THE IMPACT OF MINDFULNESS-BASED PRENATAL YOGA ON

MINDFULNESS AND PRENATAL MATERNAL

ATTACHMENT 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

Mayra A. Padilla De Luna

May 2015

CERTIFICATION OF APPROVAL

THE IMPACT OF MINDFULNESS- BASED PRENATAL YOGA ON

MINDFULNESS AND PRENATAL MATERNAL

ATTACHMENT DURING

PREGNANCY

by

Mayra A. Padilla De Luna

____________________________

Shradha Tibrewal, Ph.D.

Professor of Social Work

_____________________________

Jane Rousseau, Ph.D.

Assistant Professor of Social Work

___________________

Date

___________________

Date

Signed Certification of Approval Page

is on File with the University Library

© 2015

Mayra A. Padilla De Luna

ALL RIGHTS RESERVED

iv

DEDICATION

Esta tesis es dedicada a mis padres:

Marielena De Luna y Filemon Virgen.

Ellos fueron la motivación y el ejemplo para seguir luchando. Aunque no

asistieron a la Universidad siempre me brindaron su apoyo moral. Gracias padres por

todo el apoyo y por los sacrificios que hicieron para que yo obtuviera un título

Universitario. Sé que la transición de verme evolucionar, de niña, a toda una

profesional no fue fácil pero gracias a tal sacrificio es que hoy orgullosamente puedo

decir que he cumplido mis metas académicas y el sueño de verme realizada.

v

ACKNOWLEDGEMENTS

This thesis would have not been possible without the support of many people.

I would like to thank every single person that was with me throughout the process of

writing this thesis. It was a rocky road but I would not have made it without all the

emotional support. To all my friends and loved ones, thank you for being there for me

and for understanding the struggle of graduate school. I would also like to thank Dr.

Shradha Tibrewal, for giving me the opportunity to be part of this research and Dr.

Jane Rousseau for all the feedback.

vi

TABLE OF CONTENTS

PAGE

Dedication ............................................................................................................... iv

Acknowledgements ................................................................................................. v

List of Tables .......................................................................................................... viii

List of Figures ......................................................................................................... ix

Abstract ................................................................................................................... x

CHAPTER

I. Introduction ........................................................................................... 1

Statement of the Problem .......................................................... 1

Statement of the Purpose .......................................................... 4

Significance of the Study .......................................................... 5

II. Literature Review.................................................................................. 6

Overview ................................................................................... 6

Importance of Maternal Attachment ......................................... 7

Development of Attachment ..................................................... 8

Benefits of Prenatal Yoga ......................................................... 9

Mindfulness-Based Yoga during Prenatal Period ..................... 12

Mindfulness-Based Yoga and Maternal Attachment ................ 16

Summary ................................................................................... 18

III. Methodology ......................................................................................... 20

Overview ................................................................................... 20

Research Design........................................................................ 21

Sampling Plan ........................................................................... 21

Instrumentation ......................................................................... 22

Data Collection ......................................................................... 23

Plan for Data Analysis .............................................................. 24

Protection of Human Subjects .................................................. 24

IV. Results ................................................................................................... 26

Introduction ............................................................................... 26

vii

Overview of the Sample............................................................ 27

Prenatal Attachment Scores and Change over Time ................. 27

Comparison of Total Prenatal Attachment Scores from

Time1 to Time2............................................................. 27

Mindfulness Scores and Change over Time ............................. 29

Comparison of Total Mindfulness Scores from Time1 to

Time2 ........................................................................... 29

Five Facets of Mindfulness ..................................... 30

Qualitative Findings .................................................................. 32

Summary ................................................................................... 35

V. Discussion ............................................................................................. 37

Introduction ............................................................................... 37

Major Findings .......................................................................... 37

Implications of Social Work Practice and Policy ..................... 41

Limitation of the Study ............................................................. 44

Recommendation for Future Research ...................................... 44

References ............................................................................................................... 47

Appendices

A. Consentimiento ........................................................................................... 55

B. Informed Consent........................................................................................ 56

viii

LIST OF TABLES

TABLE PAGE

1. Prenatal Attachment Percentages ...................................................................... 29

2. Five Facet Mindfulness Questionnaire Percentages ......................................... 32

3. Statements Illustrating a Decrease in Stress and Anxiety ................................. 33

4. Statements Illustrating a Decrease in Back Pain ............................................... 34

5. Statements Illustrating an Awareness of their Body and Baby......................... 35

ix

LIST OF FIGURES

FIGURE PAGE

1. Total Prenatal Attachment Mean Scores ........................................................... 28

2. Total Mindfulness Mean Scores ....................................................................... 30

x

ABSTRACT

Research has shown that maternal attachment is important during pregnancy. A 10-

week Mindfulness- based Prenatal Yoga (MBPY) program, communicated in

Spanish, was offered to Latina pregnant women. This study examined the

effectiveness of this MBPY program on prenatal maternal attachment and

mindfulness levels throughout pregnancy. A total of 14 women were part of the

study. The participants scores were gathered at two different times, baseline (time 1)

and at the end of the program (time 2). Data were collected using the Prenatal

Attachment Inventory to measure attachment, and the Five Facet Mindfulness

Questionnaire to measure mindfulness. Participants’ prenatal attachment and

mindfulness scores increased significantly from baseline (time1) to program

conclusion (time 2).The results for this study indicate that mindfulness-based

programs are an effective intervention that might help increase mindfulness during

pregnancy. Mindfulness-based yoga practice may help participants who are reluctant

to seek traditional treatment to engage in these practice; due to the immediate benefit

they would experience in term of reduced pain. Due to the exploratory nature of the

study, future research can replicate this study with a large sample size because it

would allow generalization to the Latino culture and will add to the knowledge base

of mindfulness-based interventions.

1

CHAPTER I

INTRODUCTION

Statement of the Problem

According to the Center for Health Statistics, 243,722 children were born to

Hispanic mothers in 2010. A woman experiences tremendous physical and emotional

adjustment during the nine month period of their pregnancy- some women may

experience physical challenges, like a decreasing appetite, frequent urination,

decreased lung capacity and breathing issues and lower back pain (Abram, 2008).

Emotional challenges can combine with physical symptoms during pregnancy,

including stress resulting from ongoing lower back pain, reduced sleep, decreased

concentration, and declining work performance. These transitions become part of the

process which may create tension, anxiety and stress. Considerable research reveals

that life changes for a woman when she realizes she is becoming a mother, assuming

the role of the primary caregiver for the infant are significant.

Perhaps one critical element for a successful pregnancy is the ability of a

mother to develop a close bonding relationship with the fetus. Bowlby and Ainsworth

developed a theory of attachment describing bonding as an ongoing process between

individuals, like a child and a parent as cited in Young (2013). If the fetus feels the

attachment early in the pregnancy, it may affect the individual’s social and parenting

relationships across generations (Alhusen, Hayat & Gross, 2013). They may also gain

positive outcomes over their lifespan, including successful physical, psychological

2

and emotional development. However, if parents do not show nurturing and

protective behaviors towards the child, they may experience negative side effects to

their social, emotional and cognitive development (Alhusen, Hayat & Gross, 2013). If

the above factors are present before conceiving or during pregnancy, the process of

fetus/mother attachment may become compromised and create stress. For example, if

the mother is single, low socioeconomic status, has little support and a difficult

history of mental and physical health, her ability to bond with the fetus may be

compromised. (Copeland & Harbaugh, 2005). According to Copeland and Harbaugh,

single mothers will demonstrate more prenatal stress compared to married mothers

because of the lack of internal and external support. Conversely, some positive factors

that impact the relationship with the child are emotional self-awareness, including

recognizing personal needs (Snyder, 2010).

Culture is another potential factor playing a critically important role in a

child’s attachment to the mother and parenting behaviors. Perry, Ettienger, and

Medelson’s (2011) research suggests child attachment can be demonstrated

differently in Latino populations when compared to European-American populations.

For example, Latinas appear to have a slightly lower percentage of securely attached

infants compared with European-American infants (Perry et al., 2011). According to

the study, this is because cultural values differ among European-Americans and

Latinas. One example in the study is that European- American mothers valued the

child’s self-confidence and independency whereas Latina mothers valued the child’s

obedience (Perry et al., 2011). Culture, not only impacts attachment but also access to

3

prenatal care. Shaffer (2002) conducted a study that included 46 Hispanic women

who were asked about the factors influencing their access to prenatal care. All

participants responded that a physician who speaks their language would facilitate

their access to prenatal care. By interacting with someone that understood their

language, participants could express their feelings and know they were being

understood. Another factor mentioned was the physician's cultural sensitivity.

Participants revealed that it helps when the physician is knowledgeable of cultural

customs, expectations and norms other than his or her own. The last factor identified

by Shaffer’s study was limited availability for prenatal care due to transportation,

work schedules, or their husbands.

Mindfulness is an emerging practice that shows promising results regarding

attachment between mothers and their fetus. According to Dhiman (2008), “In its

original Buddhist form, the practice of mindfulness refers to the technique of

developing awareness of the body and the mind in the present moment” (p.

35).Within mindfulness there are two forms of meditation. Samatha Mediation is “the

development of serenity or calm” and Vipassana Mediation is “the development of

insight” (Dihamn, 2008, p. 2). Calm meditation prepares the mind for the individual

to be at peace and stable, transitioning the mind into insight meditation by letting

their mind be clear. Some of the most common components of mindfulness are body

scan, breath concentration, self-compassion and acceptance. Mindfulness is the

connection between the body and the mind creating awareness of the present moment.

Studies show that individuals who practice mindfulness receive both short and long

4

term benefits such as reduction in psychological distress and affective disturbance,

increases in affect/emotional regulation and decreases with overall stress and anxiety

(Snyder, 2010). All these benefits may potentially facilitate the attachment between

mother and fetus.

Additionally, mindfulness can be combined with yoga as a practice during

pregnancy. The meaning of the word yoga is union, unified, yoked together. In

ancient Sanskrit, yoking together is the root sound of the word (Verney, 1987). Yoga

originated from India thousands of years ago and is a combination of physical poses

and meditation (Muzik, Hamilton, Rosenblum, Waxler, & Hadi, 2012). Research

shows that the combination of mindfulness and yoga practice can be powerful;

increasing stress tolerance and sleep quality while also decreasing psychosocial

distress and chronic pain intensity (Muzik et al., 2012). Their research found that

mindfulness based yoga had a positive impact on maternal-fetal attachment. In other

words, the study revealed that mindfulness based yoga provided a supportive

environment during the transition to motherhood, and mothers were able to engage in

healthy behaviors. Even though research on benefits of mindfulness during pregnancy

and postpartum are increasing, there is little research that discusses the correlation

between mindfulness based yoga and prenatal mother-fetus attachment, among the

Latino population.

Statement of the Purpose

The purpose of this exploratory study was to examine if mindfulness based

prenatal yoga correlated to mindfulness and prenatal mother-fetus attachment. The

5

information was gathered through quantitative surveys and a focus group. The

surveys were administered longitudinally at three different periods throughout the 10

week program. There is limited information about mindfulness based prenatal yoga in

Spanish because past research focused on English speaking mothers only. This

research is guided by two major questions. Firstly, does mindfulness based prenatal

yoga have an impact on prenatal attachment of pregnant Latina women? Secondly,

does mindfulness based prenatal yoga have an impact on the mindfulness of pregnant

Latina women?

Significance of the Study

The study is relevant for the social work profession because it potentially

brings awareness to a known and helpful technique that can easily be provided to

pregnant Latina mothers for increased support with their maternal-fetus attachment.

Overall, the study provides useful information regarding the benefits of mindfulness

based yoga and the positive potential impact it may have on women who practice it

during pregnancy. Having this knowledge could prompt social workers to advocate

for similar programs or classes to help support pregnant Latina women. Health care

providers may also gain knowledge on the impact mindfulness based yoga can

potentially have with pregnant Latina women.

The findings may increase awareness about the benefits of mindfulness based

yoga during pregnancy and promote a stronger bond between the mother and baby.

Furthermore, the research brought further understanding to a different method of

coping with the stress associated with pregnancy.

6

CHAPTER II

LITERATURE REVIEW

Overview

The literature reviewed for the study discusses the importance of maternal

attachment and the factors that impact attachment during pregnancy. Literature that

focuses on the practice of mindfulness and prenatal yoga as a form of intervention

during pregnancy to improve maternal and child outcomes and attachment is also

reviewed. This chapter, subsequently, addresses the importance of maternal

attachment and the urgency to continue evidence- based research as a means to better

understand the potential correlation between mindfulness based prenatal yoga and

prenatal maternal attachment.

The concept of prenatal attachment originated from attachment theory.

According to John Bowlby (1982), attachment is described in terms of feelings and

behaviors that relate to the mother’s own rational self-image as a caregiver. Laxton

and Slade (2002) describe prenatal attachment as a maternal-fetal relationship where

the mother attends to all necessary needs of the fetus. For instance, “mother seeks: to

know; to be with; to avoid separation or loss; to protect; and to identify and gratify

the needs of the fetus” (Laxton & Slade, 2002, p. 2). Rubin further expands on the

concept of prenatal attachment by explaining that a mother seeks “safe passage for

herself and the child, (b) ensuring that the child is accepted by significant others, (c)

binding-in to the fetus and (d) giving of herself” (Laxton & Slade, 2002, p. 2). It has

been shown that without maternal attachment, a child’s social, emotional and

7

cognitive developments are at risk of being impaired (Alhusen, Hayat & Gross,

2013).

Importance of Maternal Attachment

Attachment theory suggests that humans have the ability to connect with one

another on an emotional level, forming intimate relationships. Furthermore, a child is

strongly influenced by the way they are treated by their parents, especially by the

mother and based on early experiences the child will develop later relationships

(Bowlby, 1988). According to Siegel and Hartzell (2003), the child’s earliest

relationship is considered to be a mold that will shape their societal expectations for

future relationships. Therefore, through connection between mother and infant, the

child will learn basic rules for relationships, social norms, conversational techniques,

and self-regulation (Snyder & Treleaven, 2012). Krongold’s research (2012)

addresses the fact that in order for infants to fully develop physically, emotionally,

and cognitively, they need emotional attention in addition to just physical care.

There are four categories of attachment: secure, insecure-avoidant, insecure-

anxious/ambivalent and insecure disorganized (Snyder & Treleaven, 2012). Secure

attachment occurs when the infant is aware that the mother will meet his or her needs.

The infant is able to feel safe during times of stress because they know that mother

will be there to comfort them (Bowlby, 1988). This style of attachment has been

associated with lower levels of aggressive behaviors towards friends by age three

(McElwain, Cox Burchinal & Macfie, 2003), less negative interactions with friends

by age five (Youngblade & Belsky, 1992) and the capacity to form close friendships

8

by age ten (Frietag, Belsky, Grossman, Grossman & Schuerer-Englisch, 1996). On

the contrary, insecure-avoidant infants are very independent, both physically and

emotionally. Some infants may not have comforting or loving caregivers to fulfill the

infant’s needs (Ainsworth, 1970). Sable (2007) explains that the absence of secure

attachment may bring about difficulties in regulating emotions and relations to others,

which can cause psychological distress. Additionally, the Eunice Kennedy Shriver

National Institute of Children Health and Human Development (2001) reports that

children who display insecure maternal attachment tend to have high irregular

responses when interacting with others, which can compromise their ability to bond.

These attachment patterns are self-perpetuating, and tend to stay with the child as she

or he develops, due to the parents being more likely to continue treating the child the

same way (Snyder & Treleaven, 2012). A child’s brain continues to develop after it is

born and the caretaker plays an immeasurable role in that development (Krongold,

2012).

Development of Attachment

Research has found that many children portray the same attachment patterns

as their mothers (Snyder & Treleaven, 2102). This research has given rise to the

concept of “intergenerational transmission’’ of attachment styles (Siegel & Hartzell,

2003). Intergenerational transmission is defined as attachment patterns that are

“passed on” to the infant due to the previous interaction that the mothers had with

their mother (Siegel & Hartzell, 2003). A meta-analysis of 18 studies and a combined

sample of 854 parents have reported the effect size of the correlation of

9

intergenerational transmission attachment patterns to be strong between parents and

their infants (Snyder & Treleaven, 2012).

Intergenerational transmission is not considered to be permanent in a child or

mother’s life (Snyder & Treleaven, 2012). According to Bowlby (1988), the

development of an individual is never “fixed”; the individual can be impacted

negatively or positively at any time during their life. Theorists have written about

“earned security,” meaning that an individual who has insecure attachment can “earn”

secure attachment patterns in their lifetime (Snyder & Treleaven, 2012). In order for

an individual to achieve security, he or she needs supportive relationships and must

be able to obtain self-understanding, meaning an awareness of, as well as an ability to

understand, one's own actions and reactions (Siegel & Hartzell, 2003). Self-

understanding could be gained through a process of self-reflection and self-awareness

(Snyder & Treleaven, 2012). One technique used to help obtain self-awareness is to

practice mindfulness, which will be discussed in another section of the literature

(Siegel, 2007). Furthermore, if the mother is capable of changing her attachment style

by engaging in healthy activities that nourish secure attachment, she will interact with

her child in a way from which the baby will obtain the benefits (Siegel & Hartzell,

2003).

Benefits of Prenatal Yoga

Prenatal yoga is a healthy activity that expecting mothers may engage to assist

them with their pregnancy (White, 2001). White explains that practicing yoga

involves working both the mind and body, and during pregnancy, this can create both

10

physical and emotional experiences. According to Remer (2012), yoga is composed

of four main elements: breathing, feeling, listening to the body, and letting go of

judgment and expectation. The above four principles of yoga deliver crucial messages

to the pregnant women and their partners such as awareness, active consciousness and

healthy preparation for birth (Remer, 2012). Throughout the process of prenatal yoga,

expecting women learn to understand their body’s ability to give birth while at the

same time acquire relaxation techniques (White, 2001). In addition, the postures

performed help to physically prepare the body for the process of birth, while, at the

same time, also nourishing the mind. These postures include: bound angel pose,

warrior pose II, cat pose and relaxation pose (White, 2001). “As the expecting mother

practices relaxation during her pregnancy, she will become aware of what the

sensation of relaxation feels like within her own body so that she is better able to tap

into this sensation during labor” (White, 2001, p. 8). It is important for the mother to

learn relaxation techniques as it will help her bond with the child. Several studies

have reported that practicing yoga can have positive benefits during pregnancy, which

include pain reduction, lowered stress and anxiety, (Beddoe, Yang, Kennedy, Weiss,

& Lee, 2009) reduced experience of labor pains, (Sun, Hung, Chang, & Kuo, 2010)

and a shorter duration of total labor time (Chuntharpat, Petpichetchian, & Hatthakit,

2008).

Furthermore, a study done by Rakhshani, Maharana, Raghuram, Nagendra

and Venkatram (2010) assigned 102 pregnant women to a 16- week yoga training

group and a control group. The objective of this study was to investigate the effect of

11

integrated yoga on the quality of life and interpersonal relationships among normal

pregnant women. In order to take part in this study, women were required to be

healthy and to be between 10 and 20 weeks of gestation. The participants were

randomly assigned to two groups. The control group participated only in antenatal

exercises while the treatment group participated only in integrated yoga. Both groups

participated in the class for an hour at a time, three times a week. Assessments were

completed at baseline and at the conclusion of the program using WHOQOL-100,

FIRO-B questionnaires. World Health Organization Quality of life assessment

instrument (WHOQOL-100) is focused in the definition of quality of life advocated

by World Health Organization which includes culture and context which influence an

individual’s perception of health. Fundamental Interpersonal Relations Orientation

(FIRO-B) instrument is a theory that incorporates three dimensions of interpersonal

relations which are, socializing, leadership and responsibilities and more intimate

personal relations (Rakhshani et al., 2010). The participants demonstrated an

improvement in their quality of life and interpersonal relationships. The study found

that yoga can significantly improve physical, psychological, social, and general health

domains (Rakshani et al., 2010). According to Bonura (2014), various studies have

demonstrated that when used as a preventative intervention, prenatal yoga may offer

benefits to manage sleep conditions such as insomnia and depression. There is a lot of

research that supports the use of yoga as a non-pharmaceutical approach to insomnia

and depression demonstrating that prenatal yoga is effective during pregnancy,

impacting not only the mother, but the baby as well (Bonura, 2014).

12

In another study, Narendran, Nagarathna, Narendran, Gunasheela and

Nagendra (2005) examined the efficacy of yoga on pregnancy outcomes. In

Bangalore, India, three hundred and fifty five women between the gestational periods

of eighteen and twenty weeks participated in this study. The study randomly assigned

169 women to the yoga group and 166 women to the control group. In order to

participate in the study, women were matched for age, parity, body weight, and

Doppler velocimetry scores of umbilical and uterine arteries (Narendran et al., 2005).

The researchers created an integrative approach to yoga therapy (IAYT) with the

intended goal of decreasing the stress felt by the pregnant women and, in turn,

increasing positive maternal attachment over the course of a 20-week program.

During the first week of the program, all participants in the intervention group took

part in an IAYT training course in order to learn specific techniques. For the

remainder of the study, the women were asked to practice IAYT methods (breathing,

meditation and yoga postures) at home every day and were scheduled to meet with

the researchers every 3-4 weeks to discuss their experience. All participants were

monitored by telephone calls and activity diaries. The findings demonstrated an 18%

reduction in prenatal stress and a 21% reduction in prenatal physiological distress,

both of which can have a pronounced impact on the mother’s ability to form healthy

prenatal attachment to her growing baby (Narendran et al., 2005).

Mindfulness-Based Yoga during Prenatal Period

Mindfulness has many qualities, some of which include: “non-judgmental,

trust/self-reliance, non-striving, acceptance, and letting go” (Warriner, Dymond, &

13

Williams, 2013, p. 520). Wahler, Rowinski, and Williams (2008) theorized that the

concept of nonjudgmental awareness of mindfulness allows parents to view their

experiences during pregnancy in a different light, and by doing so, helps them to get

rid of old habits while also changing their behavior patterns with the infant. An

individual who practices mindfulness is less likely to get depressed and will

experience positive changes in their well-being (Warriner, Dymond, & Williams,

2013). Studies show that practicing mindfulness reduces the risk of postpartum

depression and increases attention to the infant (Warriner et al., 2013).

There have been three more recent studies conducted that have examined the

impact of mindfulness during prenatal period. Vieten and Astin’s (2008) study

consisted of thirty one women who received a mindfulness-based intervention; the

study only included women who spoke and read English. The participants were

married, highly educated, and had a high income. Seventy four percent were white

and thirteen percent were Hispanic. The researchers developed an intervention called

Mindful Motherhood that incorporated three approaches to capture mindfulness: (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” (p. 69). The

intervention consisted of two hours of mindfulness training per week over an eight

week period. These trainings were supplemented by weekly readings, and a compact

disc containing three 20 minute guided mediations. The study included a randomized

14

waitlist control group. The study collected data at three time points: pre-measure,

post-measure, and during a follow up conducted three months after the completion of

the course. The researchers examined the levels of anxiety, stress, depression, affect

regulation, positive and negative affect, and mindfulness. The study found that the

mindfulness intervention had a large effect size in decreasing anxiety during

pregnancy, as well as an increase, though insignificant, in mindfulness. Stress and

depression were shown to have decreased in the treatment group but not in the control

group.

In relation to mindfulness-based yoga during the prenatal period, Ducan and

Bardacke’s (2010) conducted a study of twenty seven women who participated in

Mindfulness-Based Childbirth and Parenting program during their third trimester of

pregnancy. The program was comprised of a weekly three hour course over a nine

week period, and also included a daylong retreat. The program included the

participants’ partners and if the partner was not able to attend, the participants were

permitted to bring a support person with them. The goal of the study was to reduce

stress through the duration of the pregnancy, the birth process, as well as in the post-

natal period. Ducan and Bardacke (2010) found that when the participants focused on

the present moment, they realized that their experiences throughout pregnancy,

childbirth, and parenting were temporary and would soon be replaced by the next

moment. Findings suggested that the main concept of mindfulness (staying in the

present moment) was beneficial to the individual’s emotional well-being, bringing

15

about a sense of peace and improving the quality of the relationship between mother,

child, and partner.

In addition, a study conducted by Beddoe, Yang, Kennedy, Weiss, and Lee

(2009) examined the feasibility of a mindful yoga intervention with regard to its

ability to reduce distress among pregnant women. A total of 16 women took part in a

seven week mindful yoga intervention which combined elements of lyengar yoga and

mindfulness-based stress reduction. Data were gathered at baseline and post-treatment

examining state and trait anxiety, perceived stress, pain, and morning salivary cortisol

levels. Post-treatment data collection also included participants' evaluations of the

program. The results for this study show a decrease in physical pain among women

who were in their second trimester from baseline to post-intervention. On the other

hand, for women in their third trimester physical pain increased, but showed a

reduction in perceived stress and trait anxiety. Overall, this study supports mindful

yoga’s effectiveness in reducing physical pain, perceived stress, and trait anxiety,

specially, if started early in pregnancy.

All three studies were completed during the prenatal period. Vieten and Astin

(2008) did have a control group while Ducan and Bardacke (2010) did not. However,

both included women who were mostly Caucasian and highly educated, with high

incomes. Additionally, Ducan and Bardacke (2010) analyzed qualitative data. This

allowed for a more in-depth study, as they were able to analyze the narratives of the

women involved in the study. Through the qualitative interviews they found that

partner participation in the women’s use of mindfulness skills during the birth and

16

postpartum period was seen as important by the women. The involvement attributed

improvements in the couple’s relationship to their MBCP course participation. Ducan

and Bardacke (2010) state that “Mindfulness-based interventions delivered to the

family unit during pregnancy may be one way to effectively influence aspects of the

stress response that can in turn influence maternal-fetal health and family

relationships” (p. 10). Mindfulness may be the foundation for healthy coping during

the perinatal period, creating family resilience over its life span (Ducan & Bardacke,

2010).

Mindfulness-Based Prenatal Yoga and Maternal Attachment

Research on the correlation between mindfulness based prenatal yoga and

maternal attachment is limited, yet promising (Muzik, Hamilton, Rosenblum, Waxler,

& Hadi, 2012). In a recent study by Muzik et al. (2012), it was shown that

mindfulness yoga may be an alternative treatment to pharmacotherapy for expecting

mothers at high risk for psychopathology. The study evaluated a 10-week prenatal

mindfulness based yoga class of eighteen participants. The purpose of the study was

to analyze mindfulness based yoga practice as a means of reducing stress and

increasing attachment with the baby. The women who took part in the study were

white, college educated, and in a relationship. The class was facilitated by two

instructors and consisted of a 90 minute session which focused on a variety of

different poses. Classes met once a week with two sessions a day for a total of 10

sessions. One class took place during the evening hours while the other during the

day. Classes began with a check-in session, during which the women were able to

17

share any physical and emotional feelings. The class ended with a restorative pose, a

full-body relaxation exercise, and a reading of various passages from the book:

Everyday Blessing; The Inner Work of Mindfulness Parenting. Participants in the

study completed an initial psychiatric interview and completed self-report

questionnaires about depression, mindfulness, and maternal-fetal attachment both at

baseline and after the final mindfulness yoga class. The findings demonstrated an

increase in mindfulness and maternal attachment. Women reported being more

cognizant of the present moment without judgment and engaging in interacting and

connecting behaviors with their unborn child. Overall, the pilot study suggests further

study on mindfulness-based yoga practice as an alternative treatment for high-risk

depression during pregnancy, as this can reduce the threats to attachment and

bonding.

Similarly, Krongold’s (2012) study focused on the influences of mindfulness-

based prenatal yoga during the postpartum period as well as the relationship between

the mothers and infants. A total of 15 pregnant women participated in an eight-week

mindfulness-based intervention for prenatal care. The intervention utilized in this

study, Mindful Motherhood, was developed by Vieten and Astin (2008). The

intervention also included several elements of Mindfulness-Based Cognitive Therapy

(MBCT) and Mindfulness Childbirth and Parenting (MBCP) (Krongold, 2012). The

mothers participating in the study were provided with weekly meditation and prenatal

yoga classes. The data for this study were collected at baseline and four months after

the program ended (postpartum). Through in-depth interviews, researchers were able

18

to analyze the participants’ feelings of mindfulness and maternal attachment

(Krongold, 2012).

In the postnatal interviews, each mother described the ways in which

mindfulness skills impacted her relational capacities, behaviors, and attitudes. These

descriptions were categorized into four themes: a) affect regulation and cognitive

flexibility of the mothers, b) increased attention for their babies, c) emotional

regulation with the baby and dyadic regulation of emotion, and d) initiation of

mother-infant contact and the ability to reconnect after rupture (Krongold, 2012).

Fourteen of the fifteen mothers reported experiencing an increase in their ability to

recognize their baby’s emotions, needs and behaviors. They also felt a bond with their

child and felt as though their increased awareness in the themes listed above allowed

them to better handle emotionally draining circumstances.

Summary

The importance of a healthy postnatal relationship between mother and baby

has been well recognized in literature; however, the literature also identifies several

factors that can impact the attachment between mother and baby. Mindfulness-based

practices are emerging as an intervention that show promising results. Studies have

shown that mothers who recognize and respond to the fetal activity tend to report an

increase in affection towards their unborn child (Rubin, 1975). In Muzik et al’s.,

(2012) study of mindfulness based yoga, the overall total scores as well as all five

subscale scores showed a positive effect on maternal-fetal attachment. However, most

of the existing research on mindfulness-based practices have focused on primarily

19

white, highly educated populations. Therefore, the purpose of this study was to

examine the impact of a Mindfulness-Based Prenatal Yoga program on mindfulness

and prenatal maternal attachment among a low-income sample of pregnant Latina

women.

20

CHAPTER III

METHODOLOGY

Overview

The purpose of the study was to explore the impact of mindfulness-based

prenatal yoga (MBPY) communicated in Spanish on pregnant Latina mothers'

mindfulness and prenatal mother-fetus attachment. A study by Siddiqui and Hagglof

(2000) reveals that maternal parental attachment towards the unborn baby is a good

predictor of the early mother infant attachment. This exploratory study attempted to

explore the potential impact of this program on maternal attachment because the

impact of a mindfulness-based prenatal yoga program on a Latina population has

never been evaluated. This research was part of a larger research study that examined

the impact of a MBPY program, offered by Blossom Birth, a non-profit organization

in Palo Alto, CA, on the stress, mindfulness, and pre and post-natal attachment with

baby on pregnant Latina women. The primary researcher, a faculty member in the

MSW program at CSU Stanislaus, along with two research assistants, conducted the

study. The research team had been invited by Blossom Birth to help them evaluate

this program. The questions guiding this research are: 1) Does the Mindfulness Based

Prenatal Yoga program in Spanish (offered by Blossom Birth) impact the prenatal

attachment of pregnant Latina women? 2) Does Mindfulness-based Prenatal Yoga

program in Spanish have an impact on the mindfulness of pregnant Latina women?

21

Research Design

Rubin and Babbie (2011) suggest an exploratory design is utilized when the

subject of the study is new and unstudied, or when the researcher seeks to test the

feasibility of undertaking a more careful study. Therefore, the research design

suggested for implementation in this study is essentially exploratory. A combined

qualitative and quantitative approach potentially revealed important theoretical and

practical components regarding mindfulness and pregnancy and prenatal and

postnatal attachment for Latina mothers and their children.

Qualitative research provides more in depth information regarding particular

human experiences and quantitative approaches provide more objective numerical

data for the variables under study (Rubin & Babbie, 2011). Quantitative data were

captured through standardized instruments measuring mindfulness and prenatal

attachment, completed at the beginning of the program (baseline) followed by

program completion.

Qualitative data were collected using a focus group. The focus group, with the

participants, was conducted on the last day of the program for a post-evaluation. The

quantitative measures and focus group are described in more detail below.

Sampling Plan

All participants were required to meet the following criteria for inclusion in

the MBPY program, they had to be Latina and had to be pregnant. The study was

conducted at Blossom Birth in Palo Alto, CA, a nonprofit education and resource

center that provides parents and birth professionals with a balanced, non-judgmental

22

view of pregnancy, childbirth, and early parenting. As part of the requirements of the

grant received by Blossom Birth to offer the program, the MBPY program was at no

cost to the participants, and the participants received a $50 gift card for their

participation in the program and the study.

The study consisted of 15 low to moderate-income Spanish speaking pregnant

women between 18-35 years of age. A non-probability purposive sampling was

utilized in this study. According to Rubin and Babbie (2011), a non-probability

purposive sampling design recommends selecting a sample based on the knowledge

of the population. This type of study was not based on random selection because the

individuals are purposely selected to meet the purpose of the program and study and

eligibility criteria identified for the study. Blossom recruited the participants through

multiple community organizations and provided the researcher with access to the

participants.

Instrumentation

The researcher collected qualitative and quantitative data for this study and

implemented several instruments for data collection. The instruments included a

demographic profile, the Prenatal Attachment Inventory (PAI), and the Five Facet

Mindfulness Questionnaire (FFMQ). The FFMQ is already translated into Spanish

and the PAI was translated into Spanish with permission from the original author.

The demographic profile collected information on the participant's’ income,

age, ethnicity, relationship status, education, gestational weeks, occupation status and

medical coverage. This was collected only once at the beginning of the program.

23

The Prenatal Attachment Inventory developed by Muller (1993), is a scale for

women to assess the extent of the relationship that developed between a woman and

her fetus. This questionnaire uses a Likert Scale with twenty one questions (1 almost

never and 4 always). Chronbach’s alpha coefficient for the PAI was .81 when tested

by the developer (Muller, 1993).

The FFMQ is a 39-items measure that focuses on five facets of mindfulness:

observing, describing, acting with awareness, non-judging of inner experiences and

non-reactivity to inner experience (Baer, Hopkins, Krietemeyer, Smith, & Toney,

2006). 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 Collection

This research is part of a larger research study that examines the impact of the

MBPY program on the stress, mindfulness, and pre and post-natal attachment with

baby of pregnant Latina women. The research assistants, students in the MSW

program, distributed the surveys to the participants and helped facilitate the focus

group in Spanish.

The researcher collected baseline data before the class began during the first

day of the program (Time 1), and again at the conclusion of the program (Time 2).

All instruments were self-administered by the participants, which took approximately

30-40 minutes to complete.

24

At the conclusion of the program, participants shared how the mindfulness-

based yoga class impacted their physical and emotional health. All participants signed

a consent form before participating in the study. The study was approved by the

review process of the California State University, Stanislaus Institutional Review

Board.

Plan for Data Analysis

All data collected were coded for input into SPSS. The instructions provided

by each instrument were followed to code and calculated the cumulative score.

Univariate analysis was conducted to calculate frequencies on all variables, while

bivariate analysis was conducted to examine the differences in scores over time. The

focus group from the last session was analyzed to identify the common themes shared

by the participants. The findings were reported in a narrative format with graphs to

illustrate the outcomes.

Protection of Human Subjects

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

The first level related to Blossom’s process and the eligibility to even apply to this

program and the second level related to the evaluation piece. Blossom required all its

clients to sign a waiver form. Also, as explained above, they 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

25

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

the tools/interviews to help evaluate the program as the complete pilot project is

being funded by the Bella Vista Foundation and they can choose to not be part of the

pilot program without any penalty or loss of benefits. Participants were informed that

the data obtained was protected from inappropriate disclosure under the law and was

securely locked during the course of the study. They were informed that their names

and any kind of identifying information that were reported in the study and that all

findings were reported as aggregate. Finally, participants were notified that all

recorded notes were shredded and tapes erased one year following the completion of

the study.

26

CHAPTER IV

RESULTS

Introduction

The purpose of this study was to examine the impact of a Mindfulness-based

Prenatal Yoga (MBPY) program, communicated in Spanish, on Latina pregnant

women’s prenatal mindfulness and mother-fetus attachment. The research questions

that guided this research were:

1. Does the Mindfulness Based Prenatal Yoga program in Spanish (offered by

Blossom Birth) impact the prenatal attachment of pregnant Latina women?

2. Does the Mindfulness-based Prenatal Yoga program in Spanish have an

impact on the mindfulness of pregnant Latina women?

All quantitative data were gathered via paper surveys during the 10 week program.

All data were entered into SPSS and coded and analyzed. Qualitative data were

collected via one focus group and phone interviews. The focus group was completed

midway through the program and the phone interviews were conducted at the end of

the program. The data collected were transcribed and analyzed for patterns and

themes. This chapter provides a description of the sample and presents the results of

the study and the comparison of mindfulness and prenatal attachment scores from

time 1 (start of the program) to time 2 (program completion).

27

Overview of Sample

A total of 15 pregnant Latina women were included in this study, all of whom

voluntarily took part in the 10 week MBPY program. Throughout the program, there

was a variation in attendance and one woman had a miscarriage during the first week

of the program. The mean age of the participants was 29.71 years with a standard

deviation of 5.48. The average attendance was 5.78.

Prenatal Attachment Scores and Changes over Time

The Prenatal Attachment Inventory is a scale that helps expecting mothers

measure the level of relationship between them and the fetus. This survey consists of

21 questions that describe thoughts and feelings, and it also assesses the extent of the

relationship that develops between a woman and her fetus. This questionnaire utilizes

a Likert Scale that ranges from 1-4 (1 almost never and 4 always).

Comparison of Total Prenatal Attachment Scores from Time 1 to Time 2

In order to measure the change in prenatal attachment through the duration of

the program, data were collected at two different times. Baseline data were collected

before the class began on the first day of the program (Time 1), and post intervention

data were collected at the conclusion of the program (Time 2). A Wilcoxon signed-

rank test was utilized to examine the difference in the prenatal attachment score from

time 1 (M= 47, SD=12.23) to time 2 (M= 62.50, SD= 9.79). The results showed a

statistically significant increase in the attachment scores (z = -2.201 and p = .028).

This result demonstrates that there was a significant change in the prenatal attachment

from the beginning of the program to the end of the program.

28

Figure 1. Total Prenatal Attachment Means Scores.

Table 1 summarizes the percentages of responses from the individual items on

the PAI. From time 1 (start of the program) to time 2 (program completion) there is

an increase in the prenatal attachment scores. For example, the statement, “I enjoy

feeling the baby move” showed an increase from 49% at time 1 to 100% of the

participants at time 2 rating the responses as often/ almost often. Similarly, for

question six, 42.8% of participants, at time 1, stated that they will often/ almost

always do things to make a difference to the baby compared to 83.4% of women at

time 2 who shared the same.

47

62.5

0

10

20

30

40

50

60

70

Prenatalattachment

Mea

n S

core

s

Total Prenatal Attachment Mean Scores

Time 1 Time 2

29

Table 1

Prenatal Attachment Percentages

PAI Item Almost Never Sometimes Often/ Almost

Always

Time 1 Time2 Time1 Time 2 Time1 Time2

Enjoy feeling baby

move

35.7% 0% 14.3% 0% 49% 100%

Think the baby has a

personality

21.4% 0% 35.7% 33.3% 42.9% 66.7%

Things I will do to

make a difference to

the baby

21.4% 0% 35.7% 16.7% 42.8% 83.4%

I know why the baby

is moving

57.1% 0% 21.4% 50% 21.4% 50%

Mindfulness Scores and Changes over Time

The FFMQ is a measure that concentrates on five facets of mindfulness: (1)

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

experiences and (5) non-reactivity to inner experience. It consists of 39 questions that

are rated on a 1-5 point Likert scale ranging from “1= never or very rarely true” to

“5= very often or always true”, with higher scores indicating higher levels of

mindfulness.

Comparison of Total Mindfulness Scores from Time 1 to Time 2

Baseline data were collected before the class began on the first day of the

program (Time 1), and post intervention data were collected at the conclusion of the

program (Time 2). A Wilcoxon signed-rank test was utilized to examine the

difference in total mindfulness scores from time 1 (M= 112.42, SD= 17.46) to time 2

30

(M= 129.66, SD= 16.62). The results showed a statistically significant difference in

the mindfulness scores (z = -2.201 and p = .05). This result demonstrates that there

was a significant increase in the total mindfulness from the beginning of the program

to the end of the program.

Figure 2. Total Mindfulness Mean Scores.

Five Facets of Mindfulness. There are five facets of mindfulness, which include

observing, describing, acting with awareness, non-judging of inner experiences and

non-reactivity to inner experience. A Wilcoxon signed-rank test identified a

statistically significant difference in the mean rank for describing from time 1 (3.50)

to time 2 (.00) with a (z = -2.264 and p =.02). Participants’ ability to describe

mindfulness increased from the time they started the program to the time they ended

the program. For non-reactivity there was a statistically significant difference in the

112.4

129.6

100

105

110

115

120

125

130

135

TotalMindfulness

Mea

n S

core

s

Total Mindfulness Mean Scores

Time 1 Time 2

31

mean rank from time 1 (3.50) to time 2 (.00) with a (z = -2.207 and p .03). The results

suggest that there was a statistically significant increase in the scores from time 1 to

time 2 for describing and non-reactivity.

On the other hand, the Wilcoxon signed-rank test identified no statistically

significant difference in the aspects of observing, acting with awareness and non-

judging. For observing there was no statistically significant difference from time

1(4.13) to time 2 (2.25) with a (z = -1.261 and p = .207). For acting with awareness

there was no statistically significant difference from time 1 (3.50) to time 2(3.50)

with a (z =-.742 and p=.458). Lastly, for non-judging there was no statistically

significant difference from time 1 (3.50) to time 2 (3.50) with a (z = .000 and p

=1.00). The findings indicate that the scores for observing, acting with awareness and

non-judging of inner experiences did not change significantly from the start of the

program to the end of the program.

Table 2 summarizes the percentages of responses from the individual items on

the FFMQ. For example, for question 16, “I have trouble thinking of the right word to

express my feelings”, at time 1 most of the participants stated sometimes true with

50% and at time 2 percentage of response to sometimes increased to 66.7%. For

question 23, “It seems I am “running on automatic” without much awareness of what

I’m doing”, there is a decrease in the percentages of responses from time1 (0%) to

time 2 (23.8%). This means that women are more aware of what they are doing at the

end of the program.

32

Table 2

Five Facet Mindfulness Questioner Percentages

FFMQ Item

Never or Very

rarely true/

Rarely true

Sometimes True

Often true/ Very

often/ Always

true

Time1 Time2 Time1 Time2 Time1 Time2

Trouble thinking of

right word to express

feelings

7.1%

16.7%

50.0%

66.7%

42.9%

16.7%

Criticize myself for

irrational/

inappropriate

emotions

28.6% 0% 35.7% 50.0% 35.6% 50%

Distressing thoughts/

images “step back”

aware without getting

taken over by it

57.2% 16.7% 35.7% 66.7% 7.1% 16.7%

“Running on

automatic” without

much awareness of

what I’m doing

21.4% 16.7% 21.4% 33.3% 57.1% 50%

Noticed smells/

aromas of things

28.6% 16.7% 21.3% 16.7% 42.9% 66.7%

Qualitative Findings

The phone interviews were conducted with only six participants because the

researchers were not able to reach the other eight participants. Three major themes

emerged from the analysis of the interviews that illustrate some changes that mothers

experienced. Five participants mentioned that their stress and anxiety was reduced

after each session that they participated in and they felt more relaxed. Participants

33

were aware of how stress and anxiety impact their lives and their bodies. For

example, a participant explained, “I was able to practice the breathing exercises at

home and the exercises helped me a lot” The statements from participants who

reported a decrease in their stress and anxiety are summarized in table 3.

Table 3

Statements Illustrating a Decrease in Stress and Anxiety

Participant Statement

Participant 1

I learned that stress impacts every part of your body including

your way of thinking, and after attending Blossom’s classes I

learned so much. It helped me reduce stress.

Participant 2 Even the breathing techniques helped me during the birth. It did

help me with my stress. I was even able to practice the breathing

exercises at home.

Participant 3 It has really helped me reduce stress and I’m able to apply

mindfulness on day to day activities and life in general. I learned

that stress impacts every part of your body including your way of

thinking, and after attending Blossom’s classes I learned so much.

Participant 4

It did work for me because I felt relaxed and calm. It helps me

with my stress.

Participant 5 It lowered my anxiety levels and it helped me a lot. It lowered my

anxiety levels I felt tranquil after coming out of the class.

Another theme that emerged was that four of the six women interviewed

described experiencing a change in their levels of physical pain. They reported that

after participating in the MBPY classes, their back pain decreased and sometimes

they even experienced no pain. For example, a participant stated, “the pain was

almost gone after class and I enjoyed being around others that were going through the

34

same thing as me…it was a place where I could socialize and forget about my pain

and just enjoy myself”. These are the statements from the other participants who

reported a decrease in their back pain as a result of participating in the MBPY

program.

Table 4

Statements Illustrating a Decrease in Back Pain

Participant Statement

Participant 1 There were times which I couldn’t get out of bed because of all the

pain I was going through, but when practicing mindfulness it

helped reduce the pain that I was going through as well as

reducing stress”.

Participant 2 It helped my lower back pain and it helped me during birth

because I went (to the MBPY classes) the last days of my

pregnancy.

Participant 3 It also helps me with my physical pains. My back is what hurt the

most, once I was in class I would forget about the pain”.

Participant 4 The afternoon was a special time for me because all my muscles

were relaxed and it helped me with my back pain”.

Lastly, participants were more mindful of themselves and their unborn baby.

Four participants shared feeling more connected with themselves and two stated it

helped them connect with the baby. Some of the women suggested being aware of

their body and the baby because they were able to just concentrate on their bodies.

Direct quotes from the expecting women who experienced an increased awareness of

their body and baby are summarized in table 5.

35

Table 5

Statements Illustrating an Awareness of their Body and Baby

Participant Statement

Participant 1 I am able to use mindfulness not only in reducing stress and pain

but I’m able to use it every day, to connect with myself and relax.

Participant 2 I was able to relax and be conscious of my own pregnancy. I was

always looking forward for Thursdays because it meant time for

me. Most of the time I do activities with my child because all the

activities that we have are together. After coming out of the class

I would have a better positive attitude.

Participant 3 Mindfulness helped me with stress, connecting with myself and

my baby…

Participant 4 It helped me reduce stress, get connected to my body, but most

important mindfulness help me connect with my baby growing

inside of me. I’ve been able to use mindfulness with myself, my

family, my baby, and at work.

Summary

The findings of this study demonstrate that pregnant women who participated

in the MBPY program did demonstrate statistically significant changes in their total

prenatal attachment and mindfulness over time. The mindfulness scores and

attachment significantly increased from the time they started the program to when

they completed the program. Results identified statistically significant differences in

two of the five facets of mindfulness, which are describing and non-reactivity from

time 1 to time 2. This means that expecting mothers experienced an increase in their

ability to describe their feelings, thoughts, and emotions through the MBPY program.

It also shows that the expecting mothers were more mindful when reacting to their

36

inner experiences. Additionally, the qualitative findings identified various effects of

the MBPY program which included a decrease in stress, anxiety, and physical pain

and an increase in self-awareness. From these results, this researcher can conclude

that pregnant women who participated in the MBPY program showed significant

improvements in both prenatal attachment and some improvements in mindfulness

over time.

37

CHAPTER V

DISCUSSION

Introduction

The objective of this study was to examine the impact of a 10-week

Mindfulness-Based Prenatal Yoga pilot program on pregnant Latina women’s

mindfulness and prenatal maternal attachment. An exploratory pilot study was

conducted with 14 pregnant women who participated in a weekly class for 10-weeks.

The study sought to capture and document changes in their mindfulness and

attachment scores from the beginning of the program (time 1) to the end of the

program (time 2).

This chapter represents a summary of the major findings of the study and

compares and contrasts them with existing literature. Furthermore, this chapter

discusses the implications for social work practice and policy, identifies limitations of

the study, and provides recommendations for future research.

Major Findings

The study examined two crucial components - mindfulness and prenatal

maternal attachment among pregnant Latina women. In regards to mindfulness, one

major finding related to the overall mindfulness scores, because they were

significantly different from the first day of the program (time 1) to the conclusion of

the program (time 2). The mindfulness scores increased significantly for the

participants in the MBPY program from time 1 to time 2. This finding is consistent

with the literature, because the literature reviewed also suggests that pregnant women,

38

who participated in some form of mindfulness-based practice, significantly increased

their mindfulness skills at the end of the program as when compared to baseline

(Vieten & Astin, 2008; Dunn et al., 2012; Beddoe et al., 2009). This indicates that

mindfulness-based programs are effective interventions that might help to increase

mindfulness during pregnancy. This finding supports Krongold (2012) who found

that women who practice mindfulness are more aware of their emotions, body and

thoughts. Being mindful is associated with many benefits, generally, and during

pregnancy. Past research (Vieten & Astin, 2008; Beddoe et al., 2009) indicates that

practice of mindfulness leads to a decrease in anxiety, stress and physical pain

decreased, resulting in women being able to concentrate more in the present moment.

Therefore, it seems that the benefits of mindfulness practices, such as reduction in

pain, also support the continued practice of mindfulness.

In addition, the five facets of mindfulness, when reviewed in detail, showed

that mindfulness skills related to describing ( being able to described their thoughts,

feelings and emotions) and non-reactivity (being more mindfulness of inner

experiences without aggressive reaction) significant changes (increases) from

baseline (time 1) to conclusion of the program (time 2). Through mindfulness based

prenatal yoga practice, women were able to describe in words their thoughts,

emotions and felt more connected to their body. Similarly, Muzik, Hamilton,

Rosenblum, Waxler, and Hadi, (2012) found that mindfulness skills helped

participants, in their study, experience the present moment with curiosity. On the

other hand, regarding non-reactivity, women were able to process experiences,

39

thoughts, and feelings before reacting to them. Muzik et al., (2012) analyzed the five

facets individually as well and they found improvements in all five subscale scores.

However, for this study, there were no significant changes for observing (able to

observe physical, emotional changes that are happening in the present moment),

acting with awareness (able to act verbally and physically to express thoughts and

emotions and feelings with awareness of the causation of the action) and non-judging

(accepting their bodies with no judgement by being aware that is happening) it is

possible that the high number of absences contributed to this lack of statistically

significant change in three of the facets of mindfulness. Also, the class was only

offered once a week for 10 weeks. The frequency of mindfulness practice does impact

the level of mindfulness; therefore, it might be helpful to explore how much the

participants are being able to practice outside of class to get a more in depth picture of

their mindfulness skill levels.

In respect to prenatal maternal attachment, one of the major findings was that

prenatal attachment levels increased significantly from baseline (time 1) to program

conclusion (time 2). This finding coincided with the literature, because the literature

reviewed also suggested an increase in attachment from baseline to program

completion among pregnant women after participation in a mindfulness-based

program. One difference is that this study included pregnant Latina women and

Muzik, Hamilton, Rosenblum, Waxler, and Hadi’s (2012) study focused on

Caucasian pregnant women. However, findings with regard to increased attachment

are consistent between this study and Muzik’s study, indicating that mindfulness

40

might work for women from different ethnic groups. Muzik el al. explain that

attachment might increase when depression decreases and by practicing mindfulness

one does reduce their stress, and therefore, attachment may improve, which in the

long run will promote the child’s wellbeing. This suggests that mindfulness based

prenatal yoga programs may be effective interventions for prenatal attachment during

pregnancy but there is a need for further research.

When analyzing individual items on the Prenatal Attachment Inventory (PAI),

the researcher found that some items showed a high increase in percentage of positive

responses from baseline to the end of the program. For example, women were able to

recognize the reason why the baby was moving, meaning that through mindfulness

based yoga women were able to connect with their unborn baby and pay attention to

their bodies. Another item showed that women thought the baby had a personality,

more so at the end of the program compared to the beginning. The findings in this

study are consistent with the literature analyzed, which suggest that mindfulness was

beneficial to the individual’s emotional well-being, the quality of the relationship

between the mother and the baby, and brought a sense of peace (Ducan & Bardacke,

2010). In Krongold’s (2012) study, mothers reported feeling a greater bond with their

child and felt they were better able to handle emotionally exhausting situations.

Therefore, it seems likely that the negative correlation between mindfulness-based

yoga practices and stress also contribute to greater attachment. Again, the pilot nature

of this study as well as the limited number and scope of past research strongly

41

indicate the need for more future research to examine the relationships among these

variables.

The theme of attachment also emerged from the qualitative data. Four

participants shared that they felt a connection with themselves and their baby when

practicing mindfulness based yoga. Literature was limited regarding the correlation

between mindfulness based prenatal yoga and attachment. Most of the literature

analyzed other components of pregnancy such as emotional, physical distress and

partner involvement. However, the existing studies do demonstrate that as emotional

and physical distress decrease, attachment increases (Krongold, 2012, Muzik et al.,

2012). The qualitative data from this study did show that mothers’ experience of

being present in the moment and being able to breathe, did decrease their stress and

enable to them feel more connected to their babies.

Implications for Social Work Practice and Policy

Based on the findings of this study, there are several implications for social

work practice and policy. This study bring us closer to the conclusion that

mindfulness based yoga has the potential to increase prenatal attachment and increase

mindfulness skills during pregnancy. Prenatal attachment is important because the

child learns basic rules for relationships, social norms, conversational techniques, and

self-regulation when the mother is able to be present in the moment (Snyder &

Treleaven, 2012). Also, because, maternal attachment is critical for the child’s

physical, emotional, and cognitive development. Therefore, mindfulness based

prenatal yoga may be an important practice of pregnant women who are learning to

42

be more aware of their emotions, thoughts and experiences, and to potentially

increase attachment between themselves and their babies. Mindfulness based yoga

may be used as a preventative intervention to avoid negative outcomes for the baby

and the mother.

The findings of this study are important to the social work field because it is a

safe and effective intervention for pregnant mothers. If social workers become aware

of this effective method of intervention, they would be able to link clients to those

resources. At the same time, they would meet their ethical duty of promoting general

welfare and well-being of those they serve. Additionally, past research shows that

Latina women are less likely to access any prenatal care compared to Caucasian

women. Participants, in this study, shared that they really liked the program and the

instructor and found the classes to be very helpful with their focus on breathing and

being present in the moment during their pregnancies. If, we, as social workers, can

offer programs that are evidence-based and are a good fit for and connect with

different ethnic groups, we might be able to increase their access to and utilization of

services, leading to better maternal and child outcomes during pregnancy.

Research shows that many Latina women did not attend to prenatal care until

much later in the pregnancy because of embarrassment and pain (Torres, 2005).

Through mindfulness women learn to accept experiences in the present moment

without embarrassment. At the same time, the findings in this research suggest a

decrease in physical pain through the practice of mindfulness making pregnancy

much more comfortable. Mindfulness practice gently helps observe each experience

43

with non- judgment, and patience, focusing on what is happening in the present

moment. In addition, yoga alone has been shown to have many positive effects,

including reducing stress and improving chronic pain. Mindfulness-based yoga

practice may help participants who are reluctant to seek traditional treatment to

engage in these practices, due to the immediate benefit they would experience in term

of reduced pain. This intervention might be more realistic to the Latino population

who otherwise would not access services because they are not sure what would work

for them or are culturally relevant appropriate (Torres, 2005).

The practice of mindfulness-based skills is rooted in the principle of being

present without judgment. Non-judgment is accomplished through experiencing

moment to moment, without ruminating in the past or worrying about the future. This

value correlates with the core social work value of being non-judgmental in our

practice with clients. If non-judgment is presented when working with clients, social

workers will provide empathy and compassion when dealing with difficult

circumstances. By modeling non-judgment, empathy and compassion to clients it may

promote the learning of non-judgment within their own lives. In the process the

individual experiences acceptance.

In addition, mindfulness based yoga practice can be utilized not only for the

clients but for the social workers themselves. This will alleviate the stress that a social

worker consistently handless. At the same time, it might also help decrease the

burnout rate for this profession. Therefore, if mindfulness practices were

implemented in social work settings, it would decrease stress. Even though stress was

44

not the focus of this study, participants shared experiencing a decrease in stress, when

interviewed. Based on the findings of this study and previous research, there does

seem to be a correlation among mindfulness, stress, and attachment, which deserves

further examination.

Limitations of the Study

Even though the study shows promising results for mindfulness based prenatal

yoga, there were a few limitations to the study. One major limitation of this study

involved inconsistent participant in attendance during the ten week program.

Attendance was inconsistent throughout the program and on the last day of the class,

attendance was six participants. Different participants came each week even though

during the program the average attendance was higher. This resulted in a lot of

missing data for time 2, program completion. One participant had to leave the

program at the beginning because of a miscarriage and another individual because of

being put on bed rest by her doctor. Also, follow-up data could not be included in the

thesis due to time constraints.

Recommendations for Future Research

Due to the exploratory nature of the research, there are several

recommendations for future research. Future research should replicate the study with

a larger sample size because it would allow generalization in the Latino culture. Also,

this is the first study that examines the impact of a mindfulness based prenatal yoga

on pregnant Latina women. Therefore, more research on MBPY among a Latina

population will add to the knowledge base and the effectiveness of mindfulness-based

45

interventions. More experimental and qualitative research that includes random

assignment to an intervention and control group would help strengthen the evidence

base for mindfulness-based practices.

Additionally, future research needs to explore the role that that culture plays

in engaging in any mindfulness based practices. This would help understand how

cultural practices encourage or prevent participants from integrating mindfulness

daily in their lives. Additionally, future study should include follow-up data from the

post-partum period. This would help the researchers to examine if attachment

increased after the baby was born and if mindfulness skills were sustained. It would

also help shed light on when refresher courses in mindfulness are needed, if any, to

help with continuing to practice the skills.

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APPENDICES

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APPENDIX A

CONSENTIMIENTO

La Universidad del Estado de California, Facultad Stanislaus, está colaborando con Blossom para

hacer un estudio piloto de 12 semanas, dentro del programa Mindfulness Based Prenatal Yoga

(MBPY) “Cuidado Antes del Nacimiento Basado en Yoga” ofrecido por Blossom. Este programa se le

ofrece gratis a usted a través de la Fundación Bella Vista, por lo tanto, como le expliqué durante su

solicitud y el proceso de selección, incluye una evaluación, componente que forma parte del programa.

El propósito de ésta evaluación es explorar sus experiencias durante el embarazo, su cuidado antes del

nacimiento y su conexión maternal durante el desarrollo de su bebé a través del programa.

Investigaciones muestran que las mujeres que se comprometen en un cuidadoso entrenamiento durante

el embarazo, han reducido su ansiedad y también muestran mayor conexión con su bebé aún antes del

nacimiento. Esperamos que con su participación, usted experimente algunos de éstos beneficios y nos

ayude a aumentar el conocimiento sobre el “Cuidado Antes del Nacimiento Basado en Yoga”.

Como parte y siendo un participante del programa, usted deberá contestar 4 cuestionarios, lo cual le

tomará aproximadamente 30 minutos en los 4 diferentes puntos. La primera vez será antes de empezar

las 12 semanas del programa MBPY “Cuidado Antes del Nacimiento Basado en Yoga”, obteniendo así

una base de partida. Después se le preguntará completar las medidas de 5 semanas dentro del

programa, seguido por la conclusión del mismo y 3 meses después del parto.

Nosotros formaremos un grupo de discusión a la mitad y al final del proceso para explorar sus

experiencias con el programa y el maestro, así podremos ver que trabaja y que no trabaja para usted en

éste programa. Tomaremos notas y grabaremos ésta discusión. Si usted completa la evaluación y todos

los componentes del programa, recibirá una tarjeta de regalo de $50. Por parte de Blossom. El costo de

la clase de yoga, el tapete y los materiales serán cubiertos por nosotros.

Toda la información será confidencial y estará protegida de acuerdo a la ley. Todos los datos serán

guardados en un lugar seguro. Cuando reportemos los resultados del estudio, no se mencionará ningún

nombre específico y todos los encontrados serán reportados en un agregado. Un año después de

terminado el estudio, todas las grabaciones serán borradas y todas las notas serán destruidas.

Como parte del proceso de Blossom’s, para ser incluido en el programa piloto, se le requerirá que

provea el consentimiento o autorización de su proveedor de salud. No hay riesgos anticipados como

resultado de su participación en el estudio de evaluación. Al firmar el presente documento indica que

usted entiende y acepta participar en las 12 semanas MBPY “Cuidado Antes del Nacimiento Basado en

Yoga” y en la evaluación. Si usted tiene alguna pregunta acerca de la evaluación favor de llamar a

Shradha Tibrewal al (209) 813-0271. Si tiene alguna pregunta acerca de sus derechos como

participante, favor de comunicarse con el Administrador de UIRB al teléfono (209) 667-3784 o al

email: IRBAdmin@csustan.edu. Gracias por su consideración.

Sinceramente

Shradha Tibrewal. Ph. D. Profesor, Universidad de California, Facultad Stanislaus

___________________________________ __________________________

Firma del participante Fecha

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APPENDIX B

INFORMED CONSENT

Faculty from California State University, Stanislaus are collaborating with Blossom to do a

pilot study on the 10-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.

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 5 weeks into the program followed by at the conclusion of

the program and a 3 month postpartum follow-up. We will engage in a group discussion mid-

way into the program and at the end of the program to explore your experiences with the

program and the teacher and what is working or not working for you. We will take notes and

record this discussion. If you complete all the components of the program and evaluation you

will be provided a $50 Blossom gift card. The cost of 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. You signing the form indicates that

you understand you are agreeing to participate in the 10 week MBPY program and its

evaluation. If you have any questions about this evaluation please contact me Shradha

Tibrewal, at 209-613-0271. 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