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R E S E A R C H A R T I C L E Open Access
How group singing facilitates recovery from
the symptoms of postnatal depression: a
comparative qualitative study
Rosie Perkins
1,2*
, Sarah Yorke
1
and Daisy Fancourt
1,3,4
Abstract
Background: Previous research has demonstrated that making music can enhance positive emotions as well as
support positive psychological functioning. However, studies tend to be limited by lack of comparison with other
psychosocial interventions. This study builds on a three-arm randomised controlled trial (RCT) that demonstrated
that group singing for mothers and babies, but not group creative play, can lead to faster recovery from moderate-
severe symptoms of postnatal depression than usual care. The aim was to elucidate the mechanisms of the group
singing intervention in order to account for its recovery properties.
Methods: Qualitative research was conducted with 54 mothers who had experienced symptoms of postnatal
depression. Mothers completed a 10-week programme of either group singing or group creative play as part of the
wider RCT study. Data were collected via a series of 10 semi-structured focus groups conducted at the end of each
10-week programme. These were designed to elicit subjective and constructed experiences of the singing and play
interventions and were analysed inductively for emergent themes.
Results: Five distinctive features of the group singing emerged: (i) providing an authentic, social and multicultural
creative experience, (ii) ability to calm babies; (iii) providing immersive ‘me time’for mothers; (iv) facilitating a sense
of achievement and identity; (v) enhancing mother-infant bond.
Conclusions: Community group singing interventions may reduce symptoms of postnatal depression through
facilitating a functional emotional response rooted in the needs of new motherhood. These features are of
relevance to others seeking to implement creative interventions for maternal mental health.
Trial registration: NCT02526407. Registered 18 August 2015.
Keywords: Postnatal depression, Singing, Community, Music, Qualitative, Focus groups
Background
Postnatal depression (PND) is a debilitating condition
characterised by fatigue and low energy, insomnia and
anhedonia. Prevalence figures vary, but it is estimated
that PND affects 12.9% of mothers with at least 75,000
cases per year in the UK alone [1,2]. The impact of
PND can be severe, with suicide being a leading cause of
maternal death in the first year after childbirth [2], and
indications that PND can impact negatively on children’s
cognitive, socio-emotional and behavioural development
[3–5]. Additionally, PND can continue to impact on
how mothers parent their children after the postpartum
period [6], and maternal PND can impact negatively on
fathers’experiences of parenting [7].
Consequently, there has been significant attention
given to the best treatment models for PND. Boath &
Henshaw identified five main treatment areas: pharma-
cological; psychological and psychodynamic; pharmaco-
logical and psychological; hormonal; and social support
and relaxation [1]. In a 2013 systematic review, Dennis
& Dowswell demonstrated that psychosocial and psycho-
logical interventions significantly reduce the number of
women who develop PND, with professionally-based
* Correspondence: rosie.perkins@rcm.ac.uk
1
Centre for Performance Science, Royal College of Music, Prince Consort
Road, London SW7 2BS, UK
2
Faculty of Medicine, Imperial College London, London SW7 2AZ, UK
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Perkins et al. BMC Psychology (2018) 6:41
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home visits, telephone peer support and interpersonal
psychotherapy showing promise [8]. Focusing on social
support, Boath & Henshaw reviewed a number of social
interventions including support groups, massage therapy
and relaxation. While there were methodological flaws
in the impact evidence provided, their recommendation
was for further research to be conducted into a field that
may well prove fruitful [1]. Subsequently, Honey,
Bennett, & Morgan reported a controlled psycho-educa-
tional group intervention that reduced scores on the Ed-
inburgh Postnatal Depression Scale (EPDS), but led to
no changes in perceptions of social support, coping or
marital relationships [9]. Creative social interventions
have also received attention. Perry, Thurston, & Osborn
reported that a creative arts group was felt by mothers
to be a relaxed safe space [10] while Feeley, Bell, Hayton,
Zelkowitz, & Carrier showed that mothers perceived cre-
ative activities to provide social interaction and relax-
ation, decrease monotony and meet other personal
needs [11].
Nonetheless, there remain a lack of psychosocial
creative intervention studies for women with PND. This
is perhaps surprising given the rapidly accumulating
evidence base for the positive role of the arts in mental
health and wellbeing [12–14]. Crawford, Lewis, Brown,
& Manning (2013) argued that the arts have an import-
ant place in mental health recovery, with the potential to
facilitate spaces of compassion, trust and shared under-
standing [15]. Indeed, studies from music [16–19], dance
[20,21] and art [22,23] have all contributed to evidence
that creative arts activities can support and enhance as-
pects of mental health. Singing, in particular, has re-
ceived research attention in relation to its health
benefits. Among the general public, singing has been
demonstrated to be a joyful, life-enhancing activity that
promotes wellbeing [24]. Among participants experien-
cing mental distress, singing has been shown to aid
recovery from serious or enduring mental illness [25],
and to facilitate personal and social impact as well as
functional outcomes for adults living with a chronic
mental illness or disability [26]. Further, von Lob, Camic,
& Clift demonstrated that group singing may be a useful
coping strategy for people living through times of adver-
sity [27]. Finally, Kreutz demonstrated that choral sing-
ing, but not chatting, can lead to increases in oxytocin, a
hormone associated with social bonding [28], a point re-
inforced by other studies [29,30].
Given the prevalence and severity of PND, and chal-
lenges with current treatment models such as low com-
pliance or lack of availability of suitably trained
professionals [2], new psychosocial community interven-
tions that build upon the existing evidence from arts
and health are timely. In particular, the potential for
singing to enhance bonding and to facilitate personal,
social and functional impact may directly address the
psychosocial risk factors connected with PND [31]. In
order to explore this, a randomised controlled trial
(RCT) was carried out [32]. This compared the effects of
a 10-week programme of group singing for new mothers
and their babies with 10 weeks of usual care. While pre-
vious studies have attempted to explain the mechanisms
behind music’s impact on health [33,34], these are lim-
ited by a lack of comparison with other, perhaps equally
effective, psychosocial interventions. Consequently, in
order to start to identify whether group singing per se is
an effective intervention or whether other group social
engagement is equally effective, a third arm was included
within the RCT comprising 10 weeks of group creative
play activities for mothers with symptoms of PND and
their babies.
The RCT revealed that symptoms of PND reduced sig-
nificantly faster amongst mothers in the singing group
with moderate-severe PND than for mothers in the
usual care group. Interestingly, there was no significant
difference in recovery between the singing and play
groups, as measured by EPDS scores at baseline, week 6
and week 10, or between the play and control groups
[32]. This suggests that group singing may have specific
benefits over and above the comparison psychosocial
intervention. Yet why this happened, and the mecha-
nisms underpinning the singing group, remain unknown.
As DeNora and Ansdell argued, RCTs run the risk of
‘the middle period, in other words the time in which
music is active, [being] left in shadow, which means that
the processes by which music might be “having an ef-
fect”are left in darkness, made mysterious’([35], no
page number). Indeed, that qualitative methods can in-
form and/or illuminate the results of an RCT is also ac-
knowledged within wider mental health research [36,
37]. Therefore, this study aimed to explore how the
group singing programme facilitated recovery from the
symptoms of PND through a qualitative analysis of the
experiences of mothers involved in the singing group
and comparisons with qualitative data from mothers in
the play group. The driving research question was:
What are the specific features of a community group
singing intervention known to support recovery from
symptoms of PND?
Methods
Procedure
The interventions
The RCT on which this study is based had three arms:
singing (experimental), creative play (comparison) and
usual care (control). RCT participants randomised to the
singing and play groups received free 60 min workshops
for them and their baby every week for 10 weeks in a
community children’s centre. Between 8 and 12 women
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plus their babies were recruited into each group, and five
singing groups and five play groups ran over a
six-month period in 2016 (n= 134 women completed
the RCT and provided full data). Groups were led by one
of two professional workshop leaders, specially recruited
to work on the project and with experience of facilitating
music and/or creative workshops in community settings.
The leaders were supported by a team of seven
specially-trained conservatoire students (one per each
10-week programme) and a project coordinator. The
two leaders led both singing and creative play sessions
to ensure consistency between the two conditions, and
worked together to plan materials and content. Singing
workshops involved mothers listening to songs sung by
the leader, learning and singing songs with their babies
and creating new songs together reflecting aspects of
motherhood. Creative play workshops involved mothers
engaging in sensory play with their babies, doing arts
and crafts and playing simple games together. Songs and
creative play activities were selected initially by the
workshop leader, but were also suggested by the partici-
pants. They were designed to be engaging for the
mothers as well as to support the mothers interacting
with their babies (e.g. through singing lullabies or
through designing art work based on the babies’hand-
prints). Participants provided background and demo-
graphic data as well as completing the EPDS at baseline,
week 6 and week 10. The median number of sessions
attended by women was eight for the singing group and
six for the play group. Full details of the RCT interven-
tion and outcomes are published elsewhere [32,38].
Methodology and methods of data collection
The study was underpinned by social constructionism,
assuming that the interventions were socially con-
structed and that the ways in which mothers reported
their salient features represented socially constructed
knowledge. The qualitative design therefore sought a
rich understanding of the features of the singing groups
as they were reported by the participants themselves. In
an attempt to isolate the specific features of the singing
group that might have led to a faster reduction in PND
symptoms, this study qualitatively compared the experi-
ences of mothers in the singing group with the experi-
ences of mothers in the play group.
Data were collected via a series of 10 focus groups,
divided equally between five focus groups for singing
and five focus groups for play. Focus groups were se-
lected to account for and capture the shared experiences
and understandings constructed within each group over
the 10-week period, although in one case there was only
one woman in attendance and so this was conducted as
a semi-structured interview. Focus groups were held im-
mediately or soon after the final session of each 10-week
programme, and women self-selected to attend. The
schedule concentrated on experiences of the interven-
tion and of new motherhood. Each focus group was
facilitated by one researcher, comprised on average 5.4
members (see Table 1), and lasted for between 16 and
26 min. The women attended with their babies and
therefore it was not appropriate to aim for a lengthy dis-
cussion, so the facilitator aimed to draw out the salient
points as efficiently as possible. This point may also
account for the low uptake in some groups, as attending
data collection with a baby included significant logistical
challenges. The focus groups were audio recorded with
permission and fully transcribed.
Participants
Participants included in the RCT were women with ba-
bies up to 40 weeks post birth who scored 10 or higher
on the EPDS at baseline, indicating some symptoms of
PND. Women were recruited through midwives, doc-
tors, perinatal psychiatrists, health visitors and General
Practitioners (GPs) in the Greater London area of the
United Kingdom (UK), as well as through social media,
leaflets and by a project coordinator in children’s centres
and in the local community. Women were excluded
from the RCT if their baby was outside the specified age
range (0–9 months), if a healthcare professional advised
that the intervention was not suitable for them (in prac-
tice we recorded no instances of this), if they did not or
could not provide informed consent or if they lived
outside the Greater London area. Women were not
expected to have any prior experience or knowledge of
singing. The UK National Health Service (NHS) South
East Scotland Research Ethics Committee approved the
project [reference 15/SS/016], and women gave written
informed consent.
All women who had participated in either the singing
or play groups as part of the wider RCT study were
invited to take part in this study through email and oral
communication at the sessions, and 54 women volun-
teered and consented to take part. Of these, four did not
provide data for the RCT study, meaning that of the 91
women who completed the singing and play workshops
in the RCT, 50 (55%) are represented in this study. Par-
ticipant characteristics are presented in Table 1; across
the 54 participants, 92% were first time mothers. Na-
tionalities represented in the sample included British,
French, Polish, Canadian, Columbian, Australian, Jap-
anese, Italian and North American.
Analysis
An inductive thematic analysis of the transcripts was
undertaken, acknowledging that there is as yet no one
established theory as to music’s effects on mental health.
The analysis proceeded in four main steps, specifically
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designed to provide a qualitative description [39] of the
constructed features of the singing intervention. First,
each transcript was read for familiarity before, second,
important units of meaning were selected and labelled
as emergent nodes in NVivo10 by the first author. The
units of meaning emerged inductively, but there was
a pre-determined focus on the features of the singing/
play activities constructed by the participants as im-
portant or meaningful. Third, the units of meaning
were cross-checked by the second author and addi-
tions or changes were discussed until consensus was
reached. Finally, the units of meaning were clustered
into sub-themes and, ultimately, overarching themes
that characterise the main features of the singing and
play activities, again cross-checked between two re-
searchers. Sub-themes were only classed as such when
they were represented across at least three of the five
respective focus groups. Reflexivity was addressed
through the interplay between the two analysts, both
of whom had a different position in relation to the
research and the participants: one as the lead
researcher, only in attendance at a small number of
the sessions and the second as the project coordinator,
in attendance at the vast majority of sessions over the
course of the RCT and the first point of contact for
the women. These different positions enabled both
analysts to engage with the data from their own start-
ing points, to recognise where different interpreta-
tions may lie and to agree a shared understanding of
the central themes.
Results
Four overarching themes identified the main features of
the two interventions: (1) activity mechanisms (features
of the activity itself ), (2) environmental mechanisms
(features of the environment created within the
sessions), (3) social mechanisms (social features of the
activity), and (4) psycho-emotional mechanisms (psycho-
logical and/or emotional features of the activity). A total
of 13 sub-themes emerged for the singing activity
(labelled S) and a total of 9 sub-themes emerged for the
play activity (labelled P), as summarised in Table 2.
In what follows, each overarching theme will be
described in turn. Sub-themes from the singing activity
will be presented alongside sub-themes from the play
activity, either to demonstrate consistent features
across the two activities or to illustrate differences.
Indicative quotations are used to support each
sub-theme, but interpretation is reserved for the follow-
ing discussion.
Activity mechanisms
Two activity sub-themes were consistent across both
singing and play. First, both groups reported that they
took away new skills or ideas from the activities
(sub-themes ‘new singing skills’and ‘new play ideas’):
I’ve found it very rewarding to have something to take
away with me each week as well. Coming in to being
a mum, and knowing a few songs, but not many, it’s
been really nice to learn songs [Sing 3].
I find it’s hard to imagine what to do creatively at
home with him and now we’ve got lots of really
creative ideas and I feel really inspired [Play 4].
Additionally, the play group reported that they appre-
ciated the variety of activities introduced across the
programme, and the flexibility with which the leaders
introduced activities to meet the needs of the group
(sub-theme ‘varied play activities’):
Table 1 Participant characteristics, organised by focus group
Focus Group Number of
participants
Age range of
mothers (years)
Mean number of
weeks post-birth
Mean EPDS score
1
Educated to
degree level
2
(%)
Household income
above £61 k (%)
With a
partner (%)
Sing1 9
Sing2 7
Sing3 7 22–43 19.36 14.51 88.57% 65.63% 91.43%
Sing4 5
Sing5 9
Play1 2
Play2 4
Play3 2 31–45 17.13 13.50 87.50% 75.00% 87.50%
Play4 8
Play5 1
3
Note 1: EPDS ≥10 indicative of possible symptoms of PND. EPDS ≥13 indicative of moderate-severe symptoms of PND
Note 2: Missing data points excluded from all % calculations
Note 3: Run as a semi-structured interview
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I think the nice thing about this group is that there is a
structure, but it’s been changing based on the feeling of
the day of the group and I think that is the best kind of
group. You have some kind of structure, but then it’s
very kind of –what’s the word –flexible [Play 1].
Second, across both groups, the activities learned
were reported to be transferable to other contexts
(sub-themes ‘singing outside of class’and ‘playing
outside of class’), whether at home or in other, some-
times challenging, circumstances:
It gives good ideas, when you go home and you’re like
‘oh I can play with this or make that’[Play 2].
Just this weekend we were back in the hospital and she
was having to have blood taken and she was going
mental, and I found myself singing the [folk lullaby] song
to her and it just gave me something that I might not
have ... I don’tknow,anurseryrhymeorsomething,I
might not have thought to do that, but something about
the repetitiveness and the fact that we’ve done it lots of
times.Itmadeadifferencetohavethat[Sing3].
One further feature emerged from the singing group,
which was seen as a form of ‘authentic’musical engage-
ment (sub-theme ‘authentic musical engagement’). Par-
ticipants felt that the groups were natural and calming
rather than commercial, with singing that drew upon di-
verse influences and music contributed both by the
leader and the participants:
I’ve been to some other music classes and things like
that and I’ve found them, really really cheesy and
almost like sensory overload by the end of it, and I
like how [leader] really pays attention to reading all
the babies and calming things down when she needs
to and livening it up when they’re ready for it and
stuff like that, and that it doesn’t feel like commercial
and cheesy, it feels very authentic, lovely music that
you can sing at home and not feel like a cartoon
character or something [Sing 2].
I love that they were quite global songs, like some are
Indonesian. That’s just a wonderful thing. To be in a
group of women singing global songs was quite
powerful I thought, so that was nice. Not just nursery
rhymes [Sing 4].
It’s been really nice to learn songs from different
cultures and know that you don’t necessarily need
to know what they mean, and they don’t need to
be English words. It’s just really lovely to know
different songs. You can use them with a little bit
more amusing music to calm [baby] and entertain
her [Sing 3].
Indeed, singing was seen as particularly beneficial
when it was ‘multimodal’,or presented in parallel with
another activity or resource:
[It] was really nice because it was combined - ‘I’ll read
her a book; I’ll sing her a song’. I never really thought
to do that; to actually bring those things together was
really nice [Sing 3].
To summarise, both groups felt that they learned new
activities to do with their babies and reported increased
confidence in doing so, as well as transferability outside
of the sessions. The mothers in the singing group appre-
ciated the authentic nature of the musical engagement,
and particularly the multicultural experience as well as
the use of other creative forms (such as stories) to
accompany the singing.
Table 2 Overarching themes and sub-themes
Themes
1
Sing sub-themes Play sub-themes
1. Activity mechanisms S1.1 ‘Authentic’musical engagement
S1.2 New singing skills
S1.3 Singing outside of class
P1.1 Varied play activities
P1.2 New play ideas
P1.3 Playing outside of class
2.Psycho-emotional mechanisms S2.1 Singing feels good
S2.2 Singing time for mums
S2.3 Singing as immersive
S2.4 Singing as achievement and purpose
S2.5 Singing supports bonding
P2.1 Play feels good
3. Social mechanisms S3.1 Singing impact on babies (calming)
S3.2 Singing as part of group
S3.3 Singing supports routine
P3.1 Playing as part of group
P3.2 Play supports routine
P3.3 Play impact on babies
4. Environmental mechanisms S4.1 Calm and inclusive singing environment
S4.2 Importance of singing leader
P4.1 Calm and inclusive play environment
P4.2 Importance of play leader
Note 1: Overarching themes are organised in terms of qualitative strength for the singing group. Sub-themes are organised into qualitative strength for the
singing and play groups respectively
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Psycho-emotional mechanisms
Across both groups, the activities were perceived as
enhancing positive emotions (sub-themes ‘singing feels
good’and ‘play feels good’):
It’s one of the activities that I look forward to and we
will certainly miss not coming to the sessions any
more (…) You feel kind of uplifted and pleased that
you came [Play 1].
It’s very uplifting. I leave here a lot happier than I
started [Sing 2].
Indeed, the activities were seen as particularly uplifting
or supporting in the context of a challenging time in
new motherhood:
No matter how bad the night you’ve had, no matter
how knackered you are, you’ve got to still just get out
and go to the group. Because it just makes you feel
better, don’t you think? [Sing 1].
I think parts of this course has actually helped me get
through the sort of darker elements of ... the darker
days of when it does feel endless, and when it does
feel tough….because it’s [the singing] a fixed thing, it’s
something I’ve got to get out of the house for, and it’s
something that I know that even if it’s crappy to get
here, actually once I’m here I know that it will be nice
and it will be a relaxed atmosphere. Whether she’s
crying, or whether she’s hungry, or whether she’s
sleeping, or whether she’s playing, all of that is
actually nice, and accepted, and fine [Play 5].
Despite this transversal experience, however, it was in
this theme of psycho-emotional mechanisms that the
most striking differences emerged between the singing
and the play groups.
First, women in the singing group perceived the session
as a time for mothers, and not only an activity designed
for their babies (sub-theme ‘singing time for mums’):
Everything is for the baby. You go to a class and it’s
always for the baby. Then you go out and meet for
coffee with your friends and you talk about your
babies. This [singing] is also good for the baby, but at
the same time it’s something for us as well [Sing 3].
Perhaps as a result of this perceived focus, the singing
sessions also emerged as a form of ‘me time’, where the
mothers could do an activity for themselves:
I hadn’t really thought about music really, helping me.
Especially at the beginning, you’re just surviving, I
think. But as soon as I started singing, it seemed to
relax me and really made a big difference to [my
baby] [Sing 4].
I think even though you’re actively participating it
almost does feel like a bit of down time as well. It’sa
bit of relaxing time. Another woman: Yeah, that’s why
it’s nice for mums as well [Sing 3].
Linked with these points, the singing sessions were
also reported to be immersive for some of the
mothers (sub-theme ‘singing as immersive’):
Because I’m still working, I work throughout, I’m
always using my mobile phone and it’stheone
time that I actually have never picked up my
phone. Normally in a class I’ll just check my
phone, I’ll just check my emails, but actually I
haven’t in this class. So that’s been hugely
beneficial to me, just to have that time out that I
don’t normally give myself [Sing 2].
I think it’s so helpful just being here, like being in the
present, instead of thinking about what am I going to
do in five minutes. I need to prep this, prep that (…)
Here, I’m just being here singing, and that’s a huge
difference [Sing 5].
Interestingly, some the features of the singing itself
seem to be instrumental to this immersion, facilitating a
musical experience that can also be aesthetically
absorbing:
With the singing I find that, I said before about
how it’s nice all the songs having a beginning and
an end, and I find the way [the leader] would
sometimes make it fast, sometimes slow,
sometimes loud, sometimes quiet, that’ssomething
really lovely about getting lost in the song in that
way [Sing 2].
Moving on, the singing also enabled a sense of achieve-
ment (sub-theme ‘singing as achievement and purpose’):
Sometimes it makes me anxious that you are doing
all that is expected, taking care of your baby, but
other than that you are doing nothing (…)Soin
this sense as well, I think coming to here and I
started to sing ... I feel like I was doing at least
something in a more tangible way. I was coming
here, I did something today [Sing 4].
We went through a period of her not being very well,
but with breastfeeding not working, and her losing
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weight that was quite stressful. Coming to this made
me feel like I was doing something that was really
nurturing her while I felt like I was struggling to
nurture her, so that really made a difference in that
time [Sing 3].
We see here the women reflecting on the daily chal-
lenges that they faced as new mothers, and the ways in
which singing helped them to discover a sense of accom-
plishment. Singing also appeared to support a reconnec-
tion with a sense of self and purpose that had been lost
in the transition to motherhood:
Speaker 1: When I first came (…) I wasn’t very well,
and as a result, was slightly lacking in confidence and
I think over a period of time, as I’ve gotten better and
sort of been on medication as well as coming to the
class and as well as interacting with lovely people -
mothers, again - it’s been hugely beneficial to me, I
feel. I feel like new again and I think in a big way in
the beginning that wasn’t there. I never thought I
would feel like me again, post baby. Speaker 2: You
came back to yourself again. Speaker 1: Yes [Sing 2].
I think just feeling, like you go from work, which is
another identity, and then you go off a bit lost into
motherhood identity, where you know your role but
you probably don’t know what it means. Having
songs, and having this, it helps you to be able to add
to your purpose, and you’ve got some strings to your
bow. We’re all great mums, but sometimes you feel
like you’re not. You need, if you come to something
like this, you feel like you’ve got different songs and
things [Sing 3].
Finally, a small number of women reported that sing-
ing helped them to bond with their baby (sub-theme
‘singing supports bonding’):
It helps the bond between us, too. Something that
[the leader] first said, on the first day was actually that
they want to hear the sound of your voice, so don’tbe
scared about singing [Sing 3].
I have a good relationship with him because I sing to
him every day, some songs - so it’s useful [Sing 5].
To summarise, mothers in both groups reported that
their activity facilitated positive emotions, especially in
relation to the challenges of new motherhood. Among
the singing group only, the mothers also reflected on
singing being a form of ‘me time’; a space for them as
well as for their baby that could also be immersive.
Additionally, singing facilitated a sense of achievement
for the mothers, particularly in relation to nurturing
their babies and rediscovering a sense of self and
purpose. Finally, for some of the mothers singing was a
means of enhancing the mother-baby bond.
Social mechanisms
Both sets of mothers reported that they benefited from
being part of a group (sub-themes ‘singing as part of
group’and ‘playing as part of group’):
I felt like I was really part of the group (…) with so
many of the other drop in classes and groups and
things, you don’t really get to know the babies that
well and you’re more focused on you and the baby
and what’s going on, not like you and everyone else
and their babies (…)Soit’s been really nice to feel
part of a group [Play 2].
You feel part of the community, and (…)it’s lovely
[Sing 4].
In addition to the experience of being a group mem-
ber, this social forum also provided a means of learning
from other mothers:
I think you learn from other mums as well. You see
how they are with their children (…)soit’s not only
just about the music, it’s about like you get to interact
with other mums and see how they parent their
babies and I might implement like that in my routine
with my child and so it’s a lot more than just the
music [Sing 2].
You can learn a lot from each other (…) just how
much you can learn off each other in really informal
way [Play 1].
That the mothers are brought together regularly each
week appears to create an opportunity for sharing tips
and resources that are beneficial to their ongoing experi-
ences of motherhood. Finally, among the singing group
this social cohesion seems to be strengthened through
the act of singing:
I think if it was shorter, if it was only two or three
sessions, it wouldn’t really work. I think the first
time I came, I came away saying ‘Oh, that’s nice,
but it’s nothing that you wouldn’t get from another
group or something’but then after ten weeks, you
really do feel like the songs become the group
[Sing 3].
Singing as a group, that’s one of the things that I like
[Sing 2].
Perkins et al. BMC Psychology (2018) 6:41 Page 7 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
While all participants experienced the benefits of feeling
part of a regular group and learning from other mothers,
those in the singing group also benefited from the social
cohesion facilitated by the music itself.
Furthermore, both singing and play participants
described their activities as a motivation and structure for
getting out of the house with a young baby (sub-themes
‘singing supports routine’and ‘play supports routine’):
I had a difficult labour and first few months keeping
the baby healthy, and I was home a lot with the
challenges and this gave me an opportunity to meet
other people, so that I’m not alone with kids [Play 4].
I think it was really good for me to have something to
go to, that meant I wasn’t home all the time. It was
also something different, away from just walking to
[the] park again [Sing 3].
In addition to facilitating a change of scene, the activ-
ities also provided routine within the mothers’week:
I always have something to do each day. And knowing
that we have something to come to [Play 4].
I didn’t have ideas of how to start or how to start
again, reorganise my daily life and to have routine.
So having the session every week, every Friday at the
same time, actually I think it helps to re-establish your
rhythm [Sing 4].
Additionally, the mothers reported that they enjoyed
seeing the impact of both singing and play activities on
their babies (sub-themes ‘singing impact on babies’and
‘play impact on babies’):
It’s just the way that [the babies] are with each other
and you can see that they remember each other (…)it
just shows that once a week and with the music and
the drum and then the singing, they’ve all developed
and they’ve all grown up so much [Sing 2].
Seeing the babies develop and change week on week, in
a kind of creative setting, has been really lovely [Play 2].
For mothers in all the singing groups, it was also re-
ported that singing calmed their babies, including out-
side of the sessions:
The songs have (…) been calming for [baby] when
he’s really crying. Just standing like this, singing some
of the songs. Sometimes you just get into a zone
where you’re just singing them on repeat in a trance
singing it …[Sing 1].
I can use them. Lots of times, like in the middle of the
night, I sing hours on end. Rocking him [Sing 5].
Socially, then, the activities provided a sense of group
belonging for the participants, in which knowledge
about motherhood could also be shared. For the singing
group in particular, this sense of social cohesion was
strengthened by the act of singing itself. Both activities
provided a sense of structure and routine in the mothers’
lives and a shared experience of seeing their babies de-
velop. Finally, singing was also reported as a useful way
to help calm and soothe babies.
Environmental mechanisms
For mothers in both groups, the environment in the
sessions was reported to be calm (sub-themes ‘calm and
inclusive singing environment’and ‘calm and inclusive
play environment’):
I think it was also a really calm environment. That
was good [Play 3].
It’s much calmer than any of the other baby classes
that we go to together [Sing 2].
Furthermore, the mothers experienced the spaces as
non-judgemental, particularly in relation to their babies’
behaviour:
I knew that nobody would mind if she [baby] was
squawking and people have been really supportive
about her wanting to be carried around, ok let’s take it
in turns to do that (...) I remember when I started this
group, I was still slightly in the phase of I would go to
things and be slightly on edge about whether she’dbe
in a meltdown, and I can feel that I’ve relaxed. Not
necessarily in every setting, I wouldn’t like it if it
happened on the train or something, but here, yes, I
know that it’s absolutely fine and it will be okay, and I
think that’s helped my confidence with her as well, so
that’s been really nice [Play 5].
I think it’s been nice about this group –it’s because
wherever you go, as a mum, you feel judged. But here,
it’s just like naked. We’re all in exactly the same
position [Sing 1].
Linked with this, the mothers appeared to appreciate
the lack of pressure put on them to participate in the
activities in a certain way or to a certain degree:
That it, there’snopressuretogetsuperinvolved
[Play 2].
Perkins et al. BMC Psychology (2018) 6:41 Page 8 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
I don’t sing very well at all, but we don’t judge each
other here and it’s just all about just being isn’tit
[Sing 1].
In the play group, some of the mothers also recognised
the value of the sessions as an opportunity to talk –
alongside the creative play activities –in a trusting
space:
It felt a little more comfortable here to discuss certain
things and quite open conversations, and it’s all felt
very comfortable and very trusting, warm
environment [Play 1].
Moving to the final sub-theme, both groups empha-
sised the vital importance of the leader in facilitating
effective interventions for new mothers (sub-themes
'importance of singing leader’and ‘importance of play
leader’):
I think [leader] was a really lovely moderator, and I
think the atmosphere that she created was very
relaxed and very positive. So a big element is actually
having her as the person who’s brought it all together
[Play 5].
[Leader] brings her experience and positivity. I think
she brought a lot of humanity into it, that’s probably
why we really liked it and the kids reacted that way
[Sing 1].
In sum, the calm and inclusive leader was identified as
important to the mothers, as was the quality and tem-
perament of the workshop leaders.
Discussion
This article has scrutinised the features of a community
group singing intervention known to support recovery
for mothers with moderate-severe symptoms of PND. By
situating data from the singing group alongside data
from women in a parallel creative play group, the aim
has been to illuminate the specific features of the singing
group. Nonetheless, across both interventions a series of
transversal mechanisms emerged to account for the po-
tential benefits of more generic creative interventions
for postnatal mental health recovery: (1) a shared experi-
ence for mothers of seeing babies develop and enjoy a
creative activity; (2) learning new activities to do with
babies, and increased confidence in doing this outside of
the intervention sessions themselves; (3) an enhanced
sense of ‘feeling good’; (4) a sense of group belonging, in
which knowledge about motherhood can be shared; (5) a
sense of structure and routine in daily life; (6) a calm
and inclusive environment, facilitated by high quality
creative leaders and support team. Given that low levels
of social support are widely acknowledged to predict
PND [31], it is particularly interesting that many of the
social benefits of being part of a creative group were
evident across both singing and play, perhaps helping to
account for the lack of a significant difference in
recovery speed found in the RCT between these two
conditions [32]. However, as we also know from the
RCT, singing –but not play –led to more rapid reduc-
tions in moderate-severe symptoms of PND than usual
care [32], suggesting that there are other factors that
may differentiate the impact of singing.
Indeed, a number of features emerged that may ac-
count for this activity’s ability to reduce PND symptoms.
Beck includes self-esteem as a predictor of PND based
on her meta-analysis of 84 studies [40]. That singing al-
lows women to feel a sense of achievement, specifically
in caring for and nurturing their baby, is of relevance
here, contributing to what Leahy-Warren, McCarthy, &
Corcoran term maternal parental self-efficacy, or
‘mothers’beliefs about their ability to be successful in
the parenting role’([41], p.390). Leahy-Warren, McCar-
thy, and Corcoran’s research posited a link between ma-
ternal parental self-efficacy and reduced symptoms of
PND, suggesting that the role of singing to enable a
mother to feel able to look after and care for her baby
may be important. Further, that singing can calm babies
may also support this point; with the ‘tool’of singing to
support being able to calm down a crying baby, mothers
may feel more competent and able to deal with challen-
ging infant behaviour or situations. Indeed, other studies
have pinpointed the importance of postnatal interven-
tions in supporting aspects of maternal confidence [42],
although evidence on this is limited [43].
The mothers’reports of the singing sessions as relax-
ing and immersive, creating ‘me time’, also set them
aside from the play sessions. Indeed, within mental
health research more widely, there is some evidence –
albeit limited –that relaxation techniques could support
recovery from depression [44]. For the mothers, singing
appeared to offer an immersive experience that provided
some relief from the practical and emotional concerns of
early motherhood. Importantly, the activity was also seen
as a unique opportunity to engage in something de-
signed for the mother rather than only for the baby,
highlighting the mother’s own needs for care and
nurture, a point also made by Feeley et al. [11]. Linked
with this point is the value that the mothers placed on
what they perceived as the authenticity of the singing
activity, which moved away from more standard reper-
toire for mothers and babies (such as nursery rhymes) to
include songs and music from around the world. This
enabled mothers to contribute songs from their own cul-
tures and backgrounds for the group to learn together,
Perkins et al. BMC Psychology (2018) 6:41 Page 9 of 12
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further emphasizing the feeling of community and group
learning. This may be a key feature of the intervention, as
it appeared to facilitate an emotional and social connec-
tion specifically with the music that allowed the mothers
to relax and become absorbed in the activity with their
baby, subsequently providing some relief from the symp-
toms of PND. Indeed, others have reported on the role of
lullabies in enhancing feelings associated with mother-
hood and in understanding babies’responses [45].
Finally, the enhanced mother-baby bond that some
mothers reported as a result of singing is of note. It has
been posited that singing may have developed out of
‘motherese’, a form of speech directed by mothers at
their infants that consists of formalisations, repetitions,
exaggerations and elaborations of ordinary adult vocal
communication [46,47]. Motherese is thought to be an
interactive process between mother and baby [48], and
singing may achieve similar responses from a baby such
as enhanced engagement, visual attention and modula-
tion of infant arousal [49,50]. PND has been linked with
reduced mother-infant bond [51], and it appears that
singing may provide one mechanism for supporting this
bond through the shared interaction of singing vocalisa-
tions. Indeed, singing with other populations has also
been reported as a means of enhanced interpersonal
communication and bonding [27–30]. Further, Mualem
& Klein [52] demonstrated that musical interactions pro-
vided more opportunities for synchronisation between
mothers and one-year olds, as well as positive emotional
arousal, than play. It is possible that singing facilitates a
unique mother-infant bonding experience, and further
work is required in this area.
What, then, can we infer as to the specific benefits of
community group singing for reducing symptoms of
PND? Interestingly, the majority of the mechanisms dis-
tinct to singing were categorised under the ‘psycho-emo-
tional mechanisms’sub-theme. These mechanisms are
concerned with the mother’s affective and psychological
response to the singing activity, and may relate to sub-
jective feelings, expression, action tendency or regulation
invoked through the musical experience [53]. Music has
for a long while been associated with strong emotional
responses [54], and it could be argued that what we see
in this group singing intervention is the use of singing to
facilitate an emotional response to music that is
context-specific to the experience of new motherhood.
Indeed, Sloboda and Juslin [55] make clear that emo-
tional responses to music occur in a complex interaction
between the music, listener and situation, and are
dependent on the goals and motives of the listener.
While both singing and play elicited ‘feel good’emotions
such as happiness and a feeling of being uplifted, only
singing appeared to elicit a more functional emotional
response rooted in the needs of new motherhood: to
have time to reframe the self, to feel immersed in an
activity beyond looking after the baby alone, to feel com-
petent as a mother and to feel bonded with the baby.
The experience of functional positive emotions in rela-
tion to the experience of motherhood, facilitated
through the creative act of singing, may help to explain
the faster reduction in symptoms that this intervention
elicits. Indeed, this response may also reflect the ability
of the workshop leaders to recognise and respond to the
women’s emotional state through the singing itself,
modifying the songs to allow women to rest, be close to
their baby or to learn new repertoire to take away from
the session.
Finally, this work contributes to the wider body of lit-
erature pointing to the mental health benefits of singing.
We saw in the opening of this article that singing can be
life-enhancing [24], support recovery from serious or en-
during mental illness [25]and provide a useful coping
strategy in times of adversity [27]. Our findings confirm
the recovery potential of signing, both in terms of sup-
porting women to ‘feel good’(Hedonia) and to ‘function
well’(Eudaimonia) [56]. Further, as discussed above,
singing emerged as a tool to facilitate a feeling of close-
ness or bonding between mother and baby, which can
be compromised when a women is experiencing symp-
toms of PND [51]. This supports Kreutz’s argument that
singing may have emerged to enhance social bonding
and mutual attachment [28] and echoes findings from
our recent study demonstrating that singing, but not
chatting, is associated with increases in maternal percep-
tion of emotional closeness with their baby [57]. Finally,
our study resonates with the so-called ‘functional out-
comes’of singing identified in a previous study [26],
with singing appearing to be a tool that can be modified
to meet participants’emotional needs in their particular
context. Our findings make it clear that, for the women
in this study, the impact of singing appeared to be
specific to their needs as new mothers. Whether or not
this specificity arose as a result of careful leadership
from the facilitators and/or the innate qualities of sing-
ing itself requires further investigation. Indeed, this issue
of specificity will be important to continue unpacking if
we are to fully uncover the potential of singing to sup-
port diverse participant groups.
Conclusions
This article uses a comparative qualitative methodology to
describe the specific features of a community group sing-
ing intervention known to reduce moderate-severe symp-
toms of PND more rapidly than usual care: (1) the
authentic, social and multicultural nature of the singing
experience, which was not seen as ‘commercial’and which
drew upon global songs that were meaningful to the
mothers as well as other creative forms; (2) the ability of
Perkins et al. BMC Psychology (2018) 6:41 Page 10 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
singing to calm babies, both in and out of the sessions; (3)
the singing session as ‘me time’for mothers, that can be
both relaxing and immersive; (4) the ability of singing to
facilitate a sense of achievement and identity for mothers,
particularly in relation to nurturing their babies and redis-
covering a sense of self and purpose after the transition to
motherhood; (5) singing as a means of enhancing the
mother-baby bond. In summary, the psycho-emotional
mechanisms of the activity emerge as central to the re-
ported benefits, with community group singing appearing
to facilitate the experience of functional positive emotions
in relation to the experience of motherhood. Further re-
search is needed to scrutinise the extendibility of this find-
ing, as well as to further understand the complex
interactions of responses to singing and recovery from
symptoms of PND.
Limitations
While one of the first to attempt to account for the
mental health benefit of singing for new mothers, this
article is not without its limitations. More women com-
pleted the singing intervention than the play interven-
tion [38] and therefore more women were represented
in the singing focus groups than the play. Although this
means that the perspectives of fewer mothers are in-
cluded in the play data, this is arguably a function of the
singing intervention being the most effective for postna-
tal mothers. Additionally, not all mothers were able or
willing to participate in the focus groups, potentially dis-
torting the resulting data, and biasing them in favour of
mothers who reported predominantly positive outcomes.
Similarly, the focus groups were relatively short and
therefore the richness of the data may be compromised.
Further, the singing intervention was shown to be par-
ticularly effective for mothers with moderate-severe
symptoms of PND [32], yet the focus groups were open
to all mothers who participated in the activities, includ-
ing those with milder symptoms. Indeed, the data are
also limited by the characteristics of the sample, which
includes a high percentage of degree-educated women in
relatively high earning households. Further research will
benefit from addressing these limitations in order to
continue building the evidence base for the role of sing-
ing in maternal mental health.
Abbreviations
EPDS: Edinburgh Postnatal Depression Scale; GP: General Practitioner;
NHS: National Health Service; PND: Postnatal Depression; RCT: Randomised
Controlled Trial; UK: United Kingdom
Acknowledgements
The study team acknowledge the support of the National Institute of
Health Research Clinical Research Network (NIHR CRN). The authors
would like to thank the hospitals involved as Participant Identification
Centres, the workshop leaders and assistants and Diana Roberts, Miss
Sunita Sharma and Prof Aaron Williamon for their support with the RCT
on which this study is based.
Funding
The study was funded by Arts Council England Research Grants Fund, grant
number 29230014 (Lottery) with additional support from CW+ and Dasha
Shenkman. The funders had no role in the design of the study and
collection, analysis, and interpretation of data or in writing the manuscript.
Availability of data and materials
Data are not available as (1) the study protocol stated that data are only
available to the immediate study team and (2) participants consented to
anonymised data being included in scientific publications or presentations
but did not consent to raw data transcripts being made available.
Authors’contributions
RP designed the study, collected data, led analysis and wrote the first draft
of the manuscript. SY collected and analysed data and contributed to the
final manuscript. DF designed the study, collected data and contributed to
the final manuscript. All authors read and approved the final manuscript.
Ethics approval and consent to participate
The study was approved by the National Health Service South East Scotland
Research Ethics Committee (15/SS/016). Women provided written informed
consent to participate.
Consent for publication
Women provided written informed consent for their anonymised data to be
published.
Competing interests
The authors declare that they have no competing interests.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Centre for Performance Science, Royal College of Music, Prince Consort
Road, London SW7 2BS, UK.
2
Faculty of Medicine, Imperial College London,
London SW7 2AZ, UK.
3
Present Address: Faculty of Medicine, Imperial
College London, London SW7 2AZ, UK.
4
Present Address: Department of
Behavioural Science and Health, University College London, London WC1E
7HB, UK.
Received: 17 January 2018 Accepted: 24 July 2018
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