year Postpartum. Mindfulness, 11, 928–939. https://doi.org/https://doi.org/10.1007/s12671-

020-01306-9

Grös, D. F., Antony, M. M., Simms, L. J., & McCabe, R. E. (2007). Psychometric properties of

the State-Trait Inventory for Cognitive and Somatic Anxiety (STICSA): Comparison to the

State-Trait Anxiety Inventory (STAI). Psychological Assessment, 19(4), 369–381.

https://doi.org/10.1037/1040-3590.19.4.369

Haga, S. M., Kinser, P., Wentzel-Larsen, T., Lisoy, C., & Garthus-Niegel, S. (2020). Mamma

Mia – A randomized controlled trial of an internet intervention to enhance subjective well-

being in perinatal women. The Journal of Positive Psychology.

https://doi.org/10.1080/17439760.2020.1738535

Harrsion, V., Moore, D., & Lazard, L. (2020). Supporting perinatal anxiety in the digital age; a

qualitative exploration of stressors and support strategies. BMC Pregnancy and Childbirth,

20, 1–20. https://doi.org/http://dx.doi.org/10.1186/s12884-020-02990-0

Heron, J., O’Connor, T. G., Evans, J., Golding, J., & Glover, V. (2004). The course of anxiety

and depression through pregnancy and the postpartum in a community sample. Journal of

Affective Disorders, 80(1), 65–73. https://doi.org/10.1016/J.JAD.2003.08.004

Jomeen, J., Martin, C. R., Jones, C., Marshall, C., Ayers, S., Burt, K., Frodsham, L., Horsch, A.,

Midwinter, D., O’Connell, M., Shakespeare, J., Sheen, K., & Thomson, G. (2021).

Tokophobia and fear of birth: a workshop consensus statement on current issues and

recommendations for future research. Journal of Reproductive and Infant Psychology,

39(1), 2–15. https://doi.org/10.1080/02646838.2020.1843908

Kersting, A., Dölemeyer, R., Steinig, J., Walter, F., Kroker, K., Baust, K., & Wagner, B. (2013).

Brief Internet-Based Intervention Reduces Posttraumatic Stress and Prolonged Grief in

 HEAD TRASH CLEARANCE 11

Parents after the Loss of a Child during Pregnancy: A Randomized Controlled Trial.

https://doi.org/10.1159/000348713

Leachman, A. (2018a). Clear Your Head Trash: How to Create Clarity, Peace and Confidence

in Your Life and Work (1st ed.). Mankai Media.

Leachman, A. (2018b). Fearless Birthing (1st ed.). Mankai Media.

Leachman, A. (2018c). Head Trash Clearance Method.

https://www.headtrashclearance.com/head-trash-clearance-method/

Leachman, A. (2018d). What is Fearless Birthing? https://fearless-birthing.com/about/

Lobel, M., Cannella, D. L., Graham, J. E., DeVincent, C., Schneider, J., & Meyer, B. A. (2008).

Pregnancy-specific stress, prenatal health behaviors, and birth outcomes. Health

Psychology, 27(5), 604–615. https://doi.org/10.1037/a0013242

Loughnan, S. A., Sie, A., Hobbs, M. J., Joubert, A. E., Smith, J., Haskelberg, H., Mahoney, A. E.

J., Kladnitski, N., Holt, C. J., Milgrom, J., Austin, M., Andrews, G., & Newby, J. M.

(2019). A randomized controlled trial of ‘MUMentum Pregnancy’: Internet-delivered

cognitive behavioral therapy program for antenatal anxiety and depression. Journal of

Affective Disorders, 243, 381–390. https://doi.org/10.1016/j.jad.2018.09.057

Madhavanprabhakaran, G. K., D’Souza, M. S., & Nairy, K. S. (2015). Prevalence of pregnancy

anxiety and associated factors. International Journal of Africa Nursing Sciences, 3, 1–7.

https://doi.org/10.1016/j.ijans.2015.06.002

Milbank, C. (2017). About Reflective Repatterning RR.

Milbank, C. (2018). Reflective Repatterning Claire Testimonial.

Moyer, C. A., Compton, S. D., Kaselitz, E., & Muzik, M. (2020). Pregnancy-related anxiety

during COVID-19: a nationwide survey of 2740 pregnant women. Archives of Women’s

 HEAD TRASH CLEARANCE 12

Mental Health, 23(6), 757–765. https://doi.org/10.1007/s00737-020-01073-5

Nieminen, K., Andersson, G., Wijma, B., Ryding, E., & Wijma, K. (2016). Treatment of

nulliparous women with severe fear of childbirth via the Internet: a feasibility study.

Journal of Psychosomatic Obstetrics and Gynecology, 37(2), 37–43.

https://doi.org/10.3109/0167482X.2016.1140143

Nieminen, K., Malmquist, A., Wijma, B., Ryding, E., Andersson, G., & Wijma, K. (2015).

Nulliparous pregnant women’s narratives of imminent childbirth before and after internet‐

based cognitive behavioural therapy for severe fear of childbirth: a qualitative study. BJOG-

An International Journal of Obstetrics and Gynaecology, 122(9), 1259–1265.

https://doi.org/10.1111/1471-0528.13358

Nilsson, C., Hessman, E., Sjoblom, H., Dencker, A., Jangsten, E., Mollberg, M., Patel, H.,

Sparud-Lundin, C., Wigert, H., & Begley, C. (2018). Definitions, measurements and

prevalence of fear of childbirth: a systematic review. BMC Pregnancy and Childbirth,

18(28). https://doi.org/10.1186/s12884-018-1659-7

O’Connell, M. A., Leahy-Warren, P., Khashan, A. S., Kenny, L. C., & O’Neill, S. M. (2017).

Worldwide prevalence of tocophobia in pregnant women: systematic review and meta‐

analysis. Acta Obstet Gynecol Scand, 96, 907–920. https://doi.org/10.1111/aogs.13138

Qiao, Y., Wang, J., & Li, J. (2012). Effects of depressive and anxiety symptoms during

pregnancy on pregnant, obstetric and neonatal outcomes: A follow-up study Eff ects of

depressive and anxiety symptoms during pregnancy on pregnant, obstetric and neonatal

outcomes: A follow-up study.

https://doi.org/10.3109/01443615.2011.647736doi.org/10.3109/01443615.2011.647736

Rini, C. K., Dunkel-Schetter, C., Wadhwa, P. D., & Sandman, C. A. (1999). Psychological
 HEAD TRASH CLEARANCE 13

Adaptation and Birth Outcomes: The Role of Personal Resources, Stress, and Sociocultural

Context in Pregnancy. Health Psychology, 18(4), 333–345.

https://www.researchgate.net/profile/Christine_Schetter/publication/

12867698_Psychological_adaptation_and_birth_outcomes_The_role_of_personal_resource

s_stress_and_sociocultural_context_in_pregnancy/links/09e414ff2108f8dc98000000/

Psychological-adaptation-and-birth-outcomes-The-role-of-personal-resources-stress-and-

sociocultural-context-in-pregnancy.pdf

Rondung, E., Ternstrom, E., Hildingsson, I., Haines, H. M., Sundin, O., Ekdahl, J., Karlstrom,

A., Larsson, B., Sergeblad, B., Baylis, R., & Rubertsson, C. (2018). Comparing Internet-

Based Cognitive Behavioral Therapy With Standard Care for Women With Fear of Birth:

Randomized Controlled Trial. JMIR Mental Health, 5(3), e10420.

https://doi.org/10.2196/10420

Rubertsson, C., Hellstrom, J., Cross, M., & Sydsjo, G. (2014). Anxiety in early pregnancy:

prevalence and contributing factors. Archives of Women’s Mental Health, 17, 221–228.

https://doi.org/10.1007/s00737-013-0409-0

Saisto, T., Salmela-Aro, K., & Nurmi, J. E. (2001). A randomized controlled trial of intervention

in fear of childbirth. Obstetrics and Gynecology, 98(5), 820–826.

https://doi.org/10.1016/S0029-7844(01)01552-6

Salehi, L., Rahimzadeh, M., Molaei, E., Zaheri, H., & Esmaelzadeh-Saeieh, S. (2020). The

relationship among fear and anxiety of COVID-19, pregnancy experience, and mental

health disorder in pregnant women: A structural equation model. Brain and Behavior,

10(11), e01835. https://doi.org/10.1002/brb3.1835

Shahsavan, F., Akbari, N., Gharraaee, B., Abolghasemi, J., & Khedmat, L. (2020). The effect of
 HEAD TRASH CLEARANCE 14

internet‐based guided self‐help cognitive‐behavioral therapies on Iranian women’s

psychological symptoms and preferred method of childbirth. Perspectives in Psychiatric

Care, 1–10. https://doi.org/10.1111/ppc.12535

Solness, C. L., Kroska, E. B., Holdefer, P. J., & O’Hara, M. W. (2020). Treating postpartum

depression in rural veterans using internet delivered CBT: program evaluation of

MomMoodBooster. Journal of Behavioral Medicine. https://doi.org/https://doi.org/10.1007/

s10865-020-00188-5

Teixeira, C., Figueiredo, B., Conde, A., Pacheco, A., & Costa, R. (2009). Anxiety and depression

during pregnancy in women and men. Journal of Affective Disorders, 119(1–3), 142–148.

https://doi.org/10.1016/J.JAD.2009.03.005

Timmins, N. (2005). Challenges of private provision in the NHS. BMJ, 331(7526), 1193. https://

doi.org/10.1136/bmj.331.7526.1193

Tsai, Y., Hsu, Y., Hou, T., & Chang, C. (2018). Effects of a Web‐Based Antenatal Care System

on Maternal Stress and Self‐Efficacy During Pregnancy: A Study in Taiwan. Journal of

Midwifery and Women’s Health, 63(2), 205–213. https://doi.org/10.1111/jmwh.12685

Valsraj, K. M., & Gardner, N. (2007). Choice in mental health: Myths and possibilities.

Advances in Psychiatric Treatment, 13(1), 60–67.

https://doi.org/10.1192/apt.bp.105.002196
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Appendix ‘A’: Results for the mixed design ANOVAs conducted on STICSA anxiety, pregnancy anxiety, and depression levels

Measure Analysis F df p np2 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
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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
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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