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
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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
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.
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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
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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
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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
(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
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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
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(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
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(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
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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.
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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
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 [email protected]. 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