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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.
REFERENCES
47
REFERENCES
Abram, A. (2008). Motherhood as a transformative experience for first-time mothers
Retrieved from
http://ezproxy.lib.csustan.edu:2048/login?url=http://search.proquest.com/docv
iew/61751381?accountid=10364.
Ainsworth, M., & Bell, S. (1970). Attachment, exploration, and separation: Illustrated
by the behavior of one-year-olds in a strange situation. Child Development,
41(1) 49.
Alhusen, J. L., Hayat, M. J., & Gross, D. (2013). A longitudinal study of maternal
attachment and infant developmental outcomes. Archives of Women's Mental
Health, 16(6), 521-529. doi:10.1007/s00737-013-0357-8.
Baer, R. A., Hopkins, J., Krietemeyer, J., Smith, G. T., & Toney, L. (2006). Using
self-report assessment methods to explore facets of mindfulness. Assessment,
13, 27-45. doi: 10.1177/1073191105283504.
Beddoe, A. E., Yang, C. P., Kennedy, H. P., Weiss, S. J., & Lee, K. A. (2009). The
effects of mindfulness-based yoga during pregnancy on maternal
psychological and physical distress. Journal of Obstetric, Gynecologic, &
Neonatal Nursing, 38, 310-319. doi:10.1111/j.1552-6909.2009.01023.x.
Bender, D., & Castro, D. (2000). Explaining the birth weight paradox: Latina
immigrants' perceptions of resilience and risk. Journal of Immigrant Health,
2(3), 155-173.
48
Bonura, K. B. (2014). Yoga Mind While Expecting: The Psychological Benefits of
Prenatal Yoga Practice. International Journal of Childbirth Education, 29(4),
49-54.
Bowlby, J. (1988). A secure base. New York: Basic Books Center for Health
Statistics, California Department of Public Health. Retrieved from
http://www.randstatestats.org.ezproxy.lib.csustan.edu:2048/showSearchedDat
a.php#sthh.
Copeland, D., & Harbaugh, B. L. (2005). Differences in parenting stress between
married and single first time mothers at six to eight weeks after birth. Issues in
Comprehensive Pediatric Nursing, 28(3), 139-152.
doi:10.1080/01460860500227556.
Chuntharpat, S., Petpichetchian, W., & Hatthakit, U. (2008). Yoga during
pregnancy:Effects on maternal comfort, labor pain, and birth outcomes.
Complementary Therapies in Clinical Practice, 14(2), 105 – 115.
Dhiman, S. (2008). Cultivating mindfulness: The Buddhist art of paying attention to
attention. Interbeing, 2(2), 35-52. Retrieved from
http://ezproxy.lib.csustan.edu:2048/login?url=http://search.proquest.com/docv
iew/214820142?accountid=10364
Duncan, L. G., & Bardacke, N. (2010). Mindfulness-based childbirth and parenting
education: Promoting family mindfulness during the perinatal period. Journal
of Child and Family Studies, 19(2), 190-202. doi: 10.1007/s10826-009-
9313-7.
49
Dunn, C., Hanieh, E., Roberts, R., & Powrie, R. (2012). Mindful pregnancy and
childbirth: Effects of a mindfulness-based intervention on women’s
psychological distress and well-being in the perinatal period. Archives of
Women's Mental Health, 15, 139-143. doi:10.1007/s00737-012-0264-4.
Durham, K., & Pollard, D. (2010). Experiences of certified nurse midwives in
providing culturally competent care for Hispanic women. Southern Online
Journal of Nursing Research, 10(1), 1-14.
Eunice Kennedy Shriver National Institute of Child Health and Human Development,
(2001). Biobehavioral Development Strategic Plan. Washington, DC: U.S.
Government Printing Office. Retrieved from
https://www.nichd.nih.gov/publications/pages/pubs_details.aspx?pubs_id=122
Freitag, M. K., Belsky, J., Grossmann, K., Grossmann, K. E., & Scheuerer-Englisch,
H. (1996). Continuity in parent–child relationships from infancy to middle
childhood and relations with friendship competence. Child Development,
67(4), 1437-1454. doi:10.2307/1131710.
Krongold, K. S. (2012). Mindfulness-based prenatal care and postnatal mother-infant
relationships. Dissertation Abstracts International, 72, 7671.
Laxton-Kane, M., & Slade, P. (2002). The role of maternal prenatal attachment in a
woman's experience of pregnancy and implications for the process of care.
Journal of Reproductive & Infant Psychology, 20(4), 253-266.
Muzik, M., Hamilton, S. E., Rosenblum L., K., Waxler, E., & Hadi, Z. (2012).
Mindfulness yoga during pregnancy for psychiatrically at-risk women:
50
Preliminary results from a pilot feasibility study. Complementary Therapies in
Clinical Practice, 18(4), 235-240.
McElwain, N. L., Cox, M. J., Burchinal, M. R., & Macfie, J. (2003). Differentiating
among insecure mother-infant attachment classifications: A focus on child-
friend interaction and exploration during solitary play at 36 months.
Attachment & Human Development, 5(2), 136-164.
doi:10.1080/1461673031000108513.
Muller, M. E. (1993). Development of the prenatal attachment inventory.
Western Journal of Nursing Research, 15(2), 199-215.
doi:10.1177/019394599301500205.
Narendran, S., Nagarathna, R., Narendran, V., Gunasheela, S., & Nagendra, H.
(2005). Efficacy of yoga on pregnancy outcome. Journal of Alternative &
Complementary Medicine, 11, 237-244. doi:10.1089/acm.2005.11.237.
Perry, D. F., Ettinger, A. K., Mendelson, T., & Le, H. (2011). Prenatal depression
predicts postpartum maternal attachment in low-income Latina mothers with
infants. Infant Behavior & Development, 34(2), 339-350.
Rakhshani, A., Maharana, S., Raghuram, N., Nagendra, H., & Venkatram, P. (2010).
Effects of integrated yoga on quality of life and interpersonal relationship of
pregnant women. Quality of Life Research, 19, 1447-1455.
doi:http://dx.doi.org/10.1007/s11136-010-9709-2.
Remer, M., (2012). Incorporating prenatal yoga into childbirth education classes.
51
International Journal of Childbirth Education, 27, 92-94. Retrieved from
http://ezproxy.lib.csustan.edu:2048/login?url=http://search.proquest.com/docv
iew/1039289898?accountid=10364.
Rubin, A. & Babbie, E. R. (2011). Research methods for social work. Belmont, CA:
Brooks/Cole Cengage Learning.
Rubin, R. (1975). Maternal tasks in pregnancy. Maternal-Child Nursing Journal,
4(3), 143-153.
Sable, P. (2007). Accentuating the positive in adult attachments. Attachment &
Human Development, 9(4), 361-374. doi:10.1080/14616730701711573.
Siddiqui, A., & Hägglöf, B. (2000). Does maternal prenatal attachment predict
postnatal mother–infant interaction?. Early Human Development, 59(1), 13-
25. doi:10.1016/S0378-3782(00)00076-1.
Siegel, D. J., & Hartzell, M. (2003). Parenting from the inside out: How a deeper self
understanding can help you raise children who thrive. New York: Penguin.
Siegel, D. J. (2007). The mindful brain: Reflection and attunement in the cultivation
of well-being. New York: W.W. Norton.
Sun, Y. C., Hung, Y. C., Chang, Y., & Kuo, S. C. (2010). Effects of a prenatal yoga
programme on the discomforts of pregnancy and maternal childbirth self-
efficacy in Taiwan. Midwifery, 26(6), 31-36.
Shaffer, C. (2002). Factors influencing the access to prenatal care by Hispanic
pregnant women. Journal of the American Academy of Nurse Practitioners,
14(2), 93-96.
52
Snyder, R. A. (2010). Mindful mamas: A phenomenological study of mindfulness in
early motherhood. Dissertation Abstracts International, 71, 2726.
Snyder, R., Shapiro, S., & Treleaven, D. (2012). Attachment Theory and
Mindfulness. Journal of Child & Family Studies, 21(5), 709-717
Torres, R. (2005). Latina perceptions of prenatal care. Hispanic Health Care
International, 3(3), 153-159.
Verny, T. R. (1987). Pre-and Prenatal Psychology and Introduction. New York, NY:
Human Science Press, Inc.
Vieten, C., & Astin, J. (2008). Effects of a mindfulness-based intervention during
pregnancy on prenatal stress and mood: Results of a pilot study. Archives of
Women’s Mental Health, 11, 67–74. doi: 10.1007/s00737-008-0214-3.
Young, R., (2013). The importance of bonding. International Journal of Childbirth
Education,28, 11-16.
Youngblade, L. M., & Belsky, J. (1992). Parent-child antecedents of 5-year-olds'
close friendships: A longitudinal analysis. Developmental Psychology, 28(4),
700-713. doi:10.1037/0012-1649.28.4.700.
Warriner, S., Dymond, M., & Williams, M. (2013). Mindfulness in maternity. British
Journal of Midwifery, 21(7), 520-522.
Wahler, R., Rowinski, K., & Williams, K. (2008). Mindful parenting: An inductive
search process. In L. A. Greco, S. C. Hayes, L. A. Greco, S. C. Hayes (Eds.),
Acceptance and mindfulness treatments for children and adolescents: A
53
practitioner's guide (pp. 217-235). Oakland, CA, US: New Harbinger
Publications.
White, M. (2001, 12). Yoga for pregnancy. International Journal of Childbirth
Education, 16, 5.5. Retrieved from
http://ezproxy.lib.csustan.edu:2048/login?url=http://search.proquest.com/docv
iew/212862471?accountid=10364.
APPENDICES
55
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: [email protected]. Gracias por su consideración.
Sinceramente
Shradha Tibrewal. Ph. D. Profesor, Universidad de California, Facultad Stanislaus
___________________________________ __________________________
Firma del participante Fecha
56
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
[email protected]. Thank you for your consideration.
Sincerely,
Shradha Tibrewal, Ph.D. Professor, California State University, Stanislaus
_________________________ ____________________
Participant Signature Date