Peripartum women are exposed to a variety of stressors that have adverse health consequences for the maternal–child dyad (e.g., impaired bonding). To combat these adverse health consequences, heart rate variability biofeedback (HRVBF) may be implemented by holistic nurses to aid peripartum women experiencing a high level of stress. A systematic review was completed using the guidelines established in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. To be included in the review, studies had to meet the following criteria: (a) published scientific articles, (b) studies published in English, (c) experimental, quasi-experimental, or case reports, (d) use of HRVBF as the main treatment, (e) use of psychological stress as a dependent variable, and (f) studies published until December 2017. The major findings of this review can be described as follows: (a) HRVBF and psychological stress in peripartum women are related concepts, (b) peripartum women who completed HRVBF report a reduction in stress compared with participants who did not receive HRVBF, and (c) there is currently no information on the effectiveness of HRVBF on psychological stress in the first and early second trimester of pregnancy. Overall, this systematic review of the literature provides objective evidence that HRVBF may be a potential beneficial adjuvant treatment for stress management in peripartum women.
AbbaszadehF.Kafaei AtrianM.Masoudi AlaviN.BagheriA.SadatZ.KarimianZ. (2013). Relationship between quality of life and depression in pregnant women. Nursing Midwifery Studies, 2, 193-197.
2.
AhmadS.TejujaA.NewmanK. D.ZarychanskiR.SeelyA. J. (2009). Clinical review: A review and analysis of heart rate variability and the diagnosis and prognosis of infection. Critical Care, 13, 232. doi:10.1186/cc8132
3.
American Holistic Nurses Association. (2013). Holistic nursing (2nd ed.; Scope and Standards of Practice). Silver Spring, MD: American Nurses Association.
4.
ArmstrongR. G.KennyG. P.GreenG.SeelyA. J. (2011). Diurnal variation in heart rate variability before and after maximal exercise testing. Chronobiology International, 28, 344-351. doi:10.3109/07420528.2011.559674
5.
BarutcuI.EsenA. M.KayaD.TurkmenM.KarakayaO.MelekM.. . . BasaranY. (2005). Cigarette smoking and heart rate variability: Dynamic influence of parasympathetic and sympathetic maneuvers. Annals of Noninvasive Electrocardiology, 10, 324-329. doi:10.1111/j.1542-474X.2005.00636.x
6.
BernatS. H.WooldridgeP. J.MareckiM.SnellL. (1992). Biofeedback-assisted relaxation to reduce stress in labor. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 21, 295-303. doi:10.1111/j.1552-6909.1992.tb01740.x
7.
BianchimM. S.SperandioE. F.MartinhãoG. S.MatheusA. C.LauriaV. T.da SilvaR. P.. . . DouradoV. Z. (2016). Correlation between heart rate variability and pulmonary function adjusted by confounding factors in healthy adults [Online]. Brazilian Journal of Medical And Biological Research, 49, e4435. doi:10.1590/1414-431X20154435
8.
BobkowskiW.StefaniakM. E.KrauzeT.GenderaK.WykretowiczA.PiskorskiJ.GuzikP. (2017). Measures of heart rate variability in 24-h ECGs depend on age but not gender of healthy children. Frontiers in Physiology, 83, 11. doi:10.3389/fphys.2017.00311
9.
BoudoulasK. D.BorerJ. S.BoudoulasH. (2015). Heart rate, life expectancy and the cardiovascular system: Therapeutic considerations. Cardiology, 132, 199-212.
10.
BrugneraA.ZarboC.TarvainenM. P.MarchettiniP.AdorniR.CompareA. (2018). Heart rate variability during acute psychosocial stress: A randomized cross-over trial of verbal and non-verbal laboratory stressors. International Journal of Psychophysiology, 127, 17-25. doi:10.1016/j.ijpsycho.2018.02.016
11.
CarneyR. M.FreedlandK. E. (2009). Depression and heart rate variability in patients with coronary heart disease. Cleveland Clinic Journal of Medicine, 76(Suppl. 2), S13-S17. doi:10.3949/ccjm.76.s2.03
12.
CarpenterR. E.EmeryS. J.UzunO.RassiD.LewisM. J. (2016). Influence of antenatal physical exercise on heart rate variability and QT variability. Journal of Maternal-Fetal and Neonatal Medicine, 30, 79-84.
ChamchadD.HorrowJ. C.NakhamchikL.ArkooshV. A. (2007). Heart rate variability changes during pregnancy: An observational study. International Journal of Obstetric Anesthesia, 16, 106-109. doi:10.1016/j.ijoa.2006.08.008
15.
ChristianL. M. (2012). Psychoneuroimmunology in pregnancy: Immune pathways linking stress with maternal health, adverse birth outcomes, and fetal development. Neuroscience & Biobehavioral Reviews, 36, 350-361. doi:10.1016/j.neubiorev.2011.07.005
16.
ClemensT.DibbenC. (2017). Living in stressful neighbourhoods during pregnancy: An observational study of crime rates and birth outcomes. European Journal of Public Health, 27, 197-202.
17.
CohenS.KamarckT.MermelsteinR. (1983). A global measure of perceived stress. Journal of Health Social Behavior, 24, 385-396.
18.
CornmanJ. B.CarrC. A.HeitkemperM. M. (2006). Integrating CAM into nursing curricula: CAM camp as an educational intervention. EXPLORE: The Journal of Science and Healing, 2, 226-231. doi:10.1016/j.explore.2006.03.040
19.
D’SilvaL. A.DaviesR. E.EmeryS. J.LewisM. J. (2014). Influence of somatic state on cardiovascular measurements in pregnancy. Physiological Measurement, 35(1), 15-29. doi:10.1088/0967-3334/35/1/15
20.
DipietroJ. A. (2012). Maternal stress in pregnancy: Considerations for fetal development. Journal of Adolescent Health, 51(2 Suppl.), S3-S8. doi:10.1016/j.jadohealth.2012.04.008
21.
DiPietroJ. A.ChristensenA. L.CostiganK. A. (2008). The Pregnancy Experience Scale: Brief version. Journal of Psychosomatic Obstetrics and Gynaecology, 29, 262-267. doi:10.1080/01674820802546220
22.
DiPietroJ. A.MendelsonT.WilliamsE. L.CostiganK. A. (2012). Physiological blunting during pregnancy extends to induced relaxation. Biological Psychology, 89, 14-20. doi:10.1016/j.biopsycho.2011.07.005
23.
DishmanR. K.NakamuraY.GarciaM. E.ThompsonR. W.DunnA. L.BlairS. N. (2000). Heart rate variability, trait anxiety, and perceived stress among physically fit men and women. International Journal of Psychophysiology, 37, 121-133. doi:10.1016/S0167-8760(00)00085-4
24.
DucheneP. (1989). Effects of biofeedback on childbirth pain. Journal of Pain Symptom Management, 4, 117-123.
25.
FöhrT.KujalaU.TolvanenA.MyllymäkiT.LappalainenR.Järvelä-ReijonenE.. . . RuskoH. (2017). Physical activity, heart rate variability-based stress and recovery, and subjective stress during a 9-month study period. Scandinavian Journal of Medicine & Science in Sports, 27, 612-621.
26.
Fuller-RowellT. E.WilliamsD. R.LoveG. D.McKinleyP. S.SloanR. P.RyffC. D. (2013). Race differences in age-trends of autonomic nervous system functioning. Journal of Aging Health, 25, 839-862. doi:10.1177/0898264313491427
27.
GandhiP. H.MehtaH. B.GokhaleA. V.DesaiC. B.GokhaleP. A.ShahC. J. (2014). A study on cardiac autonomic modulation during pregnancy by non-invasive heart rate variability measurement. International Journal of Medicine & Public Health, 4, 441-445. doi:10.4103/2230-8598.144131
28.
GevirtzR. (2013). The promise of heart rate variability biofeedback: Evidence-based applications. Biofeedback, 41, 110-120. doi:10.5298/1081-5937-41.3.01
29.
GiurgescuC.MisraD. P.Sealy-JeffersonS.CaldwellC. H.TemplinT. N.Slaughter- AceyJ. C.OsypukT. L. (2015). The impact of neighborhood quality, perceived stress, and social support on depressive symptoms during pregnancy in African American women. Social Science & Medicine, 130, 172-180. doi: 10.1016/j.socscimed.2015.02.006
30.
GoesslV. C.CurtissJ. E.HofmannS. G. (2017). The effect of heart rate variability biofeedback training on stress and anxiety: A meta-analysis. Psychological Medicine, 47, 2578-2586. doi:10.1017/S0033291717001003
31.
GoletzkeJ.KocaleventR. D.HansenG.RoseM.BecherH.HecherK.. . . DiemertA. (2017). Prenatal stress perception and coping strategies: Insights from a longitudinal prospective pregnancy cohort. Journal of Psychosomatic Research, 102, 8-14. doi:10.1016/j.jpsychores.2017.09.002
32.
GormanJ. M.SloanR. P. (2000). Heart rate variability in depressive and anxiety disorders. American Heart Journal, 140(4 Suppl.), 77-83.
33.
GroteN. K.BridgeJ. A.GavinA. R.MelvilleJ. L.IyengarS.KatonW. J. (2010). A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Archives of General Psychiatry, 67, 1012-1024. doi:10.1001/archgenpsychiatry.2010.111
34.
GuzilO. V.RomanchukA. P. (2017). Heart rate variability during controlled respiration after endurance training. Journal of Physical Education & Sport, 17, 2024-2029.
35.
Helicor. (2007). Stresseraser owner’s manual. New York, NY: Author.
36.
HendersonL. A.RichardC. A.MaceyP. M.RunquistM. L.YuP. L.GalonsJ. P.HarperR. M. (2004). Functional magnetic resonance signal changes in neural structures to baroreceptor reflex activation. Journal of Applied Physiology, 96, 693-703. doi:10.1152/japplphysiol.00852.2003
HobelC. J.GoldsteinA.BarrettE. S. (2008). Psychosocial stress and pregnancy outcome. Clinical Obstetrics Gynecology, 51, 333-348. doi:10.1097/GRF.0b013e31816f2709
39.
Jimenez MorganS.Molina MoraJ. A. (2017). Effect of heart rate variability biofeedback on sport performance: A systematic review. Applied Psychophysiology Biofeedback, 42, 235-245. doi:10.1007/s10484-017-9364-2
40.
KarakayaO.BarutcuI.KayaD.EsenA. M.SaglamM.MelekM.. . . KaymazC. (2007). Acute effect of cigarette smoking on heart rate variability. Angiology, 58, 620-624. doi:10.1177/0003319706294555
41.
KeenanN. LShawK. M. (2011). Coronary heart disease and stroke deaths: United States, 2006. MMWR Surveillance Summary, 60(Suppl.), 62-66.
42.
KempA. H.QuintanaD. S.GrayM. A.FelminghamK. L.BrownK.GattJ. M. (2010). Impact of depression and antidepressant treatment on heart rate variability: A review and meta-analysis. Biological Psychiatry, 67, 1067-1074. doi:10.1016/j.biopsych.2009.12.012
43.
KherJ.DesaiH. (2015). Spectral heart rate variability during late gestation in moderately anaemic pregnancy. National Journal of Integrated Research in Medicine, 6(2), 10-14.
44.
KimH. S.YoonK. H.ChoJ. H. (2014). Diurnal heart rate variability fluctuations in normal volunteers. Journal of Diabetes Science and Technology, 8, 431-433.
45.
KingS.LaplanteD. P. (2005). The effects of prenatal maternal stress on children’s cognitive development: Project Ice Storm. Stress: The International Journal on the Biology of Stress, 8, 35-45. doi:10.1080/10253890500108391
46.
KoenigJ.JarczokM. N.KuhnW.MorschK.SchaferA.HilleckeT. K.ThayerJ. F. (2013). Impact of caffeine on heart rate variability: A systematic review [Online]. Journal of Caffeine Research, 3, 22-37. doi:10.1089/jcr.2013.0009
47.
KudoN.ShinoharaH.KodamaH. (2014). Heart rate variability biofeedback intervention for reduction of psychological stress during the early postpartum period. Applied Psychophysiology Biofeedback, 39, 203-211. doi:10.1007/s10484-014-9259-4
48.
LeeI. S.ChoiE. S. (2006). Pelvic floor muscle exercise by biofeedback and electrical stimulation to reinforce the pelvic floor muscle after normal delivery. Taehan Kanho Hakhoe Chi, 36, 1374-1380.
LehrerP. M.GevirtzR. (2014). Heart rate variability biofeedback: How and why does it work?Frontiers in Psychology, 5, 756. doi:10.3389/fpsyg.2014.00756
51.
LehrerP. M.VaschilloE.VaschilloB.LuS. E.EckbergD. L.EdelbergR.. . . HamerR. M. (2003). Heart rate variability biofeedback increases baroreflex gain and peak expiratory flow. Psychosomatic Medicine, 65, 796-805. doi:10.1097/01.PSY.0000089200.81962.19
52.
LittleB. C.HayworthJ.BensonP.HallF.BeardR. W.DewhurstJ.PriestR. G. (1984). Treatment of hypertension in pregnancy by relaxation and biofeedback. Lancet, 1(8382), 865-867.
53.
LiuC.YangY.GangeS. J.WeberK.SharpG. B.WilsonT. E.. . . MerensteinD. (2009). Disclosure of complementary and alternative medicine use to health care providers among HIV-infected women. AIDS Patient Care and STDs, 23, 965-971. doi:10.1089/apc.2009.0134
54.
LobelM.DeVincentC. J.KaminerA.MeyerB. A. (2000). The impact of prenatal maternal stress and optimistic disposition on birth outcomes in medically high-risk women. Health Psychology, 19, 544-553.
55.
LobelM.Lacey CannellaD.DevincentC.SchneiderJ.GrahamJ. E.MeyerB. A. (2008). Pregnancy-specific stress, prenatal health behaviors, and birth outcomes. Health Psychology, 27, 604-615.
56.
LowensteinL.MustafaM.BurkeY. Z.MustafaS.SegalD.WeissmanA. (2014). Steep Trendelenburg position during robotic sacrocolpopexy and heart rate variability. European Journal of Obstetrics, Gynecology, and Reproductive Biology, 178, 66-69. doi:10.1016/j.ejogrb.2014.03.046
57.
MahendruA.EverettT.WilkinsonI.LeesC.McEnieryC.MahendruA. A.. . . McEnieryC. M. (2012). Maternal cardiovascular changes from pre-pregnancy to very early pregnancy. Journal of Hypertension, 30, 2168-2172. doi:10.1097/HJH.0b013e3283588189
58.
MarcI.TourecheN.ErnstE.HodnettE. D.BlanchetC.DodinS.NjoyaM. M. (2011). Mind–body interventions during pregnancy for preventing or treating women’s anxiety. Cochrane Database of Systematic Reviews, No. 7, CD007559. doi:10.1002/14651858.CD007559.pub2
59.
MarianoC. (2013). Holistic nursing (Scope and Standards of Practice). Silver Spring, MD: American Nurses Association.
60.
McKeeK.SeplakiC.FisherS.GrothS.FernandezI. (2017). Cumulative physiologic dysfunction and pregnancy: Characterization and association with birth outcomes. Maternal & Child Health Journal, 21, 147-155. doi:10.1007/s10995-016-2103-0
61.
MelchiorreK.SharmaR.KhalilA.ThilaganathanB. (2016). Maternal cardiovascular function in normal pregnancy: Evidence of maladaptation to chronic volume overload. Hypertension, 67, 754-762.
62.
MoherD.LiberatiA.TetzlaffJ.AltmanD. G. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med, 6, e1000097. doi:10.1371/journal.pmed.1000097
63.
MulderE. J.RoblesdeMedinaP. G.HuizinkA. C.Van den BerghB. R.BuitelaarJ. K.VisserG. H. (2002). Prenatal maternal stress: Effects on pregnancy and the (unborn) child. Early Human Development, 70, 3-14.
64.
NicholsK.GergelyG.FonagyP. (2001). Experimental protocols for investigating relationships among mother–infant interaction, affect regulation, physiological markers of stress responsiveness, and attachment. Bulletin of the Menninger Clinic, 65, 371-379.
65.
NunanD.SandercockG. R.BrodieD. A. (2010). A quantitative systematic review of normal values for short-term heart rate variability in healthy adults. Pacing and Clinical Electrophysiology, 33, 1407-1417. doi:10.1111/j.1540-8159.2010.02841.x
66.
Reyes-LagosJ. J.Echeverría-ArjonillaJ. C.Peña-CastilloM. Á.García-GonzálezM. T.del Rocío Ortiz-PedrozaM.Pacheco-LópezG.. . . González-CamarenaR. (2015). A comparison of heart rate variability in women at the third trimester of pregnancy and during low-risk labour. Physiology & Behavior, 149, 255-261. doi:10.1016/j.physbeh.2015.05.041
67.
RoutledgeF. S.CampbellT. S.McFetridge-DurdleJ. A.BaconS. L. (2010). Improvements in heart rate variability with exercise therapy. Canadian Journal of Cardiology, 26, 303-312.
68.
SanghaviM.RutherfordJ. D. (2014). Cardiovascular physiology of pregnancy. Circulation, 130, 1003-1008. doi:10.1161/CIRCULATIONAHA.114.009029
69.
SauderK. A.JohnstonE. R.Skulas-RayA. C.CampbellT. S.WestS. G. (2012). Effect of meal content on heart rate variability and cardiovascular reactivity to mental stress. Psychophysiology, 49, 470-477. doi:10.1111/j.1469-8986.2011.01335.x
70.
SchäferD.NilM.HerzigD.EserP.SanerH.WilhelmM. (2015). Good reproducibility of heart rate variability after orthostatic challenge in patients with a history of acute coronary syndrome. Journal of Electrocardiology, 48, 696-702. doi:10.1016/j.jelectrocard.2015.04.004
71.
ShapiroG. D.FraserW. D.FraschM. G.SéguinJ. R. (2013). Psychosocial stress in pregnancy and preterm birth: Associations and mechanisms. Journal of Perinatal Medicine, 41, 631-645. doi:10.1515/jpm-2012-0295
72.
SiepmannM.HennigU. D.SiepmannT.NitzscheK.Mück-WeymannM.PetrowskiK.WeidnerK. (2014). The effects of heart rate variability biofeedback in patients with preterm labour. Applied Psychophysiology and Biofeedback, 39, 27-35. doi:10.1007/s10484-013-9238-1
73.
SinghJ. P.LarsonM. G.O’DonnellC. J.TsujiH.EvansJ. C.LevyD. (1999). Heritability of heart rate variability: The Framingham Heart Study. Circulation, 99, 2251-2254.
74.
SomersP. J.GevirtzR. N.JasinS. E.ChinH. G. (1989). The efficacy of biobehavioral and compliance interventions in the adjunctive treatment of mild pregnancy-induced hypertension. Biofeedback and Self-Regulation, 14, 309-318.
75.
SongH. S.LehrerP. M. (2003). The effects of specific respiratory rates on heart rate and heart rate variability. Applied Psychophysiology and Biofeedback, 28, 13-24. doi:10.1023/A:1022312815649
76.
SpenceJ. D.BarnettP. A.LindenW.RamsdenV.TaenzerP. (1999). Lifestyle modifications to prevent and control hypertension. 7. Recommendations on stress management. Canadian Hypertension Society, Canadian Coalition for High Blood Pressure Prevention and Control, Laboratory Centre for Disease Control at Health Canada, Heart and Stroke Foundation of Canada. Canadian Medical Association Journal, 160(9 Suppl.), S46-S50.
77.
St James-RobertsI.ChamberlainG.HaranF. J.HutchinsonC. M. (1982). Use of electromyographic and skin-conductance biofeedback relaxation training of facilitate childbirth in primiparae. Journal of Psychosomatic Research, 26, 455-462.
78.
StanevaA.MorawskaA.BogossianF.WittkowskiA. (2016). Pregnancy-specific distress: the role of maternal sense of coherence and antenatal mothering orientations. Journal of Mental Health, 25(5), 387-394. doi:10.3109/09638237.2015.1101425
79.
StanevaA. A.BogossianF.MorawskaA.WittkowskiA. (2017). “I just feel like I am broken. I am the worst pregnant woman ever”: A qualitative exploration of the “at odds” experience of women’s antenatal distress. Health Care for Women International, 38, 658-686. doi:10.1080/07399332.2017.1297448
80.
Strauss-BlascheG.MoserM.VoicaM.McLeodD. R.KlammerN.MarktlW. (2000). Relative timing of inspiration and expiration affects respiratory sinus arrhythmia. Clinical and Experimental Pharmacology and Physiology, 27, 601-606. doi:10.1046/j.1440-1681.2000.03306.x
81.
Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. (1996). Heart rate variability: Standards of measurement, physiological interpretation and clinical use. Circulation, 93, 1043-1065.
82.
TegegneB. S.ManT.van RoonA. M.RieseH.SniederH. (2018). Determinants of heart rate variability in the general population: The Lifelines Cohort Study determinants of heart rate variability [Online]. Heart Rhythm. doi:10.1016/j.hrthm.2018.05.006
83.
ThayerJ. F.FriedmanB. H.BorkovecT. D. (1996). Autonomic characteristics of generalized anxiety disorder and worry. Biological Psychiatry, 39, 255-266. doi:10.1016/0006-3223(95)00136-0
84.
ThayerJ. F.LaneR. D. (2000). A model of neurovisceral integration in emotion regulation and dysregulation. Journal of Affective Disorders, 61, 201-216.
85.
TsujiH.LarsonM. G.VendittiF. J.JrMandersE. S.EvansJ. C.FeldmanC. L.LevyD. (1996). Impact of reduced heart rate variability on risk for cardiac events. The Framingham Heart Study. Circulation, 94, 2850-2855.
86.
VasickoT.Prindesova-BusikovaJ.OsinaO. (2016). Analysis of autonomic nervous system functional age and heart rate variability in mine workers. Acta Medica Martiniana, 16, 22-29. doi:10.1515/acm-2016-0003
87.
VesterinenH. M.Morello-FroschR.SenS.ZeiseL.WoodruffT. J. (2017). Cumulative effects of prenatal-exposure to exogenous chemicals and psychosocial stress on fetal growth: Systematic-review of the human and animal evidence. PLoS ONE, 12, e0176331. doi:10.1371/journal.pone.0176331
88.
Von HolzenJ. J.CapaldoG.WilhelmM.StuteP. (2016). Impact of endo- and exogenous estrogens on heart rate variability in women: A review. Climacteric, 19, 222-228. doi:10.3109/13697137.2016.1145206
89.
VossA.MalbergH.SchumannA.WesselN.WaltherT.StepanH.FaberR. (2000). Baroreflex sensitivity, heart rate, and blood pressure variability in normal pregnancy. American Journal of Hypertension, 13, 1218-1225.
90.
WeinschenkS.BeiseR.LorenzJ.WeinschenkS. W.BeiseR. D.LorenzJ. (2016). Heart rate variability (HRV) in deep breathing tests and 5-min short-term recordings: Agreement of ear photoplethysmography with ECG measurements, in 343 subjects. European Journal of Applied Physiology, 116, 1527-1535.
91.
YaliA. M.LobelM. (1999). Coping and distress in pregnancy: An investigation of medically high risk women. Journal of Psychosomatic Obstetric Gynaecology, 20, 39-52.
92.
ZauszniewskiJ. A.Tsay-YiMusilC. M. (2013). Heart rate variability biofeedback in grandmothers raising grandchildren: Effects on stress, emotions, and cognitions. Biofeedback, 41, 144-149. doi:10.5298/1081-5937-41.3.06
93.
ZulfiqarU.JurivichD. A.GaoW.SingerD. H. (2010). Relation of high heart rate variability to healthy longevity. American Journal of Cardiology, 105, 1181-1185. doi:10.1016/j.amjcard.2009.12.022
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
