The World Health Organization (WHO, 2023) reports that around 13% of postnatal women experience a mental health disorder. In the UK, the Royal College of Midwives (2022) suggests that one in five women experience a mental health problem in the perinatal period.
The transition to motherhood can have a significant impact on women's psychological wellbeing (Meeussen and Van Laar, 2018; Lévesque et al, 2020; Hwang et al, 2022). Despite the postpartum period being characterised as a joyful and happy time, it often involves challenges and life adjustments (Corrigan et al, 2015), including adapting to a new identity and reconstruction of ‘self’ (Meeussen and Van Laar, 2018; Hennekam et al, 2019; Hwang et al, 2022).
Challenges may be as a result of factors including exhaustion, parental stress, lack of support, changes in societal role and relationships and unrealistic expectations of motherhood (McLeish and Redshaw, 2017; Finlayson et al, 2020). This can have a significant impact on the wellbeing of both the mother and infant (Jefferson et al, 2020; Oyetunji et al, 2020) and the early bond that they develop (Lennard et al, 2021).
Identifying effective interventions to improve this transition is essential to promote maternal mental health and mother–infant bonding (Kristensen et al, 2018). Evidence-based policies such as National Institute for Health and Care Excellence guidance (NICE, 2021), detail how health professionals can best support women in the postnatal period by managing mental health challenges, and promoting strong parent–infant relationships and infant feeding practices. Through the frequency of universal health visiting contacts, health visitors are best placed to identity adversities and offer early interventions (Public Health England (PHE), 2021a).
Background
The WHO (2022) stresses the need for high-quality postnatal care to improve the outcomes of maternal and infant health and wellbeing, and promote positive postnatal experiences. Increasingly, self-compassion is being recognised as an important source of resilience that may buffer the effects of mental health challenges, including anxiety and depression in many population groups (Gill et al, 2018; Haukaas et al, 2018; Xue et al, 2023). A meta-analysis by Ferrari et al (2019) demonstrated that self-compassion and compassion-focused therapies (CFT) are playing an increasing role in healthcare interventions, and have been linked to better psychological and medical outcomes.
Furthermore, a growing body of research has examined the psychological health benefits of self-compassion when faced with life stressors, including parenting (Felder et al, 2016; Bluth and Neff, 2018; Garcia et al, 2022). Self-compassion is thought to be a closely related concept to mindfulness, which has the potential to be as, or more, effective in promoting parental and child mental health and wellbeing (Jefferson, 2020).
Neff's seminal work on self-compassion originates from Buddhist philosophy and describes compassion turned inward (Neff, 2003a; 2023b). She defines self-compassion as being kind and understanding when experiencing suffering and personal failings (Neff, 2023a). Neff's (2003a) conceptual framework of self-compassion comes under the following three components: self-kindness, mindfulness, and common humanity. Self-kindness involves kindness and understanding towards oneself instead of judging and being self-critical. Common humanity acknowledges that all people make mistakes and that this is not something we experience alone but can connect us with others rather than isolate us. Mindfulness allows people to be aware and accepting of their feelings and circumstances without over-identifying with them. Gilbert (2005) defines self-compassion as showing kindness towards oneself, while having a deep awareness of suffering and the suffering of others, along with the desire to alleviate these feelings.
Despite these similar definitions, Gilbert's main area of interest is in CFT, while Neff's is in the development of the Mindful Self-Compassion (MSC) programme. MSC combines both mindfulness and self-compassion practices and is a powerful tool for emotional resilience (Germer and Neff, 2019). CFT is a widely used evidence-based mental health intervention that aims to help relieve suffering, particularly shame and self-criticism, by cultivating self-compassion skills that promote self-acceptance and self-regulation (Gilbert, 2014). While there are many overlapping aspects of the two interventions, including cultivating mindfulness and acceptance, Frostadottir and Dorjee (2019) argue that they differ in that MSC focuses primarily on cultivating mindfulness whereas CFT focuses on compassion toward self and others.
Self-compassion can play an important role in parenting. Neff and Faso (2015) examined the role of self-compassion on parents of children with autism spectrum disorder. The results yielded increased parental wellbeing and reduced stress. Another study by Psychogiou et al (2016) looked at mothers and fathers with a history of depression and found that those who fostered self-compassion showed more responsiveness and sensitivity towards their pre-school-aged children, as well as greater resilience. The authors suggest that self-compassion may help parents to acknowledge any negative thoughts so that they can be more aware of and less reactive to these. Despite the rapid growth of clinical research into self-compassion and psychological wellbeing, there has been little focus on how women perceive the role of self-compassion in the transition to motherhood and its effectiveness in preventing psychological challenges during this transition.
The Healthy Child Programme in England (Public Health England [PHE], 2023) and the Universal Health Visiting Pathway in Scotland (Scottish Government, 2015) offer every family an evidence-based programme of interventions, beginning antenatally. Health visitors are equipped with advanced skills and knowledge in assessments, therapeutic communication and care management (PHE, 2021b), which suggests they are ideally placed to identify and support maternal wellbeing. However, mental health challenges remain prevalent in the antenatal and postnatal period. Given the increasing interest in the role of self-compassion to improve psychological wellbeing, this review sought to explore how self-compassion can work to aid the transition to motherhood while mitigating against adverse psychological outcomes, as well as how health visitors can embed self-compassion practices into routine care delivery.
Aims
This review aimed to appraise the current literature around the role of self-compassion in the transition to motherhood and women's experiences of this and the effectiveness of self-compassion on women's psychological wellbeing in this transition.
Methodology
Design
The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Page et al, 2021). The narrative review methodology aimed to provide increased insight into study findings for different interpretation (Siddaway et al, 2019) while the systemic review principles enabled rigour and meticulous presentation (Boland et al, 2017). This was the chosen approach as it allowed a fully comprehensive search of the literature to be carried out while providing the potential for individual insight and the identification of gaps in the literature.
Literature search
Boland et al (2017) suggest the Population, Intervention, Comparison and Outcomes (PICO) tool is used to support a systematic search strategy. Its framework helped to organise key terms extracted from the main concepts in the review question to structure a robust research question as advocated by Methley et al (2014) (Table 1). EBSCOhost (including MEDLINE, CINAHL plus and APA PsycINFO) and ProQuest Central databases were searched for articles between January 2017 and February 2023 to ensure literature was up to date. The databases were chosen for their relevance to healthcare practice. Boolean operators were used, and searches were bounded to key words/phrases included in titles and abstracts only to assist with refining the search.
| Population | Intervention | Comparison | Outcome |
|---|---|---|---|
| Women/mothers in pregnancy and the postnatal period | The role of self-compassion and self-compassion interventions in the transition to motherhood | Not using self-compassion in the transition to motherhood | The effectiveness of the role of self-compassion and self-compassion interventions on maternal psychological wellbeing in the post-natal period and women's experiences of these |
Articles had to meet the following inclusion/exclusion criteria:
The following search was carried out: abstract) mother* OR postnatal OR post-natal OR matern* OR perinatal OR postpartum AND (title) “maternal self-compassion” OR “self-compassion” OR “self compassion” OR “parent self-compassion” OR “compassion for self” OR “mindful self-compassion” OR “self-directed compassion” AND intervention* OR train* OR engage* OR participat* OR involve* OR trial OR experi* OR assess* OR therap* OR programme OR course.
Search outcome
The PRISMA statement was used to assist with a transparent step-by-step account of the screening and selection process (Figure 1) (Page et al, 2021). Papers were considered relevant if they had explored self-compassion from a maternal perspective, regardless of their methodologies, to ensure all available literature was captured. A total of 94 articles were retrieved following an initial database search. Thirty-seven duplicate articles were removed and the titles and abstracts of the remaining 57 studies were screened against the eligibility criteria. This eliminated a further 40. The full-text papers of the remaining 17 were read in their entirety and a further six were excluded, with reasoning, as they did not fit the eligibility criteria. One additional article was identified through snowball sampling. A total of 11 quantitative studies were eligible for review.
Quality appraisal
The Effective Public Health Practice Project (EPHPP) (National Collaborating Centre for Methods and Tools, 2010) quality assessment tool was used to assess the quality of each quantitative study. This was chosen in preference to the popular Critical Appraisal Skills Programme (CASP) tool as in that tool there was no checklist for cross-sectional study design. The EPHPP provides a standardised and systematic approach through a validated component rating score (strong, moderate or weak) which aims to identify key aspects of study validity and reduce bias. The overall rating of each study is determined by assessing the six component ratings. The reason for using the EPHPP is that it allowed one tool to be used for all selected studies and has a strong methodological rating.
Data abstraction and synthesis
A data extraction form was used to extract relevant information from the 11 eligible studies (Table 2). This was fundamental for appraising, analysing, summarising and interpreting a body of evidence and is a crucial part of the systematic review process (Büchter et al, 2020). The eligible articles were reviewed numerous times to identify the main characteristics of each study. This was followed by a critical discussion with the second researcher. The characteristics included: country, study design, population, study aim, measurement of self-compassion, results, ethics and main themes.
| Study | Participants | Aims | Measurement of self-compassion | Results | Key themes |
|---|---|---|---|---|---|
| Carona et al (2022) Portugal Cross-sectional, correlation study | 1053 women at high risk for post-partum depression (PPD) 18 years or over Early post-partum period (up to 4 months) | Analyse the direct and indirect effects, via emotional regulation difficulties, of self-compassion (SC) on the mental health outcomes of women at high risk for PPD | The SC scale-short form (SCS-SF) self-report questionnaire | SC was directly and indirectly linked, via emotional regulation difficulties to the mental health outcomes of women at risk of PPD | Anxiety/depression symptoms, positive psychological growth, SC reduces postnatal depression (PND) and promote positive mental health |
| Fernandes et al (2021) Portugal Longitudinal design | 125 women 18 years or over Having a child aged 0–12 months | Analyse the association between SC and mother–infant bonding and explore the mediating role of mindful parenting and parenting stress in this relationship | Short version of the SCS-SF 12 self-report questionnaire | Mothers presented higher levels of SC after lifting lockdown measures SC was positively correlated with mindful parenting and parenting stress, and negatively correlated with an impaired mother–infant bonding, stress, anxiety and depressive symptoms |
Mother–infant bonding, parenting stress, COVID-19, social support, anxiety/depression symptoms, mediating role of SC |
| Fonseca and Canavarro (2018) Portugal Cross-sectional | 387 women 18 years or over Up to 12 months post-partum | Examine the direct and indirect effects, via negative automatic thoughts, of women's dysfunctional attitudes towards motherhood on their depressive symptoms |
The SC scale (SCS) Portuguese version self-report questionnaire | More dysfunctional attitudes or beliefs towards motherhood lead to higher post-partum depressive symptoms which occurs through negative automatic thoughts (post-partum and general) |
Dysfunctional attitudes/beliefs towards motherhood, depressive symptoms, negative thoughts, women's perceptions of their personal values and maternal role, expectations of motherhood, SC as a buffer on PND symptoms |
| Guo et al (2020) China Randomised controlled trial (RCT) | 354 pregnant Women presenting with antenatal depressive or anxiety symptoms |
Assess the effect of mindful SC intervention on preventing PPD in a group of symptomatic pregnant women | Chinese version of the Mindfulness Attention Awareness Scale (MAAS) Chinese version of SCS | The Mindful SC intervention was effective in preventing PPD and promoting mother and infant wellbeing |
Mindfulness and SC, mindful parenting, anxiety/depression symptoms, parenting stress and responsibility, mother–infant bond, maternal perceptions, infant temperament, psychopathology |
| Lennard et al (2021) Australia RCT | 470 women 18 years or over Women who had given birth in the last 2 years Resided in Australia or New Zealand | To test the effectiveness of a brief self-compassion intervention (small package of online resources) in improving mental health outcomes for mothers of infants Explore the fears of compassion on intervention uptake and effectiveness | The Compassion Engagement and Action Scales The Fears of Compassion Scales | Significant positive intervention effects on depressive symptoms and post-traumatic stress symptoms, including intrusion and hyperarousal No significant effects for breastfeeding satisfaction, psychological flexibility, anxiety, or stress symptoms |
Psychological flexibility, depression, anxiety and stress, post-traumatic stress, breastfeeding satisfaction, SC, compassion for others, fear of compassion |
| Mitchell et al (2018) Australia/New Zealand pilot study Longitudinal design | 262 women 18 years or over Up to 24 months post-partum Resided In Australia or New Zealand | To evaluate the acceptability and potential utility of a small package of online resources designed to improve SC for mothers <24 months post-partum | The SC scale-short form (SCS-SF) self-report questionnaire | Mothers reported increased SC, decreased post-traumatic stress symptoms and increased satisfaction with breastfeeding Tentative support of techniques grounded in Compassion Focused Therapy on maternal wellbeing Due to the limitations of the study the effectiveness of the intervention could not be concluded | Psychological flexibility, difficult breastfeeding and birth experiences, shame in the mothering role, post-traumatic stress, SC interventions and barriers, positive psychological growth stemmed from challenges in PN period |
| Monteiro et al (2019) Portugal Cross-sectional design | 185 women at risk of developing PPD Up to 3 months post-partum Over 18 years old | Examine the differences in acceptance-based processes and SC among at-risk postpartum women not presenting with depressive and anxiety symptoms |
SCS-SF self-report questionnaire | Women not presenting with depressive/anxiety symptoms reported significantly higher levels of psychological flexibility, non-judgemental appraisal of thoughts and SC than those presenting with psychological symptoms and were less likely to present psychological symptoms |
Psychological flexibility, non-judgemental appraisal of thought/acceptance of thoughts, motherhood expectations and social idealisations, depressive/anxiety symptoms |
| Monteiro et al (2021) Portugal Cross-sectional study | 661 women Up to 12 months post-partum Over 18 years old Understanding Portuguese | Investigate the factors associated with flourishing and with the absence of PPD symptoms among postpartum women | The SC scale-short form (SCS-SF) self-report questionnaire | Younger infant age, higher levels of maternal confidence and resilience increased the likelihood of flourishing |
Psychological flexibility, resilience and confidence, infants temperament and sleep problems, social support, SC and flourishing, household income, depressive symptoms, motherhood expectations and social idealisation |
| Muramoto et al (2022) Japan Observational study | 46 Japanese women 1 month postpartum Over 18 years old | The rate and degree of the perceived difficulty of ‘difficult experiences with COVID-19 pandemic-related changes’ (DE) during pregnancy among Japanese women; investigate the relationship between DE during pregnancy and SC of post-natal women, the influence of ‘compassion from a partner’ (CP) and ‘compassion from the woman's mother’ (CM) recognised by postnatal women on the relationship between DE and SC | Japanese version of the SC scale (SCS-J) self-report questionnaire | SC negatively correlates with DE in maternity hospitals and social support |
COVID 19, social support, role of SC, women's perceived challenges in motherhood, social isolation |
| Pedro et al (2019) Portugal Cross-sectional study | 686 women Up to 12 months postpartum 18 years and over | Explore the direct and indirect effects of self-criticism on postpartum depressive symptoms, through postpartum cognitions, and analyse the moderating role of self-compassion in this relationship | SCS-SF self-report questionnaire | Higher levels of self-criticism may influence negative patterns of thinking which may lead to higher likelihood of depressive symptoms SC may exert a buffer effect on the relationship between self-criticism and negative automatic thoughts | Negative automatic thoughts and self-criticism, high motherhood-related standards, rumination, acceptance of thoughts as part of the motherhood experience, depressive symptoms |
| Whittingham and Mitchell (2021) Australia and New Zealand Cross-sectional study | 396 women 3–24 months postpartum 18 years and over Residing in Australia and New Zealand | Explore the relationships between objective birth and breastfeeding events; subjective experiences of birth and breastfeeding; two modifiable psychological variables: psychological flexibility and SC; emotional availability in the mother–infant relationship | The SC scale-short form (SCS-SF) self-report questionnaire | Objective breastfeeding events (difficulties), negative subjective birth/breastfeeding experiences, poorer psychological flexibility, and lower SC correlated with poorer emotional availability |
Psychological flexibility, emotional availability, mutual attunement, mother–infant bond, breastfeeding and birth experiences, support in antenatal and postnatal period |
Study characteristics
Table 2 illustrates the characteristics of the 11 quantitative studies eligible for review. Of these, six used a cross-sectional design, two used a longitudinal design and one claimed to be an observational study but was quantitative in nature. The final two studies were randomised controlled trials (RCTS).
Three studies tested self-compassion interventions (Mitchell et al, 2018; Guo et al, 2020; Lennard et al, 2021) and the remainder explicitly measured self-compassion states using self-report questionnaires. Lennard et al (2021) and Mitchell et al (2018) used the same intervention, originally piloted by Mitchell et al (2018), which comprised of two videos: self-compassion psycho-education and a guided self-compassion visualisation exercise, and a tip sheet offering ideas to promote self-compassion. Guo et al (2020) developed a 6-week online Mindful Self-Compassion programme consisting of six 15-minute videos a week involving self-compassion exercises.
Six studies were conducted in Portugal, three in Australia, one in Japan and one in China. Sample sizes varied between 46 and 1053 participants. First-time parents and subsequent parents were included. Three studies used a randomisation procedure and were rated ‘strong’ for study design in the EPHPP quality rating table. Studies included both women at risk of psychological problems and women who were low risk. Samples were mostly self-selected via online platforms or recruited by hospital staff and research teams on the postnatal ward following birth. Mitchell et al (2018) drew participants from their previous cross-sectional study and Guo et al (2020) do not give details of how participants were enrolled. Participants came from similar demographic profiles; namely, higher educated, financially secure and in a long-term partnership.
Self-compassion was defined in most of the studies except the two RCTs. Both Neff and Gilbert's definitions and theoretical underpinnings of self-compassion were cited in the remaining studies. In 10 of the 11 studies, the Self-Compassion Scale (SCS) (Neff, 2003b) was used to measure levels of self-compassion. This comprises six dimensions: self-kindness; mindfulness; common humanity; self-judgement; isolation; and over-identification. The average score for each dimension gives an overall self-compassion score.
The SCS comes in both long (26 items) and short (12 items) form and are both recognised for their validity (Garcia-Campayo et al, 2014; Neff, 2023). The remaining study used the Compassionate Engagement and Action Scales (Gilbert, 2017) to measure the following three scales: self-compassion; compassion for others; and compassion from others. The Fears of Compassion Scales (Gilbert et al, 2011) was also used in Lennard et al's (2021) RCT to measure ‘fear of self-compassion’, ‘fear of compassion for others’ and ‘fear of compassion from others’.
Findings
Association between self-compassion and mental health or depressive symptoms
Three studies tested online self-compassion interventions that aimed to reduce mental health challenges and increase self-compassion (Mitchell et al, 2018; Guo et al, 2020; Lennard et al, 2021). Generally, results in these studies found a small but significant increase in self-compassion from pre to post intervention. Mitchell et al (2018) found a decrease in post-traumatic stress symptoms, with 61.9% of mothers moving out of the clinical range for post-traumatic stress symptoms, compared to 8% pre-intervention. Conversely, there was no change for psychological flexibility or shame in the mothering role.
Lennard et al (2021) found positive intervention effects on post-traumatic stress symptoms and lack of change in psychological flexibility. There was no intervention effect on anxiety, depressive or stress symptoms. It is assumed that the lack of change in psychological flexibility may be because this aspect was not specifically targeted in the intervention (Mitchell et al, 2018; Lennard et al, 2021). Guo et al (2020) found that, compared to the control group, depression decreased at 3 months postpartum and further again at 1 year. A significant improvement in mindfulness and self-compassion was noted. Parental stress decreased at 3 months post-partum; however, there was no significant difference observed at 1 year.
The majority of participants found the intervention extremely useful (Guo et al, 2020), but barriers to accessing resources were noted such as lack of time, feeling uncomfortable with exercises and fatigue (Mitchell et al, 2018). ‘Fear of self-compassion’ from others acted as an additional barrier (Lennard et al, 2021). Several studies highlight the importance of self-compassion to prevent anxiety and depressive symptoms and reduce parenting stress (Pedro et al, 2019; Guo et al, 2020; Lennard et al, 2021; Monteiro et al, 2021; Carona et al, 2022). In one study, self-compassion was significantly correlated with lower emotional regulation difficulties, lower psychological distress and higher levels of wellbeing (Carona et al, 2022).
This is supported by findings that report women with higher levels of self-compassion are less likely to develop PPD symptoms (Fonesca and Canavarro, 2018; Monteiro et al, 2021). Despite this, Pedro et al (2019) claimed that the moderating role of self-compassion was not found in the relationship between women already presenting high levels of self-criticism and depressive symptoms. This is aligned with another study by Monteiro et al (2019) who recommend acceptance-based therapies (ABT) that incorporate psychological flexibility and non-judgemental appraisal of thought, are needed to increase self-compassion and reduce psychological symptoms. Monteiro et al (2019) reported significantly higher levels of self-compassion in those not presenting with PPD symptoms. Paradoxically, self-compassion was only marginally associated with absence of anxiety and depressive symptoms when it was introduced in the final step of this study. Findings add tentative support to the idea that self-compassion contributes to emotional regulation and helps prevent perinatal negative thoughts (Monteiro et al, 2019; Pedro et al, 2019).
Self-criticism, dysfunctional beliefs and motherhood idealisation
The transition to motherhood represents a major life adjustment. One cross-sectional study suggested that women with clinically depressive symptoms presented with more dysfunctional attitudes towards motherhood, including feelings of personal failure, responsibility, and judgement of others (Fonesca and Canavarro, 2018). This study found no direct effects between dysfunctional beliefs and motherhood idealisation.
Further, more dysfunctional attitudes or beliefs related to judgements of others and maternal responsibility were found to lead to higher depressive symptoms. This is supported by Pedro et al (2019) who found that women's self-criticism is related to increased frequency of negative thoughts, both regarding events in motherhood and appraisal of thought content, which is thought to lead to higher levels of depressive symptoms regardless of a women's level of self-compassion. Pedro et al (2019) argue that women who are prone to self-critical thoughts may see themselves as failing to meet their perceived idealisation of motherhood, resulting in feeling less competent in their role and reinforcing feelings of inadequacy.
Using mediation models to test the relationship between self-compassion levels and psychological variables (negative thoughts/attitudes and postnatal depression), two studies found self-compassion to be a protective factor in the postpartum period which was demonstrated through negative thought patterns being moderated by self-compassion (Fonesca and Canavarro, 2018; Pedro et al, 2019). They found self-compassion exhibited a buffer effect on dysfunctional attitudes towards motherhood and PPD symptoms (Fonesca and Canavarro, 2018). They concluded that self-compassion has a positive effect on the relationship between self-criticism and post-partum patterns of thinking (Pedro et al, 2019). Aligned with findings from Fonesca and Canavarro (2018) and Pedro et al (2019), Monteiro et al (2019) suggest that women with non-judgemental appraisal of thought content were less likely to develop PPD. Further, some results indicate that women who are more accepting and non-judgemental of their own experiences may be better protected from developing psychological symptoms (Fonesca and Canavarro, 2018; Monteiro et al, 2019).
Self-compassion as a protective factor
Despite the widespread ideology of ‘perfect’ motherhood and the need to meet unrealistic standards, Mitchell et al (2018) argue that it is a time characterised by personal growth, arising from the challenges experienced entering motherhood. Their findings suggest that despite a high number of mothers describing psychological hardship, most reported positive personal growth (89.7%) (Mitchell et al, 2018). The majority said that the self-compassion resource used in the study made it easier to live in the present moment (77.5%), act within their personal values (64.5%) and be more self-compassionate (60.7%). Additionally, in a cross-sectional study by Monteiro et al (2021), significant positive associations between self-compassion, resilience and maternal confidence were found.
Two studies carried out during the COVID-19 pandemic (Fernandes et al, 2021; Muramoto et al, 2022) emphasise the added stressors of pandemic restrictions when transitioning to motherhood, specifically in terms of lack of support and changes to maternal care. Fernandes et al (2021) suggested that mothers are more likely to feel overwhelmed in their new maternal role, which may lead to feelings of failure and being unable to accept mistakes. This was more evident at the first assessment point (in the height of restrictions).
Muramato et al (2022) emphasise the need for support to overcome feelings of uncertainty and to aid a sense of security. They found that compassion from a partner and mother may exert a buffer effect on the relationships between ‘difficult experiences’ (such as the global pandemic) and self-compassion postnatally. It may be the case that ‘compassion from others’ mitigates the stress response, allowing women to view their difficulties more subjectively and lead them to become more self-compassionate (Muramato et al, 2022).
According to Fernandes et al (2021) and Muramoto et al (2022), while the risk of psychological challenges and social isolation in the postnatal period was exacerbated by the pandemic, the need for both social support and self-compassion to help develop maternal confidence and avoid psychological distress was paramount. Fernandes et al (2021) found that due to lack of social support mothers were left feeling overwhelmed in their mothering role and unable to cope with the demands of their baby, while making it harder for them to accept mistakes. With increased face-to-face contacts mothers should feel less isolated and more able to believe in their capabilities and, thus, be more compassionate towards themselves (Fernandes et al, 2021).
Moreover, both Carona et al (2022) and Monterio et al (2021) revealed that self-compassion may exert a protective effect on psychological wellbeing which could enable women to effectively deal with the stressors of the postpartum period and adapt to them sufficiently.
Promoting attachment and bonding through self-compassion
Six studies addressed the role of self-compassion in relation to mother-infant bonding and birth and breastfeeding experiences (Mitchell et al, 2018; Guo et al, 2020; Fernandes et al, 2021; Lennard et al, 2021; Monteiro et al, 2021; Whittingham and Mitchell, 2021). Several studies found that higher levels of self-compassion promoted mother–infant bonding, alleviated parenting stress and increased mindful parenting (Guo et al, 2020; Fernandes et al, 2021; Whittingham and Mitchell, 2021).
Guo et al (2020) used two validated self-report questionnaires to measure maternal warmth (part of the Comprehensive Parenting Behaviour Questionnaire) and infant wellbeing (Infant Behaviour Questionnaire short form). In contrast to the control group, who showed little change on mindfulness and mindful parenting, the intervention group demonstrated increased mindful parenting and maternal mindfulness. Specifically, a significant improvement was noted in maternal warmth, attention, affection, responsibility, negativity, and hostility which improved further at 1 year postpartum. No improvements were found in the rejection, orienting/regulatory capacity, and negative emotionality subscales. This may be because when infants receive more attention, they are generally more active, and it takes time for infants to regulate their emotions (Guo et al, 2020).
An improvement was also found in infant temperament, believed to be as a result of mothers becoming more mindful and because parental behaviours are known to influence infant wellbeing and temperament (Guo et al, 2020). Self-report questionnaires were used to assess infants' temperaments; therefore, it is possible that women may have different perceptions of these and results should be interpreted with caution. Monteiro et al (2021) agree that women who perceive their infant's temperament as easy, particularly in terms of their quality of sleep, generally have increased maternal wellbeing and psychological flexibility which may reduce the likelihood of developing depressive symptoms. Interestingly, Monteiro et al (2021) found that the younger the infant's age, along with greater maternal confidence and resilience, the greater the chances of women flourishing. This is contrary to Guo et al (2020) who suggest the older the infant and the longer women have to adapt in the postnatal period, the more mindful women become, and the more their overall wellbeing improves.
A significant positive association was found between self-compassion and mindful parenting and a significant negative correlation with impaired mother–infant relationships (Guo et al, 2020; Fernandes et al, 2021). Further, Fernandes et al (2021) found self-compassion to be indirectly associated with mother–infant bonding through two specific mediators: mindful parenting and parenting stress. The validated Postpartum Bonding Questionnaire was used to assess mother–infant bonding.
Interestingly, after controlling for depressive and anxious symptoms, differences in self-compassion and mother–infant bonding were not significant. This may have been due to the study being carried out during the COVID-19 pandemic where higher levels of depression could be possible. Not surprisingly, significant differences were noted when restrictions had eased with women reporting lower levels of depressive symptoms and more self-compassion and, consequently, less impaired mother–infant bonding. The lack of available support during COVID-19 lockdown had the potential to contribute to psychological challenges and have a negative impact on a women's ability to be emotionally responsive and in tuned with their infant. Findings emphasise the importance of support in the postnatal period, particularly during the time of COVID-19 restrictions, to reduce parenting stress and enable a more non-judgemental view of their challenges, making mothers feel more accepted (Muramoto et al, 2022).
Whittingham and Mitchell's (2021) explored birth and breastfeeding experiences and emotional availability in the mother–infant relationship. Emotional availability refers to the ‘ability of the mother–infant dyad to share an emotionally satisfying and attuned relationship’ (Whittingham and Mitchell, 2021: 719). Greater mutual attunement was associated with increased psychological flexibility and self-compassion and as a result more breastfeeding satisfaction and contentment with their infant.
Despite this, results align with two studies suggesting that self-compassion may be beneficial to help mothers cope with breastfeeding and birth experiences (Mitchell et al, 2018; Lennard et al, 2021). This provides tentative support to the idea that interventions grounded in self-compassion or CFT can be beneficial to improve post-natal wellbeing. The importance of acknowledging women's subjective experiences of birth and breastfeeding was noted as subjective experiences are stronger predictors of emotional availability and mother-infant bonding (Whittingham and Mitchell, 2021).
Monteiro et al (2021) suggest that bolstering women's beliefs in their ability to care for and meet the needs of their infant may increase maternal satisfaction and overall wellbeing. While some of these results must be interpreted within the limits of a cross-sectional study design, this evidence reinforces the suggestion that there may be greater need for support in the early postpartum period and beyond. Particularly in terms of addressing women's subjective experiences and promoting mother-infant bonding and emotional availability in this relationship.
Discussion
Results from this review affirm the idea that the transition to motherhood is associated with many psychological challenges and adjustments which often start in the antenatal period and extend beyond the first weeks and months following the birth of a child. This review offers innovative insights into how self-compassion can work to mitigate a number of psychological challenges that women may experience in this transition.
Consistent with existing knowledge demonstrating the relationship between self-compassion and increased parental wellbeing (Bluth and Neff, 2018; Garcia et al, 2022), results corroborate that self-compassion is significantly associated with increased maternal wellbeing and mother–infant bonding, as well as reduced postpartum depressive symptoms. It is noteworthy to consider, however, that all studies were of quantitative nature and may have failed to capture a richer insight into women's lived experiences and feelings around the reality of transitioning to motherhood.
It is also worth questioning the reliability of questionnaire-based research given that women may have different perceptions and understanding of various concepts, including self-compassion. Nevertheless, the results offer a richer understanding of the factors associated with the complexity of adjusting to motherhood and the emotional turbulence that this can bring. In line with current policy (Scottish Government, 2015; NICE, 2021), this narrative review highlights the crucial need for early intervention, as well as considering women's subjective experiences, to promote maternal wellbeing and combat potential adverse psychological outcomes.
Through the main themes identified, findings emphasise a number of challenges experienced in the transition to motherhood. Aligned with Neff's (2003a) theoretical construct demonstrating that cultivating self-compassion can reduce the effects of depression and anxiety, results from this review assert the notion that self-compassion may reduce the chances of developing PPD symptoms (Fonesca and Canavarro, 2018; Pedro et al, 2019; Guo et al, 2020; Lennard et al, 2021; Monteiro et al, 2021; Carona et al, 2022) and promote psychological wellbeing including mindful parenting, mindfulness, resilience and flourishing (Guo et al, 2020; Monteiro et al, 2021; Fernandes et al, 2021; Carona et al, 2022).
Results add support to Neff's (2003a) idea that self-compassion can promote a more accepting and non-judgemental attitude of one's thoughts and feelings that can help women acknowledge difficulties as part of the normal/common motherhood experience. Additionally, by cultivating a more self-compassionate attitude may help to manage current dysfunctional beliefs around motherhood with greater awareness and acceptance of difficulties. It is clear from the literature that more needs to be done in practice to help combat these challenges and negative feelings and experiences.
PHE (2021b) and the Scottish Government (2015) recommend that health visitors should prepare women for this life-changing adjustment; nevertheless, this evidence highlights a number of gaps that need to be addressed first. With the health visiting programme (Scottish Government, 2015; PHE, 2021a) centred around ‘building strong relationships from pregnancy’, health visitors are uniquely placed to promote this opportunity and positively support this transition. This may include normalising feelings around motherhood, having awareness of women's subjective experiences and encouraging confidence and resilience through promoting self-compassionate attitudes.
Health visitors and other health professionals who work with women from pregnancy and postnatally, such as midwives and family health nurses, should be provided with access to resources and training in self-compassion approaches and interventions to ensure this is embedded into practice. This may include embarking on training courses such as Neff's MSC programme or Gilbert's CFT diploma. Policy-makers should pay greater attention to new, emerging research that considers more open-minded approaches and combine these with conventional practice to help yield positive outcomes.
Aligned with NICE (2018) and the Scottish Government's (2017) perinatal mental health strategies, evidence suggests that interventions should be implemented at the earliest opportunity, including during pregnancy, as this is often when women begin to struggle with their mental health and women should have more mental capacity for engaging in self-compassion resources prior to the birth of their child. Health Promotion resources should be produced to help facilitate and support conversations around self-compassion practices.
As highlighted in the research, a women's subjective experiences must be addressed such as birth and breastfeeding experiences (Mitchell et al, 2019; Whittingham and Mitchell, 2021; Lennard et al, 2021), psychological vulnerabilities (Fonesca and Canavarro, 2018; Montiero et al, 2019; Pedro et al, 2019; Carona et al, 2022) and social support (Fernandes et al, 2019; Monteiro et al, 2019; Muromato et al, 2021).
Taking a holistic approach that addresses potential challenges and barriers, including bolstering support networks and providing support with additional needs (Scottish Government, 2015; PHE, 2021a), may encourage space and a greater opportunity to engage with self-compassion practices. This was particularly pertinent during the time of the COVID-19 pandemic, in which support was limited and psychological challenges were heightened (Fernandes et al, 2021; Muramoto et al, 2022).
When women receive the necessary support to cope with the demands of parenthood, this should help them retain their sense of identity by being able to meet their own basic needs while adjusting to a ‘new normal’ (Negron et al, 2013). Health professionals should take cognisance of women who may find it difficult to practise self-compassion due to lack of motivation or the inability to treat themselves with kindness, and acknowledge that it may take some time for women to change their perspective towards it.
Finally, considering the societal pressures to meet idealistic parenting standards, it seems crucial that women are presented with authentic and realistic advice around the challenges of the transition to motherhood so they can better prepare for this. Additional training opportunities for health visitors should enable them to have the skills necessary to facilitate self-compassion practices and integrate these into their practice.
Results demonstrate that the psychological challenges associated with the adjustment to motherhood may have a negative impact on the mother-infant bonding process (Guo et al, 2020; Fernandes et al, 2021; Whittingham and Mitchell, 2021). This is in line with research carried out by Lutkiewicz et al (2020) who emphasise that PPD symptoms and parental stress are significantly correlated with a mother's ability to bond with her baby. Moreover, Lutkiewicz et al (2020) highlight the importance of early identification of maternal mental health problems so that interventions can be facilitated to promote healthy bonding. Findings suggest that self-compassion can promote maternal warmth, affection, attention and responsibility, which resonates with Bowlby's (1951) attachment theory that postulates ‘a warm, intimate and continuous relationship with a mother figure’ is the key to mother–infant bonding.
Health visitors should educate women on the importance of the early bonding process, which can be enhanced by cultivating self-compassion skills that promote secure attachments and positive outcomes for both the infant and caregiver.
Results found no correlation between self-compassion and PPD symptoms in those who had existing self-critical styles of thinking (Monteiro et al, 2019; Pedro et al, 2019). These results were relatively unexpected given that Neff's (2003a) theory focuses on cultivating an understanding, kind and compassionate approach towards oneself while being accepting and non-critical of current challenges and adversities. Nevertheless, findings are congruent with other studies (Vliegen and Luyten, 2009; Beato et al, 2022) that have demonstrated that women with higher levels of self-criticism are more likely to develop PPD symptoms, and those with existing PPD symptoms are more likely to develop a self-critical way of thinking. Further research is needed to investigate this relationship and attention should be focused on supporting mothers with self-critical thoughts such as anger and hatred to better promote their psychological state and prevent adverse outcomes.
Another significant finding was the relationship between self-compassion, psychological flexibility and maternal wellbeing. Aligned with other studies (Mendes et al, 2021; Pyszkowska and Rönnlund, 2021), both self-compassion and psychological flexibility were found to be strong predictors of positive mental health outcomes. Most findings from this review indicate that each concept (self-compassion and psychological flexibility) has its own unique place in promoting maternal wellbeing. Results suggest that self-compassion interventions should incorporate ABT to improve wellbeing, which cannot be ascertained when self-compassion interventions or CFT are used in isolation.
This study has the potential to contribute to health visiting and family health nursing practice in a way that highlights how care and support should be delivered to support women, as well as informing self-compassion interventions that can enhance maternal wellbeing, both in the preparation for motherhood and in the postnatal period. Future research should consider alternative methods of participant recruitment as the self-selected samples in this study meant that participants came from similar sociodemographic profiles and may have had more interest in the topic, thus failing to represent the wider population.
Conclusion
Health visitors play a pivotal role in supporting women's transition to motherhood. The promotion of self-compassion practices could help buffer the effects of psychological challenges and promote mother–infant bonding in this transition. Health visitors, as well as other health professionals working with women from pregnancy through to the postnatal period, should be provided with the necessary skills and training to promote and facilitate self-compassion practices. Future studies with more robust methodologies are needed to build on current findings. Users' perspectives should be considered through qualitative research.