Interventions among Pregnant Women in the Field of Music Therapy: A Systematic Review

Objective  To investigate in the literature the studies on the benefits of music therapy interventions among pregnant women in the prenatal, delivery and postpartum periods. Data Sources  The search for articles was carried out in the following electronic databases: VHL, LILACS, SciELO, Portal CAPES, PsycINFO, ERIC, PubMed/Medline, and journals specialized in this field: Revista Brasileira de Musicoterapia (“Brazilian Journal of Music Therapy”) and Voices . Study Selection  Descriptors in Portuguese ( musicoterapia , gravidez , gestantes , revisão ), English ( music therapy , pregnancy , pregnant women , review ) and Spanish ( musicoterapi a, embarazo , mujeres embarazadas , revisión) were used. The search was delimited between January 2009 and June 2019. The process of selection and evaluation of the articles was performed through peer review. Data Collection  The following data were extracted: article title, year of publication, journal, author(s), database, country and date of collection, purpose of the study, sample size, type of care, intervention, instruments used, results, and conclusion. The data were organized in chronological order based on the year of publication of the study. Summary of the Data  In total, 146 articles were identified, and only 23 studies were included in this systematic review. The articles found indicate among their results relaxation, decreased levels of anxiety, psychosocial stress and depression, decreased pain, increase in the maternal bond, improvement in the quality of sleep, control of the fetal heart rate and maternal blood pressure, and decreased intake of drugs in the postoperative period. Conclusion  Music therapy during the prenatal, delivery and postpartum periods can provide benefits to pregnant women and newborns, thus justifying its importance in this field.


Introduction
Pregnancy is a period characterized by physical, hormonal and emotional changes. 1 The birth marks a new phase in the life of the woman, the puerperium, which ends when the woman's body returns to the stage previous to pregnancy. 2 Pregnant women are especially affected by stress during pregnancy, childbirth and the postpartum period. Several art forms have been studied in order to evaluate their relaxing potential and their effects on the physiology of individuals. Music has been a constant target of research regarding its effects on the most diverse groups of patients. The existing data point to its importance in improving the concentration, attention and physical endurance of the patients. 3 And it has been shown to be beneficial in the emotional, intellectual, psychological, physiological and social fields, 4 in addition to having specific beneficial effects regarding depression and normal postpartum pain, anxiety and greater satisfaction in the postpartum period. 5 In pregnant women, these effects can be explained by a series of physiological mechanisms that are activated at the moment of listening to music, which remain activated for a prolonged period. As the main neurotransmitters related to music therapy, natural serotoninwhich creates a state of relaxationand acetylcholine have their potential boosted, with an effect of reducing the heart rate and blood pressure, and increasing blood flow to noble organs. 6 Listening to music also causes the glucocorticoids such as cortisol, which are strongly related to the state of stress, to have a reduced release, with a consequent benefit regarding fetal development, since they are able to cross the placental barrier and directly interfere in fetal physiology. 7 A form of treatment that aims at the physical, mental and psychological integration of the patient, music therapy is also one of the methods used as a support in pregnancy. Some studies in the literature have shown that musical interventions have an insignificant effect on the reduction in stress during pregnancy 8 and in the decrease in pain during childbirth. 9 However, there a significant improvement in the levels of anxiety during pregnancy and labor has been observed. 8,9 A systematic review by Van Willenswaard et al. 8 points out that no study on music therapy was found during their detailed search, diverging from other systematic reviews that examined interventions made by a music therapist. In view of the divergent results in the literature, the importance of the present study is evident. Therefore, the aim of the current study was to investigate in the literature about the benefits of music therapy interventions among pregnant women in the prenatal, delivery and postpartum periods.

Type of study
The present is a systematic literature review performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. 10 The

Resumo
Objetivo Investigar na literatura os estudos sobre os benefícios das intervenções musicoterapêuticas em gestantes no pré-natal, parto e pós-parto. Fontes dos dados A busca dos artigos foi realizada nas seguintes bases de dados eletrônicas: BVS, LILACS, SciELO, Portal CAPES, PsycINFO, ERIC, PubMed/Medline e revistas especializadas da área: Revista Brasileira de Musicoterapia e Voices. Seleção dos estudos Utilizaram-se descritores em português (musicoterapia, gravidez, gestantes, revisão), em inglês (music therapy, pregnancy, pregnant women, review) e em espanhol (musicoterapia, embarazo, mujeres embarazadas, revisión). A busca foi delimitada de janeiro de 2009 até junho de 2019. Os processos de seleção e avaliação dos artigos foram realizados por revisão por pares. Coleta de dados Os seguintes dados foram extraídos: título do artigo, ano da publicação, revista, autor(es), base de dados, país e data da coleta, objetivo do estudo, tamanho da amostra, tipo de atendimento, intervenção, instrumentos utilizados, resultados, e conclusão. Os dados foram organizados em ordem cronológica a partir do ano de publicação do estudo. methodology of a systematic review has a high performance in identifying scientific evidence. According to the Oxford Center for Evidence-Based Medicine (OCEBM), 11 the typology of the systematic review is classified as level 1 out of 5 possible levels in the representation of evidence, as it makes it possible to establish a panorama on the studied topic. We used the The State of the Art through Systematic Review (StArt) software, developed by the Software Engineering Research Laboratory (Laboratório de Pesquisa em Engenharia de Software, LAPES, in Portuguese) of Universidade Federal de São Carlos, Brazil, which supports the researcher in the systematic review.

Search strategy
The research question was formulated using the "PICO" framework, which means population (participants), intervention (or exposure, for observational studies), comparison, and "outcome", with some researchers preferring to add and "S" (for study design), therefore naming it PICOS. 12 The search was carried out in the following electronic databases: Biblioteca Virtual de Saúde (BVS), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Scientific Eletronic Library Online (SciELO), Portal CAPES, PsycINFO, Education Resources Information Center (ERIC), PubMed/Medline, and in journals specialized in the field: Revista Brasileira de Musicoterapia ("Brazilian Journal of Music Therapy") and Voices.
It was delimited from January 2009 to June 2019, considering articles published in Portuguese, English and Spanish. We used descriptors in Health Sciences (DeCS), Medical Subject Headings (MeSH) and Thesaurus in Portuguese (musicoterapia, gravidez, gestantes, revisão), in English (music therapy, pregnancy, pregnant women, review) and in Spanish (musicoterapia, embarazo, mujeres embarazadas, revisión). Descriptors were combined using the Boolean operators "AND" and "OR".
The articles were selected and evaluated by peer review and organized in phases: in the first phase, an initial analysis of the titles of the manuscripts was carried out; in the second phase, an evaluation of the abstracts was performed. In the third phase, all selected articles were obtained in full, and were subsequently examined according to the established inclusion and exclusion criteria.

Inclusion and exclusion criteria
The inclusion criteria were: original articles published in journals; and studies published from January 2009 until June 2019. The exclusion criteria were: theses, dissertations, monographs and studies that did not reach a minimum score of 18 points in the Downs and Black 13 checklist. If differences occurred during the review of the articles, new discussions were held until both reviewers agreed with the review.

Data extraction
The following data were extracted from the articles included: title, year of publication, journal, author(s), database, country and date of collection, objective of the study, sample size, type of care, intervention, instruments used, results, and conclusion. The articles were organized in chronological order based on the year of publication.
Results ►Figure 1 presents a flowchart of the search and selection process. In the analysis of the titles, 104 studies were selected and had their abstracts read; 50 studies were considered relevant, and their full texts were read. Out of these studies, 22 were excluded because they did not meet the eligibility criteria, and 7 references were excluded because they were not found in full. During the search, we included two articles found in the references of other articles. The electronic search generated 23 studies, with 8 articles on childbirth and postpartum, and 15 studies related to prenatal care (►Figure 1).

Discussion
Regarding the studies selected (►Table 1), 6 were from Turkey, and they reported decreased anxiety, FCF, PA, and postoperative pain; 5,14-18 3 were from Brazil, with results regarding the reduction of pain; 1,19,20 3 were from Taiwan, and they reported decreased stress and anxiety, improved quality of sleep, and decreased pain in the initial phase of labor 21-23 ; 3 were from Spain, with results describing decreased anxiety, PAS, PAD and HR and fetal reactivity 4,7,24 ; 1 was from Ireland, and the researchers achieved relaxation and increased bonding; 25 1 was from the United Kingdom, and it reported decreased anxiety and prenatal depression; 26 1 ws from China, and the researchers found decreased anxiety and physiological responses. 27 1 was from the United States, reporting reduced suffering before delivery 28 ; 1 was from India, and the researchers obtained fetal stimulation; 29 1 was from South Korea, reporting decreased anxiety and FCF 30 ; 1 was from Israel, reporting an increase in positive emotions and a decrease in negative emotions; 31 and 1 was from Iran, reporting lower pain scores. 32 The articles regarding the prenatal period, delivery, and the postpartum period report relaxation, decreased levels of anxiety, psychosocial stress, depression and pain, increased maternal bond with the baby, improved quality of sleep, control of fetal heart rate and maternal blood pressure, and decreased drug intake in the postoperative period. According to Carvalho, 33 music stimulates action and emotional expression in individuals, and prompts them to control states of physical and psychological homeostasis, having effects on physiology, behavior, cognition, emotions, and social interaction. 33 Regarding the prenatal period, 15 articles were analyzed, and 9 of them were relevant for the present review, for they dealt with anxiety in parturient women, and 4 out of these 9 studies were carried out during the nonstress test. According to Primo and Amorim, 34 during pregnancy women may experience anguish and anxiety due to the need to adapt to situations regarding maternity.
As for childbirth, seven articles were analyzed; four of them were related to pain during labor, six dealt with anxiety, and two reported a significant reduction in blood pressure. In the study by Gayeski and Brüggemann, 35 the perception of mothers regarding non-pharmacological methods for pain relief, the feeling of well-being, an having emotional support were reported to facilitate the parturition process. The authors state that there is a need to expand information on these methods throughout pregnancy, and they point out that there are more investigative studies on the use of these non-pharmacological methods for pain relief in women in labor, which aim to improve humanized actions

State-Trait Anxiety Inventory
All pregnant women in the study group reported that undergoing music therapy was easy, and that they would use music therapy in the next labor. After the intervention, the researchers observed a decrese in the grade of anxiety from high to medium in 2 patients, and from high to low in 1 patient When submitted to the intervention with music therapy, there was a reduction of anxiety in 3 patients in the study group. The parturients in the control group maintained the degree of anxiety throughout delivery The study group had significantly lower scores on the anxiety scale than the controls. There were no significant differences in systolic blood pressure and pulse rate between the two groups. The baseline fetal heart rate was significantly lower in the study group than in the controls. Acceleration frequency in fetal heart rate was significantly increased in the study group compared to the controls.   To verify and describe the effects of music in the labor of women assisted in five maternities; to verify the baby's behavior and reactions, when submitted to the melodies listened to by their mothers during pregnancy and labor, through the mothers' speeches, obtained in the first three months after delivery Brazil; 2008; initially, 87 pregnant women, but only 27 fulfilled the criteria for inclusion Group care. Duration: from prenatal care to the postpartum period. Description: musical awareness through a portable tape player, a series of 8 to 10 melodies was made available, selected especially for the study, in an intensity compatible with the acceptance of the group. The period for this experiment ranged from 35 to 45 minutes. In each session, a different series of melodies was listened to by the same group. The groups ranged from two to nine women. The information recorded on the sheets of each pregnant woman was used to record an individualized CD that was then delivered to each future mother with the recommendation to take it to the maternity ward at the time of delivery. During the time of observation of labor, every 2 hours, the music was suppressed for a period of 30 minutes. At the end of each of these periods, the elements of control of the evolution of labor were recorded on an observation sheet Not mentioned Only 12 parturients had their labor accompanied by the melodies of their choice, and they were interviewed in the postpartum period. As for the effect of music on the newborns, 20 mothers were interviewed; 1 of the 12 accompanied in labor did not have her stereo during the puerperium, and could not perform the observation with her baby Effects such as pain relief during contractions, help in reducing tension and fear, environmentalization of the parturient in the hospital, encouragement to prayer and spirituality have been reported.
Effects of music therapy on labor pain and anxiety in Taiwanese  In comparison with the controls, the study group presented significantly lower pain, anxiety and finger temperature during the latent phase of labor. However, no significant differences were found between the two groups in any of the outcome measures during the active phase This study provides evidence for the use of music as an intervention for pregnant women having labor pains and anxiety during the latent phase of labor. The results confirm that listening to music is an acceptable and non-medical coping strategy for pregnant women, especially for the reduction of pain and anxiety in the initial phase of labor  The study group had a lower level of postpartum pain and anxiety than the controls, and this was statistically significant at all time intervals. A significant difference was observed between the two groups in terms of satisfaction rate (p < 0.001) and the rate of postpartum depression on days 1 and 8 The use of music therapy during labor reduced anxiety and postpartum pain, increased satisfaction with the child's birth and reduced the rate of early postpartum depression. The study group experienced a significant increase in positive emotions and a significant decline in negative emotions and perceived threat of the situation when compared to the controls, who exhibited a decline in positive emotions, an increase in perceived threat of the situation, and no change in negative emotions. The study group also exhibited a significant decrease in systolic blood pressure compared to a significant increase in sdisatolic blood pressure and RF in the controls Listening to your favorite music just before a c-section can be an economic and emotionallyfocused coping strategy

POSTPARTUM PERIOD
The efficiency and duration of the analgesic effects of musical therapy on postoperative pain; Sen et al. 18 First, to discover the effect of music therapy on postoperative analgesia, and, secondly, to determine the duration of its effect.
Turkey; 2009; 70 pregnant women; group 1 with music ¼ 35; group 2 with no music ¼ 35 Individual care. Duration: 1 hour after surgery. Description: pregnant women who underwent csections were included and randomly allocated to two groups as follows: in group 1, pregnant women listened to music through a headset for an hour after surgery, while in group 2, they did not listen to any music during the same period. In the postanesthetic care unit, pregnant women were connected to a patient-controlled analgesia device (tramadol 3 mg/ml), which was adjusted to deliver a 20 mg bolus, with a 15 min blocking interval and a maximum 4-hour dose of 150mg. Postoperative pain was assessed using the visual analog scale and tramadol consumption was recorded at 4, in assisting parturient women, resstablishing the autonomy of women regarding labor and birth. 35 As for the results found, we could not perform an in-depth analysis of the methodology, since some studies were inaccurate, omitted data, and/or presented vague information. In addition to the incomplete methodology, some of the studies selected do not inform if they were conducted by music therapists, and most of them were performed by other health professionals. As a result, these studies did not have a theoretical framework for music therapy and did not follow a validated protocol. Low methodological quality was a common finding among systematic reviews that examine music-based interventions, with variations between the number of interventions and the duration of each session, which can interfere with the results, limiting the benefits that the pregnant woman and her fetus could obtain; therefore, it is necessary to think about comprehensive interventions that cover the prenatal, delivery and postpartum periods. 8 Carvalho 33 states that, in the practice of music therapy, music is not therapeutic, and is not used as an end in itself, but becomes a mediator of therapeutic individual or group relationship guided by a qualified and certified music therapist. It is important to remember that music therapy is included among the services provided by the Brazilian Unified Health System. In addition to maintaining its autonomy, it develops a practice consistent with the principles, seeking the necessary transformations, and without restricting its vision. The conviction regarding the contribution of studies on music therapy for the medical field brings another level of scientific knowledge necessary for the development of music therapy, thus answering existing questions. The need for the area to discuss some concepts is understood, contributing to clinical practice in different contexts. 36 Another aspect to be observed was that most of the studies found were conducted outside Brazil (only three Brazilian publications were found), which suggests that further studies in this area should be carried out. Based on the results of previous studies, Brandalise 37 states that there are few music therapists who publish articles and books reporting their findings and professional experiences, suggesting that there should be an incentive and preparation for the professional to engage in research.