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Investigating the effectiveness of mindfulness training in the first trimester of

pregnancy on improvement of pregnancy outcomes and stress reduction in
pregnant women referred to Moheb Yas General Women Hospital
Marzieh Amohammadi Shirazi
Ph.D. student in Psychotherapy, Sigmund Freud University Vienna, Austria
Ph.D. student in psychology, University of Tehran, Iran
Marzieh_Shirazi@yahoo.com
09124365073
Abstract
Background and Objective:
The present study investigates the effectiveness of mindfulness training in the first trimester of
pregnancy and stress reduction in pregnant women referred to General Women hospital.
Methodology:
This study is a randomized clinical trial together with pre-test and post-test. Pregnant women
were assessed by using Hamilton Anxiety Standard Test to determine the level of their anxiety.
In this test scores from 18 to 25 were considered as low level anxiety, 25-35 as moderate
anxiety and scores more than 35 as severe anxiety. Based on this, groups of moderate anxiety
and severe anxiety received psychological treatment. The group with low anxiety just received
the interventions during pregnancy. The intervention group in addition to routine interventions
during pregnancy, by using mindfulness technique, in five 60-minute sessions by using the
refusal of conscious thoughts, conscious body examination, body checking and conscious sitting
were treated for anxiety management.
Findings: Anxiety score in every group has decreased after performing the psychological
interventions. So that the mean of anxiety score in the group with moderate anxiety was 27.52
before treatment and after treatment was 14.76 (VALUE_P0.001) and in the group with severe
anxiety was 40.12 and after the completion of treatment period, it was 16.6
(P_VALUE0.0001).
Conclusion: According to the importance of the first trimester of pregnancy in the process of
child growth and lots of anxiety in pregnant women in this critical period of growth, it can be
expressed that training techniques to deal with stress and mindfulness technique would improve
the quality of mothers life.
Keywords: stress management, mindfulness, conscious body examination, conscious
sitting, first trimester of pregnancy, pregnant women.

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Introduction:
In this century, "stress" is one of the most important fields of research in different sciences.
Today, due to the expansion of stress factors and reducing of human coping against them and
due to lifestyle changes, stress has become a big and complex phenomenon because it is
influenced by various factors and their interaction. Anxiety and stress are a condition that is
caused by the interaction between the individual and the environment and causes inconsistence,
real or unreal, between the requirements of a situation and a persons biological, psychological
and social resources. In simple word, any kind of psychological or social event that endangers
the person and causes sense of threat and damage in him, is called stress. These kinds of socialpsychological events, that disturb persons ordinary life, require the use of energy, resources and
in general require social, emotional and economic costs, and they are for the persons
compatibility with conditions.
Many researchers believe that stress and disease are related to one another. In this field, we can
mention the relationship between stressful events with heart, skin and immune system diseases
and diseases such as cancer and peptic ulcer disease. We can divide the most important effects
of stress into four types: emotional, physiological, cognitive and behavioral. Feelings of anxiety
and depression, increased physical and psychological tensions, are considered as the emotional
effects of stress on human. Decreased concentration and attention, decreased capacity of shortterm memory, increased confusion and distraction, are considered as the most cognitive effects
of this phenomenon and increased escape from work and activities, sleep disorder, decreased
academic, social and employment performance, are the behavioral effects of stress. In addition,
the secretion of adrenaline and noradrenaline, gastrointestinal dysfunction, increased heart rate,
disorder in breathing and contraction of blood vessels, are considered as the most important
physiologic effects of stress. Sources of stress and methods of responding to it are different in
men and women. Women more than men are experiencing stress. This has been observed in
cardio-vascular reactivity, blood pressure and other physiological symptoms and pregnant
women are not exception. While pregnancy and childbirth can be an enjoyable experience in
any woman's life, at the same time they are one of the crisis of womens lives that are at least as
important as the other two crisis of puberty and menopause. Since pregnancy and childbirth are
the natural events in a family, they can be considered as an evolutionary crisis. Since the first
trimester of pregnancy is the base-age and sensitive time for the formation of vital organs for the
embryo (brain to kidney and heart), therefor mothers stress in these months can put the embryo
at risk of many problems. Stress is directly related to the growth process of the embryo. During
pregnancy continuing concern causes the secretion of hormones that due to the passing of these
hormones through the placenta, the above mentioned emotional states are transferred from
mother to fetus, causing irreparable effects on the fetus. Various research have shown that
perceived stress, maternal depression, racial discrimination, acute stresses such as homelessness,
catastrophic events such as earthquake and the special pregnancy anxiety are associated with the
risk of preterm delivery. The effect of short-term stresses of pregnancy after the birth, blood
disconnection between fetus and mother gradually disappears, it means that they will be
complied with genetic and psychological-cognitive of the child and baby itself. But long-term
stresses can cause fundamental abnormalities in the fetal growth. Research have shown that
long-term stress can cause early miscarriage, stillbirth, low birth weight and premature
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childbirth. Meanwhile they make the child prone to mental illnesses such as depression,
irritability and hyperactivity. This is an important indicator that suggests maternal stress in
pregnancy can cause the perception of unpleasant experience in the fetus and physiologically
makes him/her restless. Responding to stress is one of the major tasks of hypothalamic pituitary - adrenal axis, which changes during pregnancy. Major part of this change is due to the
effect of placental corticotrophin hormone. Increased placental corticotrophin stimulates the
hypothalamic-pituitary-adrenal which results in the secretion of cortisol from the adrenal gland
and increase its blood level. According to the release of cortisol during pregnancy, Total
cortisol will be increased with the progression of pregnancy and its amount is greater than nonpregnant women. Hypertension disorders are the most common psychosomatic disorders that
are related to perceived stress and anxiety. This disorder is also considered as the most common
medical complication of pregnancy and involves 5 to 10 percent of all pregnancies. This
disorder is responsible for almost 16% of maternal mortality and preterm labor in developed
countries. Understanding the process of this disease and the effect of hypertension disorder on
pregnancy, are very important. Because these disorders are considered as one of the main causes
of maternal complications and mortality throughout the world. Many studies have emphasized
on this issue that continuing concern during pregnancy, causes irreparable effects on the fetus
and mother. Increased risk of miscarriage, premature delivery, increased blood pressure and
decreased birth weight, are some of these risks. Regarding the fact that acute and chronic stress
in this period causes problems for mother and fetus, using some methods to reduce stress and
anxiety during this critical period and using various techniques in dealing with stress and
managing them can be effective. If the results of this study confirm this presupposition that,
using the methods of anxiety control in the first trimester of pregnancy, is effective on the
course of pregnancy as well as decreased fetal gain weight from pregnancy-related
complications, so the necessity of country use for pregnant women in clinics to reduce stress
during pregnancy can be raised.
Methodology:
This study is a randomized clinical trial together with pre-test and post-test, sampling is easyavailable type and this study was done on pregnant women referred to Moheb Yas General
Women Hospital, who had decided to be admitted in this center at the time of their childbirth for
routine doctors visit and control before and after childbirth. Thus, pregnant women referred to
the clinic in general women hospital, by using standardized anxiety test -called Hamilton
Anxiety Test-were assessed by a psychologist to determine the level of anxiety. Hamilton test is
one of the standardized anxiety tests and in this test scores from 18 to 25 were considered as low
level anxiety, 25-35 as moderate anxiety and scores more than 35 as severe anxiety. Based on
this test, participants in our study were divided into three groups. People whose test score were
25-35 are moderate group, and people who had scores higher than 35 were considered as severe
anxiety and received psychological treatment. Those with scores between 18 and 25 were the
group with low anxiety and they were considered as controls and they just received ordinary
interventions during pregnancy and they received no psychological intervention. During a
consultation with a psychiatrist, none of the groups did not require medical treatment. The
sample size in each group was considered 25 patients. And taking into account the loss of 5
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people in each group-each group was considered thirty people. For moderate and severe groups,
in addition to routine interventions during pregnancy, stress management training were held
based on mindfulness during five 60-minute sessions by psychologist. In addition, these classes
were done in suitable timing, that the patient was referred for her monthly routine pregnancy
care. At the end of each sessions participants were supposed to practice the trained cases for the
next session. At the end of each session, the effects of therapy sessions during previous week,
pregnancy condition and stressful situations were studied. Then members of trial team
participated in the post-test and were assessed by Hamilton Anxiety test. Since the members of
the three groups were under routine pregnancy care until the termination of pregnancy at this
clinic, so they were under consideration and care, in terms of postpartum complications, such as
preterm childbirth and other pregnancy complications. Inclusion criteria included (gestational
age under 14 weeks, having high school diploma, age of mother 19 to 37 years, participation in
the study with content and prenatal care at this center, lack of medical chronic disease
(cardiovascular disease / thyroid illness / kidney disease/ liver disease).
Exclusion Criteria: Cognitive and learning disorder, psychotic disorder, alcohol and drug
abuse, severe and acute psychiatric disorder, a history of two or more abortion, bad obstetric
history, Including intrauterine fetal death.
For analyzing data, especially about the frequency of qualitative variables, about quantitative
variables like mean, range and standard variation were calculated. For quantitative comparison
between the two groups T-test and for quality comparison Chi square were used. Reliability is
estimated about 95 percent and results are presented as tables and diagrams. P value of less than
0.05 statistically was considered significant.
Findings:
Present study is an intervention and its statistical population is pregnant women in their first
trimester of pregnancy referred to Mohab Yas general women hospital. In the study, 75 patients
in three groups with low, moderate and severe anxiety were investigated by the Hamilton
Anxiety Test. The results show that anxiety scores in both groups after psychological
interventions have declined. So that the mean score in the group with low anxiety before the
treatment was 27.54 and after treatment was 14.76 and in the group with severe anxiety was
40.12 and after the completion of treatment 16.6, in the group with low anxiety before the study
was 20.56 and after the completion of study was 18.12 (table 1).
TABLE (1): AVERAGE OF ANXIETY LEVEL

Studied Cases

Score of Hamilton
Questionnaire in
the Beginning of
Study

Low Anxiety Level (Group 1)

Average
Standard
Deviation
20.56

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P-Value

1.89
0.2
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Score of Hamilton
Questionnaire at
the end of Study
Score of Hamilton
Questionnaire in
the Beginning of
Study
Score of Hamilton
Questionnaire at
the end of Study
Score of Hamilton
Questionnaire in
the Beginning of
Study
Score of Hamilton
Questionnaire at
the end of Study

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18.12

29.1

Moderate Anxiety Level (Group 2)

27.52
0.96
0.001
14.76

6.41

High Anxiety Level (Group 3)

40.12
9.24
0.0001
16.6

8.25

Discussion:
This research shows that psychological interventions applied in both groups have been quite
effective and have been resulted to reduce the experienced stress in this critical period of growth.
Findings of this research are aligned with a study conducted in Brazil. This means that in the
above study, it was proposed that an increase in depression and anxiety during pregnancy by
activating the hypothalamic-pituitary-adrenal, causes the increasing of cortisol and cortisol also
increases vascular function, gestational hypertension as well as pregnancy poisoning (Preeclampsia). Researchers of the above study, by doing specific psychological interventions and
techniques to deal with anxiety, were able to reduce the risk of poisoning and hypertension in
pregnancy up to 70%, in light of decreased cholesterol. In a clinical trial study on 84 pregnant
women in America suffering from anxiety and depression, women randomly in three groups
received: yoga therapy, massage therapy and they were compared with control group in terms of
the effect of intervention on improving the symptoms of anxiety and depression during pregnancy
and also their effect on improving pregnancy outcomes.
After follow-up of 12 weeks (2 sessions of 20 minutes per week) both intervention groups
compared with the control group, reported a significant decrease in anxiety, depression and
symptoms of pregnancy such as nausea and vomiting. In addition, both intervention groups were
in a more appropriate level, in terms of pregnancy duration, and significance increased birth
weight.
In a clinical trial study that was conducted in India 355 pregnant women were divided in two
groups of intervention and control group. The intervention group (including 169 persons) during
the 20 weeks were obligated to perform yoga exercises in order to reduce stress in women. Both
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groups were simulated according to maternal weight, age and uterine artery Doppler-cord.
Intervention has been continued since entering the study until childbirth. As a routine pregnancy
recommendation, control group walked 2 times a day and for 30 minutes. At the end of the
study, the decrease in infant birth weight and birth pangs, in the intervention group were
significantly lower than the control group. In a study done in Iran, the causes of decreased
weight of fetal were investigated in terms of psychological, social and gynecological between
2001 and 2012. Among the most common existing reasons, anxiety and stress in mothers during
pregnancy were known as the most common and important factors associated with decreased
fetal weight. According to the results of the above study as well as the results of similar research
in the field of psychological intervention including skills coping with stress and anxiety, it can
be stated that any psychological intervention can have a significant role in reducing stress and
anxiety. On the other hand due to the sensitivity of pregnancy on embryonic growth and
maternal and infant health and also special consideration of medical staff and families,
especially pregnant mothers from one hand and certain psychological concerns and sensitivities
in this period and on the other hand, the need to hold workshops of reducing anxiety and stress,
which is known as stress management in the whole world seems really necessary. One of the
important limitations of this plan is pregnant mothers unawareness from the symptoms of
anxiety and stress, the importance of recognizing the signs of pregnancy and its role in
improving quality of pregnancy as well as the need for any intervention in this field that brought
weak participation in training sessions. It is hoped that such studies in the country will open a
new horizon for psychologists as well as a variety of psychotherapy and psychological services
into the medical field.
Acknowledgement: This article results from approved projects of Tehran University of Medical
Sciences under the contract number 92-01-39-22189 dated 15/05/2013.

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References
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19. Loomans EM, van Dijk AE, Vrijkotte TG, van Eijsden M, Stronks K. et al. Psychosocial
stress during pregnancy is related to adverse birth outcomes: results from a large multi-ethnic
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Appendix
Effectiveness of mindfulness training in the first trimester of pregnancy on improvement of
stress reduction in General Women Hospital
75 pregnant women in the first trimester of pregnancy were selected randomly and were assessed
in pretest and posttest by Hamilton Anxiety Scale. These women were referred to the general
hospital for regular prenatal care. Based on Hamilton anxiety score, they were divided to three
groups: Low level anxiety (18-25 score),
Moderate anxiety (25-35 score), Severe anxiety (More than 35).
In this study women without anxiety and low level anxiety were considered as a control group
and women with moderate and sever anxiety were considered as experimental group. With due to
attention to low level of anxiety is very usual in pregnancy period, women with low level of
anxiety were consider as control group that no need any medical and psychological intervention.
The Inclusive criteria were: 14 weeks in pregnancy, mothers age between19 37, Lack of any
medical history such as: cardiovascular, thyroid, hepatitis and education at least diploma.
The Exclusive criteria were: History of mental disorder (psychotic, dissociation, hallucination,
delusion...), History of abortion, Alcohol or drug abuse, History of preeclampsia symptoms.
All women have received regular pregnancy care and they didnt need to medical treatment
according to the psychiatrist interview.
Women in moderate and severe anxiety were arranged for stress management workshop based on
mindfulness technique in 60 minutes in 5 session per week. For this two groups were made
available compact disk (CD) training for practicing lessons during the week. Mindfulness
technique was including: Body scan, setting meditation and passing thought technique.
In the ending of therapy, tree groups were assessed by anxiety scale again.
Data were analyzed using the statistical software SPSS version 18, T- test
Analysis was performed.
Table 1: anxiety score in pre and post test
PVALUE

Low anxiety
variance

average

1.89

20.56

29.1

18.12

0. 2

Hamilton score
Hamilton score in pre
test
Hamilton score in post
test

Moderate anxiety
0.00
1

0.96

27.52

6.41

14.76

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Hamilton score in pre

test
Hamilton score in post
test
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Table 3 :frequency of premature labor in tree groups
Issue

groups

Premature labor

P=0.4

Sever anxiety

Low level anxiety

000
1
Moderate anxiety

N
9.24
percentage
8.25
N

40.12
16.6

percentage
Sever anxiety

N
percentage
N
percentage

overall

NO

YES

0veral

22Hamilton score
3 in pre
test
88.0%
12.0%
Hamilton score in post
23
2
test
92.0%
8.0%

25
100.0%
25
100.0%

20

25

80.0%
65

20.0%
10

100.0%
75

86.7%

13.3%

100.0%

Table 2: the average of age in tree groups

AGE
p=0.5
Low anxiety (group1)
Moderate anxiety(group
2)
Sever anxiety(group 3)
0veral

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average

variance

30.68

4.34

29.20

5.07

29.68

4.96

29.85

4.77

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