THE IMPACT OF MINDFULNESS-BASED PRENATAL YOGA ON

MATERNAL STRESS DURING PREGNANCY

A Thesis Presented to the Faculty of

California State University, Stanislaus

In Partial Fulfillment of the Requirements for the Degree

of Master of Social Work

By Laura Jean Carroll

May 2014

CERTIFICATION OF APPROVAL

THE IMPACT OF MINDFULNESS-BASED PRENATAL YOGA ON

MATERNAL STRESS DURING PREGNANCY

by

Laura Jean Carroll

Certificate of Approval is on file

with the University Library

Shradha Tibrewal, Ph.D. Professor of Social Work

Yvonne Leal, MSW Lecturer of Social Work

Date

Date

© 2014

Laura Jean Carroll ALL RIGHTS RESERVED

iv

DEDICATION

This thesis is dedicated to two very important people in my life - my

grandfather, Jack O’Neil, and my aunt, Debby Carroll.

Pop: Thank you for being a living example of the true meaning of hard work

and dedication. Your attitude and outlook on life are qualities I strive to embody

every day. I feel so blessed to have you in my life. Thank you for being the smartest

man I know!

Auntie Debby: Thank you for your guidance, wisdom, and statistical

brilliance. This thesis would definitely not be complete without your long-distance

assistance. Thank you for always being there for me. I am proud to follow in your

footsteps.

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ACKNOWLEDGEMENTS

This thesis would not have been possible without the contributions from many

people. First, I would like to express my deepest appreciation to the inspiring

“Mindful Mamas” for allowing me to be part of their journey, and to Grace, for truly

being the living example of mindfulness. I would also like to thank Dr. Shradha

Tibrewal, for giving me the opportunity to be a part of this research and Yvonne Leal,

for her helpful feedback.

I would like to thank my family for all of their support and encouragement.

Mom and Dad – thank you so much for instilling in me a desire to never stop

learning. Knowing how hard you work gave me the motivation to keep going. Mom -

I am so proud of you, and your dedication and passion inspire me every day. Aunt

Lynn and Uncle Cary – thank you for your unconditional support throughout my time

in grad school, it is greatly appreciated. Timmy –thank you for being the wonderful

brother that you are, supporting me through this process, and providing the much-

needed comic relief in my life. Lexy – I’m so glad our paths crossed that day at

orientation – I really can’t imagine doing this without you. And to Anna and David,

thank you for reminding me that there is more to life than school, for making me

laugh, and loving me unconditionally.

It is impossible to name everyone who has had a hand in this journey, but

please know that I am forever grateful for your love and support.

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TABLE OF CONTENTS PAGE

Dedication............................................................................................................... iv Acknowledgements................................................................................................. v List of Tables .......................................................................................................... viii Abstract ................................................................................................................... x CHAPTER

I. Introduction........................................................................................... 1 Statement of the Problem.......................................................... 1 Statement of Purpose ................................................................ 6 Significance of the Study.......................................................... 6

II. Literature Review ................................................................................. 8 Prenatal Stress and Pre-Term Birth .......................................... 9 Prenatal Stress and Low Birth Weight...................................... 11 Prenatal Stress as a Risk Factor for Psychopathology.............. 12 Mindfulness and Pregnancy...................................................... 14 Prenatal Yoga ........................................................................... 17 Combining Mindfulness and Yoga During Pregnancy............. 19

III. Methodology......................................................................................... 22 Overview................................................................................... 22 Research Design ....................................................................... 22 Sampling Plan ........................................................................... 23 Data Collection ......................................................................... 24 Instrumentation ......................................................................... 26 Data Analysis ............................................................................ 27 Protection of Human Participants ............................................. 27

IV. Results................................................................................................... 29 Overview of Sample ................................................................. 29 Analysis of Prenatal Psychosocial Profile ................................ 31 Five Facet Mindfulness Questionnaire ..................................... 33

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Analysis of Qualitative Data..................................................... 36 Conclusion of Program Focus Group ....................................... 36 Focus Group Four Months after Program Conclusion.............. 38 Summary................................................................................... 39

V. Discussion............................................................................................. 40 Introduction............................................................................... 40 Major Findings.......................................................................... 40 Limitations of Study ................................................................. 44 Implications for Future Research.............................................. 44 Implications for Social Work Practice and Policy.................... 45 References............................................................................................................... 48 Appendices

A. Informed Consent ....................................................................................... 57 B. Demographic Questionnaire ....................................................................... 58 C. Prenatal Psychosocial Profile...................................................................... 60 D. Five Facet Mindfulness Questionnaire ....................................................... 61 E. Provider Approval Form............................................................................. 63 F. Prenatal Yoga Participation Registration.................................................... 64

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LIST OF TABLES TABLE PAGE 1. Demographic Information ............................................................................. 30

2. Means and Standard Errors by Time (Stress)................................................ 31 3. Means and Standard Errors by Item (Stress)................................................. 32

4. Means and Standard Errors for Time 1 and Time 3 (Stress)......................... 33 5. Means and Standard Errors for Five Facet Mindfulness Questionnaire ....... 34 6. Means and Standard Errors for Time by Facet Interaction (Mindfulness) ... 35

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ABSTRACT

Research has shown that stress increases during pregnancy. A 12-week mindfulness-

based prenatal yoga pilot program was evaluated for its effectiveness on maternal

stress and mindfulness levels throughout pregnancy and during the post-partum

period. Fifteen women completed the program. Participant scores were obtained at

four time points – baseline, halfway through the program (time 2), program

conclusion (time 3) and four months after program conclusion (time 4). Data was

collected via the Prenatal Psychosocial Profile to measure stress, and the Five Facet

Mindfulness Questionnaire to measure mindfulness. Participant stress scores

decreased significantly from baseline to program conclusion, and mindfulness scores

increased from baseline to time 2 (6-weeks into program) and from baseline to time 3

(program conclusion). The brief and non-invasive nature of this program makes it a

possible candidate as a stress management intervention during pregnancy.

1

CHAPTER I

INTRODUCTION

Statement of the Problem

According to the Center for Disease Control (2013), in the United States

alone, there are approximately 10,831.75 babies born every day. This amounts to over

3,953,590 babies being born each year. The nine months a woman carries a child can

be a time of great excitement and growth (McVeigh, 1997). However, no matter how

joyful the experience, pregnancy brings with it a great deal of stress and anxiety

(McVeigh, 1997). This is especially true for first-time mothers, who often report

feeling unprepared and stressed about their experience (McVeigh, 1997).

Pregnancy has been defined as “a major life transition requiring adaptation of

many kinds” (Rini, Dunkel-Schetter, Wadhwa, & Sandman, 1999, p. 333). For

example, pregnant women have reported stress concerning exposure to infection, the

effect of lifestyle choices/habits on their developing child, adequate nutritional status,

and environmental stressors (World Health Organization, 2006). Wadhwa, Sandman,

Port, Dunkel-Schetter, and Garite (1993) conducted a study that measured pregnancy-

related anxiety, and episodic and chronic stress. They found that pregnant women in

the sample reported a higher level of stress than when compared to average adults in

community-based samples. In addition, in a study of 161 pregnant women, DaCosta,

Larouche, Dritsa, and Brender (1999) found that concerns over marital adjustment,

career issues, gestational complications, and younger age were all associated with an

2

increased level of stress consistent throughout all three trimesters. Other common

stressors related directly to this population include concern over physical symptoms,

childbirth, health of the child, and potential preterm birth and complications (Yali &

Lobel, 1999).

It has long been thought that emotions and experiences of pregnant women

negatively impact the development of the growing fetus (DiPietro, 2004). Some of

these early ideas, such as the belief that a scare during early pregnancy would lead to

a birthmark on the developing child, no longer exist (DiPietro, 2004). Recently, the

study of maternal prenatal stress and its impact on the developing fetus has received a

great deal of attention (DiPietro, 2004). In fact, the World Health Organization

advises that the role of maternal stress during pregnancy be given high research

priority due to the importance of the impact of early prenatal experiences on both

physical and cognitive development (World Health Organization, 2006).

Research suggests that poor obstetric outcomes, such as low birth weight,

account for over 40% of all neonatal deaths (Witt, Litzelman, Cheng, Wakeel, &

Barker, 2013). Lederman et al. (2004) found that women who delivered full-term

after experiencing a highly stressful event had children with significantly lower birth

weights than did term infants born to women not experiencing highly stressful events.

Low birth weight can increase the risk of infant mortality, delayed physical and

cognitive development, and increased susceptibility to stress in adulthood.

Furthermore, early-life factors can predispose individuals to diseases over the life

course (Gluckman, Hanson, Cooper, & Thornburg, 2008). For example, children born

3

pre-term are at an increased risk of suffering jaundice, anemia, developmental

disabilities, cerebral palsy, learning disabilities, sleep apnea, among other things

(Torpy, Lynn, & Glass, 2009; CDC, 2013). Because of the impacts that prenatal

exposure to stress can have on a developing child (both before and after birth), it is

important to begin understanding safe, effective relaxation and stress management

strategies to reduce the negative impacts that prenatal stress can have on the

development of the growing child.

While there is a great deal of research pertaining to stress reduction and the

general population, when looking specifically at stress reduction during pregnancy,

the research is not as abundant. In the general population, exercise has been

associated with stress reduction, reduced depression, anger, perceived stress, and

anxiety as well as increases in perceived health and fitness (Hassman, Koivula, &

Uutela, 2000). As stated previously, pregnant women come with their own set of

health risks and external and internal stressors. Because of this, it is important to look

at stress-reduction techniques specifically designed for this population. One of these

ways is through the practice of prenatal yoga. Prenatal yoga is a, “multifaceted

approach to exercise that encourages stretching, mental centering, and focused

breathing” (Mayo Clinic, 2013a). The current research on prenatal yoga suggests that

it improves sleep, reduces stress and anxiety, increases strength, flexibility and

muscular endurance needed for childbirth, decreases lower back pain, nausea, and

headaches, decreases the risk of preterm labor, pregnancy-induced hypertension, and

intrauterine growth restriction (Mayo Clinic, 2013a).

4

Another approach to stress reduction is through the use of mindfulness.

Mindfulness is defined as “the awareness that emerges through paying attention on

purpose, in the present moment, and non-judgmentally to the unfolding of experience

moment to moment” (Kabat-Zinn, 2003, p. 145). It is a practice that has roots in

Buddhist teaching, and at the core of mindfulness is the lessening of suffering and

increasing health, well-being, and wholeness. A mindfulness practice can consist of a

wide range of different components, but some of the more common include a seated

meditation, body scan, self-compassion, acceptance, and a focus on the breath. While

mindfulness is most commonly known as a seated meditation practice, it can also be

incorporated into both a yoga practice and daily life (Vieten, 2009).

In combining the core principles of both prenatal yoga and mindfulness, it

leads to a practice with elements of asanas (yoga postures), a focus on deep

breathing, self-compassion, an awareness of bodily sensations, and a non-judgmental

acceptance of the current experience. The current research shows a promising

correlation between mindfulness practices and stress reduction during pregnancy, as

well as prenatal yoga practice and stress reduction during pregnancy. However, there

is limited information on the combination of both mindfulness and prenatal yoga, and

its role in decreasing stress, especially during pregnancy.

Beddoe, Yang, Kennedy, Weiss, and Lee (2009) examined the effects of

mindfulness-based yoga during pregnancy on maternal and physical distress. Sixteen

healthy, nulliparous pregnant women with singleton pregnancies between 12 and 32

weeks gestation at the time of enrollment were included in the study. Measurements

5

were taken using the perceived stress scale (PSS), prenatal psychosocial profile

(PPP), state-trait anxiety inventory (STAI), and brief pain inventory (BPI), as well as

a salivary collection to measure cortisol levels. All data were collected at baseline

prior to the beginning of the first class, and again after completion of the seven-week

class.

At baseline, participants reported moderate levels of perceived stress. There

was a significant decrease in perceived stress (p = .05) from baseline to post-

intervention, but only in the group of women in their third trimester. In addition, life

stressors and hassles were measured using the PPP. At baseline, participants reported

low levels of stressors, and while there was a trend toward decreasing stressors in

both the second and third trimester groups, it was not significant. Again, the decrease

in stressors was greater for the third trimester group, but not enough to be significant

(Beddoe et al., 2009).

While the current body of research is growing, additional knowledge is still

needed to assess the overall effectiveness of outcomes with regard to maternal

prenatal stress. Specifically, this study sought to examine whether a 12-week

mindfulness-based prenatal yoga pilot program through Blossom Birth Services in

Palo Alto, California, was associated with decreased maternal stress, or an increased

ability to cope with those stressors. In addition, this study serves as a catalyst for

future research on maternal coping during pregnancy and mindfulness-based prenatal

yoga (Beddoe et al., 2009).

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Statement of Purpose

Because stress can be harmful to the health of a pregnant mother and her

developing child, the purpose of the study was to examine the impact of mindfulness-

based prenatal yoga on stress levels in women, both prenatally and four months after

program conclusion (the post-partum period). This study was descriptive in nature,

utilizing both qualitative and quantitative data. The study was guided by two major

research questions. First, did pregnant women who participate in the mindfulness-

based prenatal yoga classes experience a decrease in stress during their pregnancy?

Second, would mindfulness skills be sustained after the conclusion of the 12-week

course? The intent of this study was to assess the effectiveness of the mindfulness-

based prenatal yoga pilot program offered through Blossom Birth Services, as it

pertained to prenatal stress. The expectation was that mothers who participated would

show decreases in prenatal stress scores as their time in the program increased, as

compared to their baselines scores.

Significance of Study

Gaining a more definitive understanding of how mindfulness-based prenatal

yoga impacts pregnant women and their experience of stress will provide vast

implications for both health care providers and pregnant women. If the study

demonstrates decreases in stress and a mastery of mindfulness skills, it could open up

a new discussion on the health of pregnant women, and a shift away from the

“medicalization of pregnancy” toward a more natural, holistic approach.

Mindfulness-based prenatal yoga has the potential to provide a very “hands off,”

7

minimally invasive, solution to many of the aches and pains that are currently

associated with pregnancy.

Being that pregnant women are a vulnerable population, and mindfulness-

based prenatal yoga aims to decrease stress in a safe, non-invasive manner, the

knowledge gained in this study is especially applicable to social work practitioners.

The research can potentially bring awareness to social workers about some of the

types of coping methods that are effective in reducing stress for pregnant women. The

literature has proven that exposure to stress prenatally can have detrimental effects on

children for the rest of their lives (Witt et al., 2013). However, there is a serious lack

of research when it comes to what interventions are both effective and realistic in

reducing this stress, and thus creating healthy babies. The research provided from this

study serves as a building block for contributing solid, evidence-based research to the

knowledge-base regarding pregnancy, with the goal that social workers will be able to

understand and provide effective interventions and education, to this highly

vulnerable population.

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CHAPTER II

LITERATURE REVIEW

The literature review for this chapter was bi-focused. First, it focused on the

impact that exposure to stress prenatally can have on an individual, both prenatally

and throughout development. Secondly, it focused on research on mindfulness during

pregnancy and prenatal yoga, independently. Most of the research related to

mindfulness was concerning mindfulness-based cognitive therapy and mindfulness-

based stress reduction. In addition, none of the articles reviewed utilized qualitative

data, which severely limits the understanding of the individual experience. The

research and articles presented relate to the importance of stress reduction during

pregnancy, and the need for evidence-based programs to better support mothers

during this life transition.

During pregnancy, the placenta plays several important roles. It provides

oxygen and nutrients to the developing child, and removes waste products from the

child’s blood (Mayo Clinic, 2012). In addition, under normal circumstances, the

placenta acts as a barrier, protecting the developing child from adverse situations that

may arise (Mayo Clinic, 2012). However, in extreme circumstances where the

maternal environment is compromised (as in highly stressful situations), the barrier

that the placenta provides can become compromised, thus exposing the developing

fetus to stress hormones (Mayo Clinic, 2012). This raises concern as studies have

shown that pregnant women report higher levels of stress than the general population

9

(Wadhwa et al., 1993), and that stressors are not necessarily huge, life-altering

traumatic events, but things as ordinary as fear of exposure to infection, the effect of

lifestyle habits/choices on the developing child, and environmental stressors (World

Health Organization, 2006).

Prenatal Stress and Preterm Birth

In the United States, 11%-13% of all births are considered preterm (birth prior

to 37 weeks gestation) (Cuossons-Read, 2012). In addition, up to 40% of preterm

births involve healthy mothers with no known risk factors (Cuossons-Read, 2012).

Known risk factors for preterm delivery include things such as poor nutrition,

smoking, incompetent cervix, multiple past miscarriages, diabetes, high blood

pressure, and physical injury or trauma (Mayo Clinic, 2013b). Currently, neither the

Center for Disease Control, National Institute of Health Child Health and Human

Development Institute, nor the American College of Obstetricians and Gynecologists

consider maternal stress as a documented risk factor for preterm birth.

Studies have shown that women who have experienced major life events, such

as death of a family member during pregnancy, had 1.4-1.8 time greater risk of

preterm delivery than those who did not (Schetter, 2011). Reports of stress life events,

including financial problems, strain in intimate relationships, family responsibilities,

employment, and pregnancy specific-stress (Schetter, 2011; Lobel et al., 2008) in

early pregnancy, predicts higher cortisol levels in late pregnancy (Obel et al., 2005),

and higher cortisol levels earlier in pregnancy have been significantly associated with

preterm birth (Sandman et al., 2006).

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Lederman et al. (2004) examined the birth outcomes of women living within a

two-mile radius of the World Trade Center on September 11, 2001. They found that

exposure to the event during the first trimester was associated with significantly

shorter gestation regardless of location of work or residence. While the researchers

are unable to determine if the effects were directly related to the stress experienced,

or to exposure to toxic substances, it has been shown that stressful experiences may

exacerbate the impact of toxicants on a developing fetus (Rauh et al., 2004).

Preterm birth is a cause for concern. According to the Center for Disease

Control and Prevention (CDC) (2013), more infants die from complications due to

preterm related problems than from any other single cause. In addition to mortality,

children born prematurely are at an increased risk for complications due to premature

organ development, jaundice, anemia, intracranial hemorrhage (Torpy et al., 2009)

developing intellectual disabilities, cerebral palsy, breathing and respiratory

problems, visual problems, hearing loss, feeding and digestive issues, and infection

(CDC, 2013). In addition, as premature children grow up, they face an increased risk

of sleep apnea, bronchopulmonary dysplasia (chronic lung disease), and learning

disabilities, among other things (Torpy et al., 2009).

In a meta-analysis, Bhutta, Cleves, Casey, Cradock, and Anand (2002) found

that preterm birth was associated with lower cognitive scores and increased risks for

ADHD diagnoses and other behaviors at school age compared with full-term controls.

However, other studies have shown that at 10 years of age, family factors were

stronger predictors of school outcomes than preterm birth.

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Prenatal Stress and Low Birth Weight

“Low birth weight remains to be one of the greatest problems faced by

perinatal medicine today” (Bolten et al., 2010, pg. 33). Bolten, et al examined the

effects of maternal distress during pregnancy on fetal development and birth weight.

Low birth weight was associated with increased fetal mortality, neonatal mortality,

infant mortality, subsequent poorer health and delayed physical and cognitive

development, and increased susceptibility to stress in adulthood (Lederman et al.,

2004).

Lederman et al. (2004) examined the birth outcomes of women living within a

two-mile radius of the World Trade Center on September 11, 2001. They found that

women who delivered full-term after experiencing the highly stressful event had

children with significantly lower birth weights and shorter birth lengths than did term

infants born to women living outside of the area. The birth weight and length effects

were only partially mediated by a shortening of gestation, which suggests some

additional effect on fetal growth, independent of length of gestation. Additionally,

occurrence of the World Trade Center event during the first trimester of pregnancy

was associated with significantly shortened gestation and slightly smaller head

circumference, regardless of place of work or residence in the month after September

11th.

Children of women living near the World Trade Center showed significant

decrements in birth weight and body weight at birth (Bolten et al., 2010). In addition,

it has been found that women with high strain jobs were also more likely to given

12

birth to infants with a low birth weight. In addition, mothers struggling with anxiety

or depression in late pregnancy were also more likely to give birth to low birth weight

babies (Bolten et al., 2010).

Cortisol has long been known as the “stress hormone.” It is well documented

that salivary cortisol specimens reflect the levels of unbound steroid in the blood

(Kirschbaum & Hellhammer, 1994). A cortisol rise after awakening is considered to

be an indicator of basic hypothalamic-pituitary-adrenal (HPA) axis activity. It has

been found that small amounts of cortisol are able to pass to the fetus. Bolten et al.

(2010) conducted a study with 70 pregnant women. The researchers collected and

measured salivary cortisol levels of mothers during early pregnancy (weeks 13-18)

and late pregnancy (35-37). They found that even after controlling for maternal age,

parity, BMI, infant’s sex and gestational age, maternal cortisol levels explained

19.8% of the variance in birth weight. In another study, Lobel et al. (2008) found that

pregnancy-specific stress contributed indirectly to low birth weight.

Prenatal Stress as a Risk Factor for Psychopathology

During pregnancy, the placenta plays several important roles. It provides

oxygen and nutrients to the developing child, and removes waste products from the

child’s blood. In addition, under normal circumstances, the placenta acts as a barrier,

protecting the developing child from adverse situations that may arise (Markham &

Koenig, 2011). However, in extreme circumstances where the maternal environment

is compromised (as in highly stressful situations), the barrier that the placenta

provides can become compromised, thus exposing the developing fetus to various

13

stress hormones (Markham & Koenig, 2011) and forcing a decrease in blood flow to

the uterus.

Several epidemiological studies have linked the incidence of schizophrenia to

various maternal stressors during pregnancy. These stressors include bereavement,

famine, earthquake, flood, and military invasion. Malaspina et al. (2008) conducted a

prospective cohort study examining the consequences of acute maternal stressors,

through a follow-up of offspring whose mothers were pregnant during the Arab-

Israeli War of 1976. They found that there was a raised incidence of schizophrenia for

those who were in their second month of fetal development, when compared to the

general population. This finding was seen more in women than in men, which is

consistent with earlier studies, but raises the need for further research, as

schizophrenia is a diagnosis more prevalent in males than females. In addition,

Huttunen and Niskanen (1978) conducted a study that examined the impact of

prenatal loss of a father on psychiatric disorders. They found that the number of

schizophrenia diagnoses and the number of people committing crime was

significantly higher in the experimental group (n=167) than in the control group

(n=168) of children whose fathers died during their first year of life.

Early studies have raised concern regarding maternal stress prenatally and an

increased fetal risk for mental and behavioral disorders (Cookson et al., 2009; Hansen

et al., 2000; O’Connor et al., 2002 as cited in Tegethoff, Green, Olsen, Schaffner, &

Meinlschmidt, 2011). A Danish study examined a birth cohort from 1996-2003. They

found that even after adjustment, maternal life stress during pregnancy was associated

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with an increased risk in 11 of 16 diagnostic categories, including mental and

behavioral disorders up to 2.5 years of age (Tegethoff et al., 2011). In addition,

exposure to early adverse experiences (stressors) prenatally may have a persistent

impact on brain development leading to negative cognitive and behavioral outcomes

(Bhutta et al., 2002). Infants whose mothers reported experiencing emotional

difficulties during pregnancy were 2.4 times more likely to have met criteria for

disruptive behavior disorder, after controlling for maternal depressive symptoms and

family conflict and cohesion (Allen, Lewinsohn, & Seely, 1998).

In a landmark study, Choudhry et al. (2012) found evidence to suggest an

interaction between a genetic and environmental factor that have been shown to be

independently associated in diagnoses of Attention Deficit Hyperactivity Disorder

(ADHD). It suggests that stress during pregnancy may serve to delineate two

pathways that lead to ADHD. However, genetic factors remain to be exposed.

Considering the potentially severe impact prenatal stress can have on

pregnancy and birth outcomes, efforts are being made to address prenatal stress in a

new way. A new body of research is developing on the impacts of mindfulness,

meditation, and yoga, on prenatal stress.

Mindfulness and Pregnancy Mindfulness is defined as “the awareness that emerges through paying

attention on purpose, in the present moment, and non-judgmentally to the unfolding

of experience moment to moment” (Kabat-Zinn, 2003, p. 145). It is a practice that has

15

roots in Buddhist teaching, and at the core of mindfulness is the lessening of suffering

and increasing health, well-being, and wholeness.

Dunn, Hanieh, Roberts, and Powrie (2012) conducted an 8-week pilot study

on mindfulness-based cognitive therapy group for pregnant women (based on the

program development of Segal et al). Although the groups were small, the program

brought forth interesting results. Of the women in the treatment group, 75%

experienced a clinically reliable decrease in stress symptoms from baseline to 6

weeks post-partum, whereas there was very little change in the control group. In

addition, all women interviewed reported continuing to use the mindfulness skills

they had acquired in the class either formally or informally. Interestingly, even those

who had not attended all sessions or completed the class still reported continuing to

use the mindfulness skills. It appears as though just the introduction to mindfulness

was an important catalyst for more mindful behavior. In addition, 67% of women

reported experiencing a positive change in their levels of self-compassion. Despite a

small sample size, the researchers were able to conclude that women who learn

mindfulness skills during pregnancy are likely to use those skills to manage stressors

during pregnancy, childbirth, and parenting. The utilization of these skills resulting in

reductions in psychological distress and improvements in psychological well-being.

In a similar study, Vieten and Astin (2008) developed an 8-week program

called the “Mindful Motherhood intervention” that consisted of components of

Mindfulness-Based Stress Reduction (Kabat-Zinn, 1990), Mindfulness-based

Cognitive Therapy (Segal et al., 2002), theoretical and clinical work on working with

16

mood concerns during pregnancy (Peterson, 1994), and acceptance-based

psychological approaches such as Acceptance and Commitment Therapy (Hayes et

al., 2004). The “Mindful Motherhood” intervention incorporated (1) mindfulness of

thoughts and feelings through breath awareness and contemplative practices, (2)

mindfulness of the body through guided body awareness meditation and mindful

hatha yoga, and (3) presentation of psychological concepts that incorporate

mindfulness such as acceptance and cultivation of an observing self. Due to the nature

of the group of women, adaptations were included in the intervention. For example,

(1) inclusion of awareness of the developing fetus and belly during the body scan

meditation, (2) use of explanatory examples and exercises having to do with

pregnancy and early parenting, (3) greater inclusion of walking and moving

mindfulness practices and forms of mindful movement that have been tailored for

pregnant women (such as prenatal yoga). They found that mindfulness training during

pregnancy resulted in a significantly greater decline in anxiety and negative affect

among participants in the intervention group when compared with the control group.

In fact, when compared to the experimental group, control group scores on depression

and affect were shown to have a large effect size, although they were not enough to

reach statistical significant (p<0.05) most likely due to small sample size.

Interestingly, between-group differences were not significantly different at the three-

month post-partum follow-up. However, the intervention group did retain 7-10% of

their improvements from base-mindfulness on all measures except perceived stress.

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Prenatal Yoga Mindfulness is just one of the ways currently being researched to aid in the

management of prenatal stress. Prenatal yoga is another method of stress

management. Babbar, Parks-Savage, and Chauhan (2012) conducted a systematic

review of research concerning yoga during pregnancy. They found that although 15

million adults in the United States practice yoga, and the roots of yoga coincide with

the traditional goals of childbirth education (reducing pain and anxiety through

relaxation techniques), there has been very little published when it comes to yoga

during pregnancy. However, of the few studies reviewed (8), participants reported

improved quality of life, decreased stress, anxiety, and sleep disturbances when

practicing yoga during pregnancy. However, the researchers do note major limitations

within the studies reviewed – the only database utilized was PubMed, sample sizes

were small, there was poor study design, five of the eight studies included middle to

upper class women, and half of the studies were conducted in India, where yoga is

more culturally acceptable. Further research with larger sample sizes and more

diverse populations are needed to increase generalizability.

In a similar study, Curtis, Weinrib, and Katz (2012) conducted a systematic

review on pregnancy and yoga. However, they used six different research databases,

and reviewed a total of six controlled studies. Overall, the research suggests that yoga

is well indicated for pregnant women during a time of intense physical change, and

that women practicing prenatal yoga experienced significantly less preterm birth and

fewer delivery complications than those in control groups. However, the researchers

18

note that randomization was a particular challenge in the studies reviewed. In

addition, there was a lack of diversity among all studies reviewed, and differing

definitions of “yoga” which leads to a lack of certainty in the aforementioned review.

Chuntharapat, Petpichetchain, and Hatthakit (2007) conducted a randomized-

controlled trial on the effects of prenatal yoga on maternal comfort, labor pains and

birth outcomes. Participants in the experimental group received a series of six, 60-

minute yoga practice sessions, at the 26-28th, 30th, 32nd, 34th, 36th, and 37th week of

gestation. The yoga program combined educational activities, yoga asanas, breathing

awareness, and chanting. In addition, the women were provided a booklet and tape

cassette for self-study that explained the principles and benefits of each yoga practice.

All participants were asked to practice at home at least three times a week (for a

minimum of 10 minutes). They were asked to maintain a record of their home-

practice via a diary. In addition, weekly telephone calls were made by researchers to

increase compliance.

Participants in the control group received routine nursing care from hospital

nurses. The researchers engaged in casual conversation with the participants for

approximately 20-30 minutes during each of their regularly scheduled hospital visits.

Yoga instruction was not provided to the control group. In addition, weekly telephone

calls were made by researchers to each participant (Chuntharapat, Petichetchain &

Hatthakit, 2007).

The experimental group demonstrated significantly higher maternal comfort at

all three assessment times during labor, as well as two hours after birth when

19

compared to the control group. In addition, each of the three times pain was assessed

during labor, the experimental group reported significantly lower scores in labor pain

than did the control group. Furthermore, there were significant differences in the

duration of the first stage of labor as well as the total duration of labor between the

two groups (with the experimental group experiencing significantly shorter durations

for both the first stage and total duration of labor). No differences were found

between the two groups in Apgar scores, or the use of pain medication during labor

(Chuntharapat, Petichetchain, & Hatthakit, 2007).

The researchers suggest that because yoga practice involves a synchronization

of breathing awareness and relaxation, participants in the experimental group

remained relatively comfortable and “in control” even as labor intensified. In

addition, yoga practice and breathing awareness have been shown to be beneficial to

spine flexibility and the circulation of cerebrospinal fluid (CSF) around the brain and

spinal cord. The increased availability of CSF endorphins and serotonin, as a result of

increased CSF circulation, could have assisted the participants in raising the threshold

of the mind-body relationship to pain (Chuntharapat, Petichetchain & Hatthakit,

2007).

Combining Mindfulness and Yoga During Pregnancy

Beddoe et al. (2009) examined the effects of mindfulness-based yoga during

pregnancy on maternal and physical distress. The seven-week mindfulness-based

yoga group combined elements of Iyengar yoga and mindfulness-based stress

reduction. Sixteen healthy, nulliparous pregnant women with singleton pregnancies

20

between 12 and 32 weeks gestation at the time of enrollment were included to

participate in the study. Measurements were taken using the perceived stress scale

(PSS), prenatal psychosocial profile (PPP), state-trait anxiety inventory (STAI), and

brief pain inventory (BPI), as well as a salivary collection to measure cortisol levels.

All data was collected at baseline prior to the beginning of the first class, and again

after completion of the seven-week class.

At baseline, participants reported moderate levels of perceived stress. There

was a significant decrease in perceived stress (p = .05) from baseline to post-

intervention, but only in the group of women in their third trimester. In addition, life

stressors and hassles were measured using the PPP. At baseline, participants reported

low levels of stressors, and while there was a trend toward decreasing stressors in

both the second and third trimester groups, it was not significant. Again, the decrease

in stressors was greater for the third trimester group, but not enough to be significant.

In a much larger study, Narendran, Nagarathna, Narendran, Gunasheela, and

Nagendra (2005) examined the impact of yoga and meditation on the pregnancy

outcomes of 335 women in Bangalore, India. The women, who were all enrolled

between 18-20 weeks gestation, were divided into either a control group (n=166) or a

yoga group (n=169). Women in the control group were instructed to for 30 minutes

twice a day, whereas women in the yoga group participated in one hour daily of yoga

practice including physical postures, breathing exercises, and meditation until

delivery.

21

The researchers found several significant differences. First, the number of

babies with a birth weight greater than or equal to 2,500 g was significantly higher in

the yoga group when compared to the control group (Narendran et al., 2005). In

addition, both preterm labor and complications such as pregnancy-induced

hypertension, were significantly lower in the yoga group than in the control group

(Narendran et al., 2005). These findings are important as research has already shown

that low birth weight can set a child up for a wide range of developmental and health

problems later on.

22

CHAPTER III

METHODOLOGY

Overview

The purpose of this study was to focus on mindfulness-based prenatal yoga,

and its effects on maternal stress, through work with Blossom Birth Services. Because

stress can be harmful to the health of a pregnant mother and her developing child, the

purpose of the study was to examine the impact of mindfulness-based prenatal yoga

on stress levels in women, both prenatally and three months post-partum. This study

was descriptive in nature, utilizing both qualitative and quantitative data. The study

was guided by two major research questions. First, do pregnant women who

participate in the mindfulness-based prenatal yoga classes experience a decrease in

stress during their pregnancy? Second, will mindfulness skills be sustained after the

conclusion of the 12-week course?

The researcher hypothesized that mothers who participated in the pilot

program would show decreases in prenatal stress scores as their time in the program

increased, as compared to their baselines scores. The researcher hoped that these

findings would influence an increased awareness about the positive benefits of

mindfulness yoga during pregnancy to reduce stress.

Research Design

The study was a descriptive, longitudinal study that utilized both qualitative

and quantitative data. Blossom Birth, a non-profit in Palo Alto, CA is providing a 12-

23

week mindfulness-based prenatal yoga pilot program to pregnant women in their

second trimester. This study was part of a larger study that is examining the

effectiveness of this program with regard to prenatal stress, prenatal and maternal

attachment and mindfulness. This particular study focused on prenatal stress and

mindfulness among the participants. The participants completed several instruments

at baseline (prior to the start of the program) 6-weeks into the program, conclusion of

the program, and 3 months post-partum. In addition, participants took part in weekly

“group sharing sessions” as well as two focus groups – one at the conclusion of the

program, and another four months after program conclusion. There was no control

group, but instead, the researcher compared the participants’ own baseline scores to

those recorded at 6-weeks, program conclusion, and four months after program

conclusion. The use of both qualitative and quantitative data enabled the researcher to

measure the impacts the program had on participants’ stress and mindfulness while

also understanding the individual experiences of participants. It also provided for

further information outside the instrumentation utilized. Quantitative data was

collected through the use of a demographic profile, Prenatal Psychosocial Profile

(PPP), and Five Facet Mindfulness Questionnaire (FFMQ).

Sampling Plan

A non-probability purposive sample was used. Participants were accessed

through Blossom Birth Services (Palo Alto, California), a non-profit education and

resource center for pregnancy, childbirth, and early parenting. Women who were

interested in taking part in the mindfulness-based prenatal yoga classes were screened

24

for the criteria and asked if they would be willing to participate in the entire program,

including the 12-week bi-weekly classes and the research, by Blossom, as part of a

grant received by them through the Bella Vista Foundation. Participants needed to

meet the following criteria to be included in the 12-week pilot program: (a) first time

pregnant mother between 18-35 years old who is in her second trimester of

pregnancy, and (b) functional knowledge of written and verbal English. Exclusion

criteria included: (a) current medical illness (diabetes, HIV), (b) mental illness, (c)

self-reported drug use, (d) previous mindfulness training or coursework, or (e) prior

regular or extensive yoga practice. The program began with nineteen women enrolled

in the program.

Blossom Birth recruited the participants for the program through collaboration

with multiple community organizations. The Executive Director and staff of Blossom

presented information about the program to the various organizations in effort to

recruit participants who met the criteria for participation. During the recruitment

process, it was emphasized that due to the requirements of the grant, Blossom needed

to evaluate this pilot program and therefore, participants who choose to be a part of

the program needed to complete the research along with the mindfulness based

prenatal classes.

Data Collection

Data was collected for the entire duration of the program (12 weeks).

Additionally, a final round of data was collected four months after program

conclusion (the post-partum period). The researcher, along with another research

25

assistant, distributed the questionnaires to the participating women on the first day of

classes to collect baseline data (before classes began), then again immediately prior to

class at six weeks, at the conclusion of the program, and again four months after

program conclusion. All instruments were self-administered to participants

themselves. It took participants approximately 15 minutes to complete the necessary

instruments.

The study originally intended to conduct informal individual interviews with

the participants at the end of each class session to capture their experiences during the

classes. However, logistically this became difficult as the participants needed to leave

immediately following the end of classes due to multiple reasons. Additionally, the

format of the classes included a brief group sharing once weekly, as well as a longer,

more in-depth sharing circle weekly, in which the participants had the opportunity to

share how the mindfulness-based yoga classes were impacting their physical and

emotional health, as well as their current struggles. In addition, all participants took

part in two focus groups – one at the end of the program, and another four months

after program conclusion to gain a more in-depth of their individual and collective

experiences in the program. All participants signed an informed consent form before

taking part in the study, and the study went through the review process of the

California State University, Stanislaus Institutional Review Board, and was approved.

26

Instrumentation

The researcher utilized three different instruments for data collection. These

instruments included a basic demographic profile, Prenatal Psychosocial Profile

(PPP), and the Five Facet Mindfulness Questionnaire (FFMQ).

Demographic Profile

The basic demographic profile collected information on the participants’ age,

relationship status, ethnicity, income, education, gestational weeks, health history,

and past experience with yoga and mindfulness. This was only collected once at the

beginning of the program.

Prenatal Psychosocial Profile (PPP)

The Prenatal Psychosocial Profile (PPP) stressor subscale (Curry, Burton, &

Fields, 1998) was used. This scale asked women to indicate on a 4-level scale (1 no

stress to 4 severe stress) the extent to which each of 11 items (e.g., financial worries

and feeling ‘‘generally overloaded’’) was a current stressor or hassle. Average PPP

scores have been between 18 and 20 (range 11-44) in studies of culturally diverse

pregnant women. Available data suggest good internal consistency (a 5 .73-.78) and

test-retest stability (.82) (Curry, Campbell, & Christian, 1994).

Five Facet Mindfulness Questionnaire (FFMQ)

The Five Facet Mindfulness Questionnaire (FFMQ) (Baer, Hopkins,

Krietemeyer, Smith, & Toney, 2006) was used. The FFMQ is a 39-item measure that

focuses on five facets of mindfulness: observing (e.g., "I notice when my moods

begin to change"), describing (e.g., "I'm good at finding words to describe my

27

feelings"), acting with awareness (e.g., "When I do things, my mind wanders off and

I'm easily distracted"), non-judging of inner experience (e.g., "I criticize myself for

having irrational or inappropriate emotions"), and non-reactivity to inner experience

(e.g., "I perceive my feelings and emotions without having to react to them"). Items

are rated on a 5-point Likert scale ranging from "never or very rarely true" to "very

often or always true," with higher scores indicating higher levels of mindfulness.

Cronbach's alpha for FFMQ subscales ranged from .79-.94 over the two time points

(Baer et al., 2006).

Data Analysis

The questionnaires were collected and then coded and entered into SPSS. The

instrument scores were calculated as per instructions provided by each instrument.

Parametric tests – specifically within-subject analysis of variance (ANOVAs) were

conducted to examine effects of time and differences in scores. In order to analyze the

qualitative data, recorded focus groups were transcribed and analyzed for recurrent

patterns and themes.

Protection of Human Participants

There were two levels of protection offered to participants in the program,

overall. The first related to Blossom Birth Services process and the eligibility to even

apply to this program and the second related to the evaluation piece. Blossom

required that all of its clients sign a waiver form that states that the participant,

“assume(s) full responsibility for my actions in this class. I also assume responsibility

for any actions I take or choose not to take related to issues discussed in this class. I

28

will participate only to the degree that is appropriate for me. Should any injury occur,

I agree not to hold liable Blossom Birth, staff, volunteers, or instructors.” Also,

Blossom Birth Services required every potential applicant to provide an approval

form signed by their primary care physician in order to be considered for this

program.

The evaluation of the program began after IRB approval. The participants

were informed by Blossom during the application and selection process that as part of

their voluntary participation in this Pilot Program they were also agreeing to complete

the tools/focus groups to help evaluate the program as the complete pilot project was

funded by the Bella Vista Foundation and they could choose to not be part of the pilot

program without any penalty or loss of benefits. Participants were notified that the

data obtained would be protected from inappropriate disclosure under the law and it

would be securely locked during the course of the study. They were informed that

their individual names or any kind of identifying information would not be reported

in the study report; that all findings would be reported in aggregate. They were also

informed that all notes would be shredded and tapes erased one year after the

completion of the study.

29

CHAPTER IV

RESULTS

The purpose of this hybrid quantitative and qualitative study was to assess the

effectiveness of the mindfulness-based prenatal yoga pilot program offered through

Blossom Birth Services, as it pertains to prenatal stress and mindfulness skills. The

research was guided by the following questions:

1.) Do pregnant women who participate in the mindfulness-based prenatal

yoga program experience a decrease in stress during their pregnancy?

2.) Will mindfulness skills be sustained after the conclusion of the 12-week

program?

All quantitative data was collected via paper surveys during the twelve-week

program. The final round of data was collected via a combination of paper surveys

(Prenatal Psychosocial Profile and Five Facet Mindfulness Questionnaire), and

electronic surveys via SurveyMonkey. All quantitative data was coded, entered and

analyzed via SPSS. Qualitative data was collected via two focus groups – one at the

conclusion of the twelve-week program and another four months after the conclusion

of the program. The focus groups were transcribed and analyzed for patterns and

themes that emerged.

Overview of Sample

Nineteen women were enrolled in the beginning of the 12-week program. A

total of 15 women completed the program. Premature birth was the main reason for

30

women leaving the program before the scheduled date (n = 2). The average age at the

onset of the program was 30.158 years old. At the onset, the average weeks gestation

was 20.63 with a range from 14 weeks to 29 weeks. See Table 1 for means and

standard errors. Of the 15 participants that completed the program, 86.67% (n = 13)

were married while 13.3% (n = 2) reported living with a partner. A majority of the

participants (53.3%, n = 8) were Caucasian, three (20%) were Asian American, and

26.67% (n = 4) reported their ethnicity as “other.” See Table 1 for means and

standard errors. The majority of participants (60%, n = 9) reported having attended

graduate/professional school, while 40% (n = 6) reported having attended college.

When it came to employment status, 60% (n = 9) were employed full-time, 20% (n =

3) were employed part time, and 20% (n = 3) were unemployed. In regards to total

approximate family income, 60% (n = 9) of participants reported above $100,000,

while 20% (n = 3) reported $50,001-$100,000, 13.33% (n = 2) reported $25,000-

$50,000, and 6.67% (n = 1) reported less than $25,000. Finally in regards to health

care coverage, 80% (n = 12) reported having private insurance, 13.33% (n = 2)

reported “other coverage,” and 6.67% (n = 1) reported Medicaid. See Table 1 for

further demographic information and Appendix B for a copy of the demographic

questionnaire

Table 1 Demographic Information

Mean N Std. Error

Age 19 1.01 Weeks Pregnant at Onset 19 1.03

31

Analysis of Prenatal Psychosocial Profile (PPP) – Measure of Maternal Stress

Participants completed the Prenatal Psychosocial Profile, which consists of

eleven items. Participants assigned scores to each item on a scale of 1-4 (where 1 =

no stress, 2 = some stress, 3 = moderate stress, and 4 = severe stress) at each of the

four time points (baseline, 6-weeks into the program, program conclusion, and 4-

months after program conclusion). Scores on each item were entered into SPSS for

analysis. See Appendix C for a copy of the PPP.

A 4 X 11 (administration time by Prenatal Psychosocial Profile item) within-

persons ANOVA was computed on the Likert-scaled item scores on the Prenatal

Psychosocial Profile. The ANOVA revealed a significant main effect of time, F (3,

42) = 7.074 MSE =.266, p = .001), η2 = .336. See Table 2 for the means and standard

errors.

Table 2 Means and Standard Errors by Time

Measure: Stress

95% Confidence Interval

Time Mean Std. Error Lower Bound Upper Bound

1 1.72 .076 1.55 1.88

2 1.58 .076 1.41 1.74

3 1.46 .076 1.31 1.60

4 1.56 .076 1.44 1.70

Post-hoc analysis of pairwise comparisons revealed that PPP scores at Time 3

(M=1.455; SE=.066) were significantly lower than PPP scores at baseline Time 1

32

(M=1.715; SE=.076), p = .006. There was a significant main effect of item number F

(10, 140) = 16.859 MSE =.642, p = .0001), η2 = .542.

Pairwise comparisons revealed that scores on items 5,7, and 8 differed

significantly from all other items, except for item 10. Items 5, 7, and 8 had the lowest

mean overall scores. There was a significant time by item interaction, F (30, 420) =

2.370, MSE =.203, p = .0001), η2 = .145. See Table 3 for means and standard

errors.

Table 3 Means and Standard Errors by Item Measure: Stress

In addition, there were six individual items on the PPP instrument that account

for the significant differences between baseline and time 3. These items included (1)

financial worries, (2) other money worries, (3) problems related to family, (4) having

to move, either recently or in the future, (9) work problems, and (11) feeling

95% Confidence Interval Item Mean Std. Error Lower Bound Upper Bound

(1) Financial Worries 1.867 .152 1.540 2.193 (2) Other money worries 2.150 .169 1.788 2.512 (3) Problems related to family 1.683 .099 1.471 1.896 (4) Having to move, either recently or in the future

1.683 .200 1.254 2.113

(5) Recent loss of a loved one 1.067 .052 .956 1.177 (6) Current pregnancy 1.767 .096 1.561 1.972 (7) Current abuse, sexual, emotional, or physical

1.017 .017 .981 1.052

(8) Problems with alcohol and/or drugs

1.000 .000 1.000 1.000

(9) Work problems 1.683 .102 1.465 1.902 (10) Problems related to friends 1.300 .074 1.141 1.459 (11) Feeling generally “overloaded” 2.133 .133 1.847 2.419

33

generally overloaded. See Table 4 for means and standard errors for these items at

baseline and time 3.

Table 4

Means and Standard Errors for Time 1 and Time 3 (Stress) Time Item Mean Std. Error

(1) Financial Worries 2.000 .218 (2) Other money worries 2.333 .211 (3) Problems related to family 1.800 .107 (4) Having to move, either recently or in the future 1.800 .279 (9) Work Problems 2.000 .195

1

(11) Feeling generally overloaded 2.267 .206 (1) Financial Worries 1.7333 .182 (2) Other money worries 1.800 .200 (3) Problems related to family 1.400 .131 (4) Having to move, either recently or in the future 1.467 .165 (9) Work Problems 1.467 .133

3

(11) Feeling generally overloaded 2.000 .169

Five Facet Mindfulness Questionnaire

Participants completed the Five Facet Mindfulness Questionnaire (FFMQ),

which consists of 39 items, which were broken down into 5 separate subscales of

mindfulness. Fifteen of the 39 items were reverse coded. The subscales include: (1)

observing, (2) describing, (3) acting with awareness, (4) non-judging of inner

experience, and (5) non-reactivity to inner experience. See Appendix D for a copy of

the Five Facet Mindfulness Questionnaire. The mean score across items was used to

compute the subscale scores.

Fifteen of the 39 items were reverse coded. Participants assigned scores to

each of the items on a scale of 1-5 (where 1 = never or very rarely true, 2 = rarely

34

true, 3 = sometimes true, 4 = often true, and 5 = very often or always true). A 4 X 5

administration time by mindfulness facet within-persons ANOVA was calculated on

the mean Likert-scaled item scores for each subscale on the Five Facet Mindfulness

Questionnaire.

The ANOVA revealed a significant main effect of time F (3, 39) = 19.775 (p

= .001) MSE = .277, η2 = .603. See Table 5 for means and standard errors. Post-hoc

analysis of pairwise comparisons revealed that there was a significant increase in

mindfulness scores from baseline to time 2 and baseline to time 3. See Table 5 for

means and standard errors.

Table 5 Means and Standard Errors for Five Facet Mindfulness Questionnaire Scores Measure: Mindfulness Time Mean Std. Error 1 2.92 .048 2 3.30 .072 3 3.49 .075 4 2.94 .085

Further examination reveals differences in the five subscales on the Five

Facet Mindfulness Questionnaire. There were significant increases in all five facet

scores (observing, describing, acting with awareness, non-judging of inner

experience, and non-reactivity to inner experience) from baseline to time 2 and

baseline to time 3. At time 4, there were significant increases in observing (facet 1)

and non-reactivity to inner experience (facet 5), when compared to baseline (time 1).

See Table 6 for means and standards errors for these items.

35

Table 6 Means and Standard Errors for Time x Facet Interaction Measure: Mindfulness

95% Confidence Interval Time Facet Mean Std. Error Lower Bound Upper Bound

(1) Observing 3.170 .145 2.856 3.483 (2) Describing 3.205 .213 2.746 3.665 (3) Acting with awareness

2.884 .129 2.604 3.163

(4) Non-judging of inner experience

2.777 .204 2.336 3.217

1

(5) Non-reactivity to inner experience

2.571 .137 2.275 2.868

(1) Observing 3.545 .107 3.314 3.776 (2) Describing 3.491 .194 3.073 3.909 (3) Acting with awareness

3.054 .133 2.767 3.340

(4) Non-judging of inner experience

3.536 .167 3.175 3.896

2

(5) Non-reactivity to inner experience

2.878 .150 2.554 3.201

(1) Observing 3.616 .118 3.361 3.872 (2) Describing 3.616 .168 3.253 3.979 (3) Acting with awareness

3.348 .156 3.011 3.686

(4) Non-judging of inner experience

3.750 .170 3.383 4.117

3

(5) Non-reactivity to inner experience

3.122 .157 2.783 3.462

(1) Observing 3.455 .172 3.083 3.827 (2) Describing 3.134 .080 2.961 3.307 (3) Acting with awareness

2.714 .129 2.436 2.992

(4) Non-judging of inner experience

2.554 .229 2.059 3.048

4

(5) Non-reactivity to inner experience

2.837 .154 2.504 3.170

36

Analysis of Qualitative Data In addition to the quantitative data, participants also took part in two separate

focus groups. The first focus group took was held at the conclusion of the program

(Time 13, 12-weeks) and the second focus group was held four months after

conclusion of the program (Time 4) at a class reunion.

Conclusion of Program Focus Group

Analysis of the focus group at the conclusion of the 12-week program

revealed an overwhelming theme– the women all agreed that they felt their stress

levels had decreased and every response as to how they were coping better was

deeply connected to the elements of mindfulness. There were a other few themes that

emerged, these include the ability to cope with life stressors, to be present, and how

mindfulness was impacting other areas of the participant’s lives, such as their

relationships and employment.

When asked about coping with stressors at the conclusion to the program (as

compared to the beginning of the program), the general response was one that showed

a tremendous increase in one’s ability to cope and to handle “the things that life threw

at them.” Participants reported handling stressors related to employment, their

emotions, and interactions with others with less energy and stress than prior to the

mindfulness training.

In addition, the women reported that their ability to “be present for the

unfolding” and to “just be there and experience what’s there” had impacted not only

their stress levels, but relationships, pregnancy, and at their places of employment.

37

The participants developed the ability to “sit with it [emotion] and just accept it and

realize that your emotions are just a reaction to something that happened, and its okay

to just sit there with it.” Another woman shared, “I find it’s [mindfulness skills]

helping me with accepting stress. It’s helpful to work on focusing on my breath and

frustration tolerance, and I’m definitely better with it. I’m able to calmly deal with

crises now.”

In addition, nearly all of the women involved in the program reported that the

mindfulness skills had “leaked” into their daily lives – at home, at work and in their

relationships. For example, one participant shared, “I had us [myself and my

husband] have a mindful conversation together, just sit and really listen to each other.

It was really great because sometimes you realize that you have no idea what the

other person is saying. It is really nice to concentrate on the words coming out of the

other person’s mouth.”

The mindfulness skills learned in the program had reached far beyond their

pregnancies, something that they had not expected, “it [the mindfulness skills] has

become so much more a part of my daily life that I know it’s made a big difference in

my stress.” Another participant reported a similar experience, “I definitely approach

stress differently now [than before the program]. I acknowledge the thought, realize it

is something I am going to think again, but don’t let it take me away from the

moment I am in.” Another participant reported, “it [the mindfulness skills] is helping

me with accepting stress.”

38

Focus Group Four Months after Program Conclusion

Finally, analysis of the focus group four months after the conclusion of the

program presented a much different dynamic. All of the participants had given birth

since the previous focus group, and just about every aspect of their lives was

different. However, despite the reported increases in stress and decreases in sleep, the

mothers continued to report how the mindfulness skills learned in the program were

impacting their lives in a positive way.

One of the themes that emerged was the use of mindfulness skills as a way to

cope with labor. One woman shared, “I remembered that you need to be present in the

moment [during labor], it was kind of hard but I would remind myself I need to enjoy

this.” Another mother shared:

The mindfulness and yoga during my labor, it was the number one thing that

helped me, it should be a requirement for all moms… I remember [the class

instructor] telling me, ‘just breathe, stay present, self-compassion’ and I don’t

know what I would’ve done without it.

Another theme continued to be the overall use of mindfulness skills in daily

life as a new mother. All of the women agreed that it was more difficult to use

mindfulness with a newborn, but that the times they were able to; made a difference.

One woman shared [after bringing a newborn home], “everything felt so hard… I

definitely employed those [mindfulness] techniques without even noticing.” Another

mother expressed:

39

My baby is only 2 weeks old, and I feel like I can’t even think straight and I

feel like I’m using ‘battlefield mindfulness.’ All I can do is remember to take

a deep breath every now and then and I find that super helpful.” Another

mother expressed, “I am very grateful, letting things unfold and letting go was

a huge blessing for me. Probably something I will have for the rest of my life.

Summary

The data collected revealed promising results as to the sustainability of certain

mindfulness elements, specifically those related to observing and non-reactivity of the

inner experience. While maternal stress levels did not remain lower than baseline at

time 4 (4 months after the conclusion of the program), there were promising

improvements in stress during the program. In addition, the data collected revealed

promising results as to the sustainability of certain mindfulness practices – showing

sustained improvements in two of the five mindfulness facets (observing and non-

reactivity to inner experience).

The qualitative data revealed a more in-depth explanation of what the

quantitative data showed. Mindfulness skills, though more difficult to use after giving

birth, were still playing a positive role in the lives of these women, helping them cope

with the stressors of being first time mothers. The mindful moments, no matter how

small, were sustainable, something that has become a part of daily life for these

women.

40

CHAPTER V

DISCUSSION

Introduction

The purpose of this mixed-method qualitative and quantitative study was to

examine the impact that the 12-week Mindfulness Based Prenatal Yoga pilot program

had on maternal stress. A descriptive study was conducted with fifteen pregnant

women who participated in bi-weekly classes for twelve weeks. Data were collected

via standardized surveys (Prenatal Psychosocial Profile and the Five Facet

Mindfulness Questionnaire) as well as semi-structured focus groups at the conclusion

of the program, and four months after the conclusion of the program. The major

themes of the qualitative data were analyzed with the intention of providing a more

in-depth explanation of what the quantitative data revealed.

This chapter summarizes the results of the study and compares the findings

with the existing literature, examines the limitations of the study and provides

recommendations for future research. This chapter ends with a discussion of the

implications for social work practice and policy.

Major Findings

This study examined two key elements – maternal stress levels and maternal

mindfulness. In regards to stress, one of the major findings was that stress levels

decreased significantly from baseline (time 1) to program conclusion (time 3). This

finding was consistent with the literature, as the literature reviewed also suggests that

41

for women involved in some sort of mindfulness-based training, stress levels are

significantly lower at program conclusion as when compared to baseline (Dunn et al.,

2012). This suggests that mindfulness-based programs are safe and effective

interventions for stress reduction during pregnancy.

In regards to stress, another major finding was that stress levels four months

after program completion (time 4, post-partum period) were not statistically different

than stress levels at baseline (time 1). This finding was somewhat consistent with the

literature, which in itself revealed inconsistencies. The literature reviewed found

significantly lower stress scores from baseline to six weeks post-partum (Dunn et al.,

2012). It is important to note that the literature reviewed involved a mindful-based

cognitive therapy program, although the elements of mindfulness remain the same,

the mindful-based cognitive therapy was facilitated by a psychiatrist and a counselor,

so there may have been a specific emphasis placed on stress reduction instead of the

overall mindful experience. In addition, in the literature reviewed, the instrument used

to measure stress was not specific to pregnancy, so that may account for the

differences in findings, as the current research used an instrument designed to

measure stress related to pregnancy. However, in a similar study, Vieten and Astin

(2008) found no post-partum differences in stress levels of participants in the

intervention group in their mindfulness-based cognitive therapy program (three

months after program conclusion).

In terms of mindfulness, one of the major findings was that mindfulness skills

increased from baseline to time 2 (6-weeks, halfway through the program). This

42

finding was unfounded in the literature as none of the programs reviewed assessed

mindfulness levels halfway through the program (or at any point beyond program

conclusion and the post-partum period). However, in regards to the general research

(not specifically pregnant women), the literature has shown significant increases in

mindfulness within two weeks of beginning a mindfulness-based stress reduction

program for individuals with stress related to chronic pain, chronic illness, and other

life stressors (Baer, Carmody, & Hunsinger, 2012).

Another finding was that mindfulness skills increased significantly from

baseline to time 3 (12-weeks, program conclusion). This finding was consistent with

the literature reviewed, which suggests that mindfulness skills are higher at

conclusion of interventions that teach elements of mindfulness skills (Vieten & Astin,

2008; Dunn et al., 2012; Beddoe et al., 2009).

In regards to mindfulness skills, another major finding was that overall

mindfulness scores were not significantly different four months after program

conclusion (during the post-partum period), as compared to baseline. This finding

was inconsistent with the literature, which revealed mindfulness levels remaining

significantly higher during the post-partum period as compared to baseline (Dunn et

al., 2012). It is important to note that this study involved mindful-based cognitive

therapy, and that the last of the eight sessions focused entirely on reviewing and

planning for regular mindfulness practice. This detail alone, may account for the

difference in findings as participants in that program were specifically trained on how

to incorporate mindfulness into their daily lives (Dunn et al., 2012). Also, this study

43

did not examine the duration or frequency of practice post-partum. It is likely that

continual practice of mindfulness is essential to maintaining high scores on

mindfulness measures.

However, even though analysis of the quantitative data revealed no significant

differences from baseline to time 4 (in terms of mindfulness), analysis of the

qualitative data revealed that participants had continued to utilize the mindfulness

skills acquired during the program, and that the skills were impacting their lives in a

positive way – participants reported greater coping with life stressors and improved

relationships. This finding was consistent with other qualitative literature, which also

found that women who participated in mindfulness programs during pregnancy

reported continuing to use mindfulness skills after program conclusion (Dunn et al.,

2012).

In terms of mindfulness, the last major finding revealed that when reviewed

more specifically, mindfulness skills related to observing and non-reactivity to inner

experience remained significantly higher at time 4 (four months after program

conclusion, post-partum period) as compared to baseline. There was no available

research examining the sustainability of specific mindfulness facets post-intervention.

It is possible that these differences were a result of an increased focus by the

instructor on the non-judging of experiences, just observing and “being in the

moment.”

44

Limitations of the Study

One of the main limitations of the study was that there was no control group,

so it was difficult to interpret (from a quantitative perspective) participant stress and

mindfulness scores after conclusion of the program, as the literature states the with

the birth of a baby comes a great deal of stress. During the post-partum period,

women report feeling stress about sleep, their child’s health, disappointment or lack

of support from a partner, financial worries, guilt over returning to work and their

bodies, among other things (Hung, Lin, Stocker, & Yu, 2011).

In addition, there was a small sample size (n = 15), and the participants were

primarily well educated, and more affluent when compared to the general population.

The location of the pilot program, in an affluent area, may have prohibited women in

a lower socioeconomic status from being able to participate, due to barriers such as

time for travel and time off of work or away from family. In addition, the sample only

included women who were committed to the 12-week program in its entirety, this

could have unintentionally only included women who were most interested in

learning more about mindfulness and pregnancy.

Implications for Future Research Future research would benefit from a study involving a larger, more diverse

sample size, with a control group. A control group would assist in understanding

stress levels, and where they might be after having a newborn baby, without any

mindfulness or prenatal yoga training. This would enable researchers to compare

stress levels between new mothers with and without mindfulness training. In

45

addition, more research examining the long-term sustainability of the mindfulness

skills (beyond 4 months) would be helpful in the further design of programs. This

knowledge would make it known if and when “refresher” mindfulness courses may

need to be offered, or for just how long the mindfulness skills remain. Finally, a study

providing a similar program, but also examining the health of the babies of women

involved in the program would have the potential to drastically change how society

views pregnancy and the importance of simple, safe interventions for stress reduction.

As mentioned throughout, the impacts of exposure to prenatal stress on a developing

child can be severe, and long-lasting. If found effective, research examining the

impact of maternal mindfulness on the development of children (both in-utero and

after birth) has the potential to reduce rates of preterm birth and low birth weight.

Implications for Social Work Practice and Policy

From this study, we can extrapolate that mindfulness based prenatal yoga has

the potential to decrease maternal stress levels and increase mindfulness skills during

pregnancy, and that it appears as though mindfulness skills remain sustainable post-

delivery. Social workers are trained to provide supportive services to clients,

therefore, if social workers are aware of safe, effective interventions, such as the one

demonstrated in this program, they would be able to link clients with those resources

and meet their ethical responsibility to promote the general welfare and wellbeing of

those they serve. Social workers can advocate for similar programs to be

implemented due to its safe, cost-effective qualities.

46

In addition, the core value of mindfulness – being present without being

judgmental, falls directly in line with the core of social work practice – being present

with clients without being judgmental. When social workers are truly present without

judgment for clients, they are able to provide the empathy and compassion clients

often need to work through difficult struggles. In addition, modeling non-judgment,

empathy and compassion to clients can also assist them in learning to be non-

judgmental within their own lives (toward themselves and others). With non-

judgment comes acceptance.

In addition, mindfulness practice can be empowering and promotes resiliency

(Garland, 2013). While research on mindfulness is an emerging area, it has the

potential to greatly impact social work as a profession. From a policy perspective, it is

possible that as we continue to discover the impacts that mindfulness can have on

many of the populations that social work as a profession serves, mindfulness training

may one day become a crucial part of social work education and training. Emerging

research has already proven mindfulness to be a successful, safe, cost-effective

intervention for certain issues such as reducing depressive symptoms when compared

to anti-depressant medication (Garland, 2013).

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48

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APPENDICES

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APPENDIX A

INFORMED CONSENT

Faculty from California State University, Stanislaus are collaborating with Blossom to do a pilot study on the 12-week Mindfulness Based Prenatal Yoga (MBPY) program being offered by Blossom. This program is being offered to you for free through a grant from the Bella Vista Foundation and therefore, and as explained to you during your application and selection process, it includes an evaluation component that is part of the program. The purpose of this evaluation is to explore your pregnancy experiences, your mindfulness, and prenatal and maternal attachment with your growing baby as you go through the program.

Research shows that women who engage in mindfulness training during pregnancy have reduced anxiety during pregnancy and also show greater connection with their unborn child. Research also shows that prenatal yoga significantly lowers preterm labor and improves babies’ birth weight. We are hoping that with your participation you will experience some of these benefits and help us add to the knowledge base on mindfulness and prenatal yoga.

As part of being a participant in the program, you will be requested to complete 4 questionnaires, which will take 30 minutes or so at 4 different points. The first time will be right before you start the 12-week MBPY Program to get a baseline measure. Next, you will be asked to complete the measures 6 weeks into the program followed by at the conclusion of the program and a 3 month postpartum follow-up. Also, during the classes, there will be 2 members of the research team checking with you briefly about how the classes are working for you, including the instructor, the structure, the class ambience, and what we need to do differently for future classes. This will be captured though brief interviews through the duration of the course. The interviews will be recorded with your permission. If you complete all the components of the program and evaluation you will be provided a $50 Blossom gift card. All costs associated with the program including the yoga mat and class materials will be covered.

The information collected will be protected from all inappropriate disclosure under the law. All data will be kept in a secure location. When we report the findings of the study, no individual names will be mentioned and all findings will be reported in aggregate. One year after the completion of the study, all tapes will be erased and all notes will be shredded.

As part of Blossom’s process for including you in the pilot program, you will be required to provide consent from your primary health care provider. There are no risks anticipated as a result of your participation in the evaluation of the study. Your signing the form indicates that you understand you are agreeing to participate in the 12 week MBPY program and its evaluation. If you have any questions about this evaluation please contact me Shradha Tibrewal, at 209-667-3951. If you have any questions about your rights as a human participant, please contact the UIRB Administrator by phone (209)667-3784 or email IRBAdmin@csustan.edu. Thank you for your consideration. Sincerely, Shradha Tibrewal, Ph.D. Professor, California State University, Stanislaus _________________________________________________________________________ Participant Signature Date

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APPENDIX B

DEMOGRAPHIC QUESTIONNAIRE

Demographic Profile Please complete this form by filling in the appropriate information below, and placing an X next to any questions with multiple choice answers. Name: _________________________________ Telephone: ______________________________ Participant Age: _____________________ Weeks Pregnant: _____________________ Date of last prenatal visit: _____________ Your racial/ethnic background: _ (1) European-American (White) _ (2) Asian-American _ (3) Native-American (Indian) _ (4) African -American _ (5) Hispanic _ (6) Other-Please specify: Marital status: _ (1) Single _ (2) Married _ (3) Living with Partner _ (3) Separated _ (4) Divorced _ (5) Widowed _ (6) Other. Please specify ___________________________ What is the highest level of education for you? _ (1) 8th grade or less _ (2) High school _ (3) High school diploma or equivalent _ (4) Junior College/Vocational School _ (5) College _ (6) Graduate/Professional School _ (7) Other-Please specify: Total number of years of education: __________________

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Current employment status: _ (1) Employed full-time _ (2) Employed part-time _ (3) Unemployed _ (4) Retired _ (5) Other-Please specify: ______________________________ Your occupation: ____________________________________ 10. Total approximate annual family income from all sources: _ (1) Less $ 25,000 _ (2) $25,000-$50,000 _ (3) $50,001-$100,000 _ (4) Above $100,000 11. Is English your native language? _ Yes _ No _ Other-Please specify: 12. Do you speak fluent English? _ Yes _ No 13. Are you able to read, comprehend, and write English? _Yes _No Coverage Medicaid ___ Uninsured ___ Private insurance ____ Other coverage _________________

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APPENDIX C

PRENATAL PSYCHOSOCIAL PROFILE

THE PRENATAL PSYCHOSOCIAL PROFILE (PPP) To what extent the following factors are current stressors/hassles. Check the column corresponding to the appropriate response. To what extent are (READ CHOICE) a current Stressor/ hassle for you? Rank of a Scale of 1-4 where 1= No Stress; 2= Some Stress; 3= Moderate Stress; 4= Severe Stress

1 2

3

4

B18A. Financial worries (e.g., food, shelter, health care,

transportation) B18B. Other money worries (e.g., bills, etc.) B18C. Problems related to family (partner, children, etc.)

B18D. Having to move, either recently or in the future.

B18E. Recent loss of a loved one B18F. Current pregnancy B18G. Current abuse, sexual, emotional, or physical

B18H. Problems with alcohol and/or drugs B18I. Work problems (e.g., being laid off, etc) B18J. Problems related to friends B18K. Feeling generally "overloaded'

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APPENDIX D

FIVE FACET MINDFULNESS QUESTIONNAIRE

Five Facet Mindfulness Questionnaire Please rate each of the following statements using the scale provided. Write the number in the blank that best describes your own opinion of what is generally true for you. 1= never or very rarely true; 2= rarely true; 3= sometimes true; 4= often true; 5=very often or always true

1. When I'm walking, I deliberately notice the sensations of my body moving. 2. I'm good at finding words to describe my feelings. 3. I criticize myself for having irrational or inappropriate emotions. 4. I perceive my feelings and emotions without having to react to them. 5. When I do things, my mind wanders off and I'm easily distracted. 6. When I take a shower or bath, I stay alert to the sensations of water on my body. 7. I can easily put my beliefs, opinions, and expectations into words. 8. I don't pay attention to what I'm doing because I'm daydreaming, worrying, or otherwise distracted. 9. I watch my feelings without getting lost in them. 10. 1 tell myself I shouldn't be feeling the way I'm feeling. 11. 1 notice how foods and drinks affect my thoughts, bodily sensations, and emotions. 12. It's hard for me to find the words to describe what I'm thinking. 13. 1 am easily distracted. 14. 1 believe some ofmy thoughts are abnormal or bad and I shouldn't think that way. 15. 1 pay attention to sensations, such as the wind in my hair or sun on my face. 16. 1 have trouble thinking ofthe right words to express how I feel about things 17. 1 make judgments about whether my thoughts are good or bad. 18. 1 find it difficult to stay focused on what's happening in the present. 19. When I have distressing thoughts or images, I "step back" and am aware of the thought or image without getting taken over by it.

20. 1 pay attention to sounds, such as clocks ticking, birds chirping, or cars passing. 21 . In difficult situations, I can pause without immediately reacting. 22. When I have a sensation in my body, it's difficult for me to describe it because I can't find the right words.

23. It seems I am "running on automatic" without much awareness of what I'm doing. 24. When I have distressing thoughts or images, I feel calm soon after. 25. 1 tell myself that I shouldn't be thinking the way I'm thinking. 26. 1 notice the smells and aromas of things. 27. Even when I'm feeling terribly upset, I can find a way to put it into words. 28. 1 rush through activities without being really attentive to them. 29. When I have distressing thoughts or images I am able just to notice them without reacting.

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30. 1 think some of my emotions are bad or inappropriate and I shouldn't feel them. 31.1 notice visual elements in art or nature, such as colors, shapes, textures, or patterns of light and shadow.

32. My natural tendency is to put my experiences into words. 33. When I have distressing thoughts or images, I just notice them and let them go. 34. 1 do jobs or tasks automatically without being aware ofwhat I'm doing. 35. When I have distressing thoughts or images, I judge myself as good or bad, depending what the thought/image is about.

36. 1 pay attention to how my emotions affect my thoughts and behavior. 37. 1 can usually describe how I feel at the moment in considerable detail. 38. 1 find myself doing things without paying attention. 39. 1 disapprove of myself when I have irrational ideas.

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APPENDIX E

PROVIDER APPROVAL FORM

Mindfulness Based Prenatal Yoga Pilot Program PROVIDER APPROVAL FORM

__________________________________ is my patient and we have discussed her plans to participate in mindfulness based prenatal yoga during her second and third trimesters and she has my approval to participate. She has no health complications that will put her or her pregnancy at risk as a result of participating in mindfulness based prenatal yoga. She is in her ___________ week of pregnancy and the due date is _______________________________. Additional Provider Comments: ____________________________________________________________________________________________________________________________________________________ PROVIDER SIGNATURE: ________________________________________ Date:____________________ Provider Name: __________________________________________________________________________ Address: ___________________________________________________________________________ Phone No: ___________________________________________________________________________

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APPENDIX F

PRENATAL YOGA PARTICIPATION REGISTRATION

Prenatal Yoga Participation Registration

Please complete this form and return to the instructor. We respect your privacy, and we do not sell, trade, or give personal information.

I assume full responsibility for my actions in this class. I also assume responsibility for any actions I take or choose not to take related to issues discussed in this class. I will participate only to the degree that is appropriate for me. Should any injury occur, I agree not to hold liable Blossom Birth, staff, volunteers, or instructors. Signature, Date ______________________________________________________ Name ____________________________________________________________ Due Date __________________________________________________________ Email ____________________________________________________________ Phone ____________________________________________________________ Address ____________________________________________________________ Emergency Contact ___________________________________________________ How did you hear about this class? _______________________________________

Please complete this form and return to the instructor. We respect your privacy, and we do

not sell, trade, or give personal information.