Effectiveness of Music on Perinatal Anxiety Among Pregnant Women and Newborn Behaviors: A Systematic Review and Narrative Synthesis

Abstract

Background:

Perinatal anxiety affects the antenatal woman, the growing fetus, and the newborn. This systematic review evaluated the effect of listening to music on perinatal anxiety among pregnant women and on newborn behaviors. No available reviews focus on interventions that include only classical forms of music or its benefit on perinatal anxiety among low-risk pregnant women or on newborn behaviors.

Methods:

We included peer-reviewed primary research studies on the effect of music on perinatal anxiety, published in English, between January 2010 and August 2022. PubMed, Embase, Scopus, and ProQuest were searched using specific keywords, resulting in 225 studies for screening by title, abstract, and full text. Two independent reviewers screened them and assessed the quality of the included randomized controlled trials (RCTs) using Cochrane’s Risk of Bias 2.0 tool (RoB2) and non-randomized controlled trial studies using the Joanna Briggs Institute Critical Appraisal tool. Due to the heterogeneity of outcome measures, the review’s findings were summarized qualitatively.

Results:

Nine studies with 1646 pregnant women and one with 260 pregnant women and their neonates were included. Results of all studies suggest that listening to classical music reduces the anxiety levels among pregnant women, as measured by the State-Trait Anxiety Inventory (STAI). Only one study reported the beneficial effect of antenatal exposure to music on improving newborn behaviors like orientation (ES 1.13, 95% CI: 0.82–1.44, P < 0.0001) and habituation (ES 1.05, 95% CI: 0.53–1.57, P = 0.0001). The risk of bias was unclear in most of the studies.

Conclusions:

Listening to classical music during the perinatal period may be an effective non-pharmacological intervention for reducing anxiety and pain and improving sleep quality and newborn behaviors. There is a need to conduct further interventional studies on the types of music provided and their effects on perinatal health outcomes.

Registration of the Protocol:

The review was prospectively registered in PROSPERO 2021 CRD42021256806.

The perinatal period starts at 22 completed weeks of gestation and ends 7 completed days after birth, as defined by the World Health Organization. ¹ Anxiety during pregnancy is reported to increase the development of postnatal depression and affect the growing fetus’s well-being. ² Possible risk factors for developing anxiety during pregnancy are physiological (such as high-risk pregnancy and the process of childbirth), environmental (daily life stressors or responsibilities), physical and social support, socioeconomic status, and psychological factors.^3,4 Stress or anxiety developed during the antenatal period is considered pregnancy-specific stress/ anxiety, general stress/anxiety, stress related to major life events, and chronic stress/anxiety.^3,4

Anxiety during the antenatal period has been reported to increase premature birth and lower Apgar scores at birth, which may influence fetal neurobehavioral development and contribute to other obstetric complications. ⁵ Higher levels of pregnancy anxiety increase the fluctuation of cortisol release between 30 and 31 weeks of gestation, which can influence birth and infant outcomes through antenatal cortisol exposure. As cortisol can cross the placental barrier, it can affect the ongoing fetal development process. It may also have long-term effects on maternal anxiety or stress, which in turn may influence the newborn’s cognitive, behavioral, and emotional control.^6,7 Pregnancy-related anxiety, when developed during the antenatal period (at least during the first and last trimesters), is also found to be associated with children born with attention deficit hyperactivity disorders. ⁸ Also, pregnancy anxiety levels specifically increase in the third trimester compared to the first trimester. ⁹ Maternal anxiety may thus be associated with preterm birth, low birth weight, and adverse effects on fetal neurodevelopment and child outcomes. ¹⁰

Complementary and alternative therapies are effective non-pharmacological interventions to reduce anxiety among pregnant women. ¹¹ Included as a com- ponent in complementary and alternative therapies, music may be provided to pregnant women in many forms, like listening to music, singing, listening to music created using simple instruments, providing guided imagery with music, and receiving music therapy provided by health care providers or music therapists. Music cannot cure, treat, or prevent any disease, but it may help alleviate anxiety, depression, pain, and other symptoms caused by physical or mental illness.^12,13 Music can alter human physiological responses (such as respiration and pulse rate) and help ease patients’ anxiety by creating a calm, relaxing environment, enhancing their tolerance to pain, and reducing muscle hyper reactivity and physical tension. ¹⁴

Music is also cost-effective and can relieve stress and anxiety, reduce sleep problems, and improve cognitive function. Music therapy is the use of music or musical elements in the forms of sound, rhythm, melodies, or harmonies. Therefore, it aids communication; relationships; learning; movement patterns like walking, speaking, and grasping; expression; organization; and other relevant therapeutic objectives, thereby solving physical, emotional, mental, social, and cognitive needs.^15,16 Listening to music during the perinatal (antenatal, intranatal, and postnatal) period helps women reduce stress, anxiety, depression, the intensity of birth pains, and the risk of postnatal depression and improve emotional bonding with their newborn(s), with a significant impact on the baby’s well-being.^3,17 Listening to musical stimuli influences the fetal heart rate, fetal body movement, and the auditory function of fetuses and newborns.^18–21

Music has proven to be an effective complementary and alternative therapy to promote women’s psychological and emotional well-being throughout pregnancy.^17,22 Previous systematic reviews showed the effectiveness of various interventions pertaining to listening to music in controlling pain during childbirth; management of depression, stress, or anxiety; management of women with high-risk pregnancies; and emotional bonding with the growing fetus or newborn.^11,23–31 However, there is limited evidence to suggest the effect of listening to music on perinatal anxiety among low-risk pregnant women, their growing fetus, and/or their newborns in terms of their behaviors. Although any type of music may have anti-anxiety effects and provide soothing or relaxation to an individual, the most effective form of music in this regard is classical music. ³² The published systematic reviews did not specify if they included the classical form of music and its effect on perinatal anxiety or neonatal behavior.^11,26 Therefore, this review was conducted to explore the findings of original research studies that included classical music.

The following are the proposed questions:

1. Does listening to music reduce perinatal anxiety among pregnant women?

2. How does listening to music during the antenatal period affect the newborn’s behavior?

Methods

Literature Search and Eligibility Criteria

The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. ³³ We used four major electronic databases, such as PubMed, Scopus, Embase, and ProQuest, to search for the available studies published between January 2010 and August 2022. The search and selection of studies were limited to the last 10 years to allow for the inclusion of the latest and the most up-to-date evidence, to practically complete the review within the set time frame, and due to the limitation in institutional access to full-text articles of all published studies from the inception period. Relevant keywords, MeSH terms, medical terms, and Boolean operators were used according to the specific database (Supplementary Table S1). The search strategies were framed according to population, intervention, comparators/controls, and outcomes (PICO).

We included primary research studies published in English with music (active or passive listening) as an intervention administered during the perinatal period. Randomized Controlled Trials (RCTs) and non-RCTs that met the above eligibility criteria were included.

Studies without a complete text, those showing feasibility or preliminary results, protocols, conference papers, books, qualitative studies, reviews, and meta-analyses were all excluded.

Population/Participants: The review included studies conducted among low-risk (the absence of active maternal and fetal complications) pregnant women (both primipara and multipara) and their newborns. The keywords/MeSH terms for the participants included “pregnant women”, “mother”, “newborn”, and “neonate”. The review included only newborns born by women exposed to music during their fetal lives. We excluded studies conducted among high-risk pregnant women, preterm neonates, and other populations.

Interventions: They included only classical forms of music such as Haydn, Mozart, Beethoven, Symphonic music, Turkish classical music (Maqam music, Acemasiran mode), Garbh Sanskar, Bach, Wolfgang Schulz, Debussy, Boccherini, Lounge music, “Musical journey through pregnancy”, and prenatal music albums with the sound of nature. We excluded studies that used only lullabies, contemporary music (such as Jazz, Pop, Country, Folk, Rock styles, Blues), vocal music, or non-classical interventions.

Comparison: We included studies in which the comparator involved interventions without music, such as reading a magazine, sitting in the waiting room, and receiving standard or routine care.

Outcome Measures: Our outcomes of interest were perinatal anxiety among pregnant women and newborn behaviors. The keywords or MeSH terms used for the outcome of interest were “perinatal anxiety”, “anxiety”, “pregnancy-related anxiety”, “neonate behavior”, and “newborn behavior”.

Screening and Selection of Studies

Following the removal of duplicate studies manually and using Rayyan software, ³⁴ the titles, abstracts, and full texts of the remaining studies were independently screened by two researchers, MK and SRB. Any queries or conflicts raised during the screening and selection were addressed and discussed with other researchers to reach an agreement on the final decision for inclusion/exclusion.

Data extracted from the included studies, using a proforma designed for the study, were author name(s), year of publication, country, study design, sample characteristics, intervention (type of music and duration), comparators, instruments used, outcome measures, and results or key findings.

Assessment of Methodological Quality

Two independent reviewers, MK and SRB, assessed the quality of the included studies, and conflicts were resolved following review and discussion with the third reviewer, SKP, to arrive at a final decision. For RCTs, the risk of bias was assessed using Cochrane’s Risk of Bias 2.0 tool (RoB2), which rates the studies’ overall risk of bias as ‘low’, ‘of some concern’, or ‘of high risk’ on the five domains, that is, randomization process, deviation from the intended intervention, missing outcome data, measurement of the outcome, and selection of the reported result. ³⁵ For the non-RCT studies, the risk of bias was assessed using the Joana Briggs Institute’s (JBI) critical appraisal tool for quasi-experimental studies. ³⁶

The review was prospectively registered in PROSPERO 2021 (CRD42021256806).

Results

A total of 225 studies were retrieved, out of which 79 were duplicates (59 duplicate studies were detected by Rayyan software and 20 manually) (Figure 1). “Titles and Abstracts” screening identified 13 possible studies for full-text review, out of which three were excluded (two were conducted among high-risk pregnant women,^37,38 and for one, the full-text was not available in English ¹⁸ ), leaving ten studies for assessment of methodological quality (Table 1 and Supplementary Table S2).

Figure 1. PRISMA Flowchart of the Included Studies.

PRISMA - Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Table 1.

Description of the Characteristics of the Non-RCT Study Included in the Review.

Study, Country, Year of Publication	Sample Size, Sample Characteristics, Study Design	Intervention: Type of Music, Duration	Comparators	Outcome Measures	Results	Comments
Shin et al. 45 South Korea, 2011	N=233 (music group=117, control group=116) Low-risk multipara and primipara, range of age 30–34 years. Quasi-experimental study.	Prenatal music album with the sound of nature. Listening to music for 30 min.	No music.	Anxiety levels were assessed using STAI score during TVUS.	Listening to music during transvaginal ultrasound showed reduced anxiety levels compared to the control group (t = –2.02, p = 0.44).	The study adopted a nonequivalent control group non-synchronized design.

STAI, State-Trait Anxiety Inventory; TVUS, transvaginal ultrasound scan.

Methodological Quality

Out of ten studies, nine were RCTs. The methodological quality of each study was assessed using RoB2. The details are as follows:

Randomization Process: In one study, ⁴³ allocation of the participants to the intervention and control groups was done day-wise, so we report this as high risk. In another study, ⁴⁰ the allocation sequence was done considering one week as a block, so we report this as having an unclear risk of bias.

Blinding: We found concerns in the reporting of the blinding of participants or personnel in four studies,^40,43,46,47 so we report them as an unclear risk. However, we found that five studies^{39,41,42,44,48} had followed the blinding process, so we report them as low risk.

Missing Outcome Data: A report related to missing outcome data was absent in one study, ⁴⁸ so we report it as high risk.

Measurement of the Outcomes: Six studies lacked clarity in reporting the blinding process followed during outcome assessment,^{39–41,44,46,47} so we report them as having an unclear risk of bias.

Selection of the Reported Result: All nine included studies have reported the findings adequately, so we consider this to be low risk (Figures 2 and 3).

Figure 2. Risk of Bias Graph: Pooled Risk of Bias for All Randomized Controlled Trial Studies Presented as Percentages.

Figure 3. Risk of Bias Graph: Review Authors’ Judgment of Each Risk of Bias Item Presented as Percentages Across All Included Randomized Controlled Trial Studies.

One non-RCT study, ⁴⁵ assessed using the JBI’s critical appraisal tool, had a low risk of bias (Table 2).

Table 2.

Risk of Bias for the Included Non-Randomized Controlled Trial Study (JBI Critical Appraisal Checklist for Quasi-Experimental Design Study).

Appraisal Checklist	Shin et al. 45 Study
Is it clear in the study what is the “cause” and what is the “effect” (i.e., there is no confusion about which variable comes first)?	Yes
Were the participants included in any comparisons similar	Yes
Were the participants included in any comparisons receiving similar treatment/care, other than the exposure or intervention of interest?	Yes
Was there a control group?	Yes
Were there multiple measurements of the outcome both pre- and postintervention/exposure?	No
Was follow up complete and if not, were differences between groups in terms of their follow up adequately described and analyzed?	Yes
Were the outcomes of participants included in any comparisons measured in the same way?	Yes
Were outcomes measured in a reliable way?	Yes
Was appropriate statistical analysis used?	Yes
Overall appraisal	Include
%	90

JBI, Joana Briggs Institute.

Summary of Socio- Demographic Characteristics

The ten studies were conducted in seven countries [Germany (n = 1), India (n = 1), Portugal (n = 1), South Korea (n = 1), Spain (n = 1), Taiwan (n = 1), and Turkey (n = 4)], with a total of 1646 pregnant women included in nine studies. One study included 260 pregnant women and their neonates. All pregnant women in the included studies were low-risk, had a singleton pregnancy, had an average age of 18–30 years, and included both multipara and primipara (Table 1 and Supplementary Table S2).

Characteristics of Music-Based Interventions Used

The classical form of music performed during the antenatal (all three trimesters of pregnancy) and intranatal (during the episiotomy procedure and cesarean section) periods was included. The duration of the music was between 20 and 50 min. Most of the music interventions were given at home settings or hospitals. In one study, nurses instructed the intervention; pregnant women in the music group were given recorded music on compact discs (CDs) and taught how to listen to music in their home settings and during the non-stress test (NST) procedure. ³⁹ Intervention in another study was pre-reordered CDs; the researcher informed the music group on how to listen to their selected music at home. ⁴⁰ In three studies, the interventions were given by nurses during NST procedures in clinical or hospital settings, using music the participants selected.^41–43 One study’s intervention was prerecorded CDs provided by researchers during the amniocentesis procedure at the hospital. ⁴⁴ Another study’s interven- tion included nurse-administered music using MP3 players during the transvaginal ultrasound scan (TVUS) procedure in the hospital. ⁴⁵ In two studies, interventions were carried out during childbirth in a hospital and provided by researchers using CDs, ⁴⁶ allowing the women to listen using earphones. ⁴⁷ One study included a prerecorded music audio cassette, and the participants were taught to listen to the music at home. ⁴⁸

Qualitative Synthesis

The included studies were heterogeneous in outcome measures, parity, type of music, duration of intervention, and gestation period. Hence, qualitative synthesis is used to present the findings of this review. The qualitative synthesis focused on the following two key elements: the effect of listening to music on perinatal anxiety (the primary outcome) and newborn behavior (the secondary outcome).

Effect on Perinatal Anxiety

Perinatal anxiety was assessed using the State-Trait Anxiety Inventory (STAI). Nine of the ten studies discussed the effect of perinatal anxiety. One study assessed the effect of listening to music compared to other interventions (reading magazines or sitting in the waiting room) on reducing the anxiety levels of women who underwent amniocentesis. The study reported that pregnant women of younger age with an early period of gestation had higher anxiety levels. After exposure to the assigned interventions, the music group had significantly lower anxiety levels than the other two. ⁴⁴

These findings were similar to those of the study by Shin et al., ⁴⁵ in which the authors assessed anxiety levels, stress, and maternal-fetal attachment during a TVUS, using 30 min of listening to music therapy as the intervention. The music group showed a significantly greater reduction in anxiety levels than the control group.

These were consistent with the findings of González et al., ³⁹ who assessed the effects of antenatal music stimulation on anxiety levels among pregnant women and its influence on childbirth. The music group was assigned to listen to music (an instrumental “musical journey through pregnancy”) at their home for 14 sessions. They were also offered to listen to one session during the NST procedure. The study revealed that the women had a significantly reduced level of anxiety, a shorter duration of the first stage of labor, and minimal use of medications during the intranatal period.

Similar to the above findings, Liu et al., ⁴⁰ who assessed the effect of listening to music on stress, anxiety, and sleep quality, using five prerecorded music and instructing the participants to listen to their preferred music before bedtime for 2 weeks, found that the STAI score had significantly reduced after the intervention.

Three studies performed the intervention during the NST procedure.^41–43 Kafali et al. ⁴¹ assessed the effect of music on maternal anxiety level, fetal movement, and fetal heart patterns. The interventions included were classical music (Haydyn, Mozart, and Beethoven), Turkish art music, and Turkish folk music. The intervention reduced the anxiety levels; however, it was not statistically significant. ⁴¹ Another study ⁴² assessed the effect of music therapy on maternal, fetal, and neonatal outcomes. The intervention was listening to music (instrumental classical Turkish Maqam music) during NST (at 36, 37, and 38 weeks of pregnancy). Compared to the baseline scores, the mean STAI scores had a significant reduction after the NST at 36, 37, and 38 weeks. This was consistent with the findings of Soylu et al., ⁴³ who assessed the effect of music on fetal well-being and maternal anxiety levels in a group assigned to listen to classical music, hymns, Turkish pop music, Kurdish music, Arabic music, and others (Turkish classical music, Turkish folk music, and Arabesque). The anxiety levels were measured before and after the NST procedure, and the music group had significantly lower STAI scores.

Out of the two studies conducted during childbirth,^46,47 one assessed the effect of music on pain and anxiety during the active phase of labor. After 30 min of listening to music, anxiety levels were assessed using the STAI and Faces Anxiety Scale. Significant reductions in STAI scores were found among the music group. ⁴⁷ This was similar to the findings of Hepp et al., ⁴⁶ who assessed the effects of listening to music on anxiety and stress levels during a cesarean section. The music group was assigned to listen to their preferred music (lounge, classical, jazz, and meditation music). Music was played from the time of entering the operating theater till the end of the procedure. Anxiety levels significantly decreased among the music group, with a significant reduction in cortisol levels during skin suturing.

All nine studies showed that listening to music was effective in reducing perinatal anxiety levels. Most studies (eight out of ten) included regular care for the control group, except one, ⁴⁴ which used two comparators like reading magazines or sitting in a waiting room. One study found that pregnant women who listened to music in their homes for 2 weeks showed a reduction in anxiety levels. ³⁹ Six studies reported that listening to music reduced anxiety levels in pregnant women who underwent certain procedures like NST,^39,41–43 TVUS, ⁴⁵ and amniocentesis ⁴⁴ during the antenatal period. Two studies found that when women listened to music intranatally, it reduced their anxiety levels during spontaneous vaginal childbirth ⁴⁷ as well as during cesarean section. ⁴⁶

Effect on Newborns’ Behavior

One study evaluated the effectiveness of maternal music exposure during the antenatal period and its influence on neonatal behaviors. The women in the music group were assigned to listen to the classical music ‘Garbh Sanskar’ before going to bed for more than 2 weeks during antenatal period. Babies born to the music group and those without exposure to music were assessed for their neonatal behaviors using the Brazelton Neonatal Behavioral Assessment Scale (BNBAS) in the early postnatal period. Neonates in the music group had significantly better performance on range and regulation of autonomic stability and behavioral states, specifically improving newborn behaviors like orientation (ES 1.13, 95% CI: 0.82–1.44, P < 0.0001) and habituation (ES 1.05, 95% CI: 0.53–1.57, P = 0.0001). ⁴⁸

The current review also revealed that pregnant women who had listened to music had improved quality of sleep, reduced labor pain, a higher rate of fetal movements, an increased number of accelerations in NST, a regulated basal fetal heart rate, and a minimum procedure time (a shorter period of the first stage of labor).^43,46,47 However, one review reported that listening to music during the antenatal period did not have any effect on fetal heart rate or body movements. ²⁸ Additional findings from one study were reduced pain scores, good contractions, and improved labor progress among the music group, but this study also reported that fetal outcomes such as fetal heart rate, pulse, and respiration were not affected by music. ⁴³

Discussion

The present review found that listening to classical music during the antenatal period and before obstetrical procedures effectively reduced anxiety levels (the primary outcome) among low-risk pregnant women. Moreover, listening to classical music during the antenatal period improved the newborn’s behavior (the secondary outcome). Our findings pertaining to the primary outcome are supported by a previous meta-analysis that revealed that listening to music significantly reduced anxiety levels among pregnant women (the standardized mean difference was –0.21 with 95% confidence intervals of –0.39 to –0.03). However, the studies included in that meta-analysis were conducted in different settings, covered both low-risk and high-risk pregnant women, and included effective forms of music such as lullabies, classical music, nature sounds, crystal music, Chinese folk music, and pleasant music. ³

The present review focused on the effect of listening to classical music on low-risk pregnant women’s anxiety level throughout pregnancy as measured by STAI and its influence on newborns’ behaviors assessed using BNBAS. We found that pregnant women who listened to music during the antenatal period showed an improved outcome in their newborns’ behaviors during the postnatal period. ⁴⁸ Consistent with these findings, a previous review ²⁵ found that listening to music (including lullabies, group singing sessions, the classical form of music, or patients’ preferred music) during pregnancy helped in relaxation; decreased anxiety, psychosocial stress, depression, and pain; improved mother-child bonding and quality of sleep; and helped in the regulation of physiological parameters such as heart rate and blood pressure. It was also observed that, other than classical music, women listening to their preferred music reduced anxiety levels, and that lullaby music also helped promote maternal-fetal bonding and well-being. However, the previous review differed from the current review for two reasons: the current review used only classical forms of music instead of all music interventions and included only low-risk pregnant women instead of women of all risk categories.

Dominguez-Solis et al. ¹¹ reviewed the effect of non-pharmacological interventions on the anxiety levels of a woman during pregnancy/antenatal period, labor, and postpartum. The interventions found to reduce anxiety were the following: in the antenatal period, behavioral activation, cognitive behavioral therapy, yoga, music therapy, and relaxation; during childbirth, aromatherapy; and during the postpartum period, antenatal training, massage by partners, self-guided book reading, and professional telephone assistance.

Moreover, the current review also found that listening to music by a pregnant woman undergoing the labor/delivery process significantly reduced anxiety levels.^46,47 Three reviews support this finding.^11,23,26

Additional clinical trials focusing on music as a non-pharmacological supportive intervention are required. Music is considered a low-cost intervention and cost-effective for caregivers. ⁴⁹ Music-based intervention is also considered an easy intervention with limited resources ⁵⁰ for reducing anxiety compared to other forms of intervention, thereby improving the pregnant woman’s perinatal mental health and the impact on their growing fetus(es) and the subsequent behaviors of their newborn(s).

Although limited to all original studies published in English over the last 10 years, evaluating the effectiveness of listening to classical music on the anxiety levels of low-risk pregnant women adds a unique strength to the current review. Our findings are derived from studies that were assessed as being methodologically strong.

Limitations

Our search did not consider any gray literature or manual searching of the list of references for included studies. The interventions used in the included studies were classical music (Haydn, Mozart, and Beethoven), Turkish classical music (Turkish folk and Maqam), musical journey through pregnancy, natural sound, and ‘Garbh Sanskar’, and findings are limited to the effectiveness of these interventions only.

Findings on the effect of music on newborn behaviors are based on only one study’s findings, which may limit their generalizability. The available studies conducted in India included music-based interventions that were exposed only to newborns born with complications or preterm newborns admitted to neonatal intensive care.^51,52

Multiple studies have been conducted in India in the past using music-based interventions.^53–55 However, there is limited or no evidence from studies done in India pertaining to the effectiveness of Indian classical music on low-risk pregnant women. Future research can evaluate the effects of listening to Indian classical music, in the forms of non-vocal recorded or live music played by music therapists or music therapy administered by healthcare personnel, in promoting mental health and assess its benefits for all pregnant women and their newborns.

Conclusion

This systematic review suggests that listening to music reduces perinatal anxiety and improves neonatal behaviors. The findings suggest that music as a supportive intervention, when provided throughout the perinatal period, can enhance positive outcomes for pregnant women, their fetus(es), and their newborn(s). However, future interventional studies using music should consider and focus on a rigorous assessment of the impact of the type(s) of music used and its genre, the importance of music listening during the perinatal period, and the analysis of its effect on perinatal health outcomes as well as mental health well-being.