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. Author manuscript; available in PMC: 2021 Jul 1.
Published in final edited form as: MCN Am J Matern Child Nurs. 2020 Jul-Aug;45(4):233–239. doi: 10.1097/NMC.0000000000000625

Mindful Moms: Motivation to self-manage depression symptoms

Sasha Russell 1, Christine Aubry 1, Amy Rider 2, Suzanne E Mazzeo 3, Patricia A Kinser 4
PMCID: PMC7338034  NIHMSID: NIHMS1568269  PMID: 32604182

Abstract

Background:

Nearly 20% of women in the United States experience depressive symptoms during the perinatal period, with known detrimental effects for the mother, child, and family. Depressive symptoms affect motivation to engage in healthy behaviors and self-management of symptoms.

Purpose:

The purpose of this study was to explore the experiences of women with depressive symptoms who participated in a 12-week mindful physical activity intervention (Mindful Moms) throughout their pregnancy.

Study Design:

In this qualitative study, we explore the lived experience of women with depressive symptoms who participated in Mindful Moms, a self-management intervention involving nurse-led motivational sessions and group-based mindful physical activity (yoga).

Methods:

Semi-structured interviews conducted at approximately six weeks postpartum provided rich qualitative data which was analyzed using a phenomenological approach.

Results:

Twenty-five women participated. Findings suggest that participants in Mindful Moms felt empowered to manage their depressive symptoms through the combination of four key factors: a newly recognized need for help, a felt sense of physical and emotional benefit from participation, the power of shared safe space with other pregnant women, support from study staff, and an overall sense of empowerment.

Clinical Implications:

Mindful Moms appears to be a feasible and acceptable approach to enhancing motivation to self-manage depressive symptoms in pregnant women. Nurses working with childbearing women should be aware of the potential benefits of self-management strategies, such as mindful physical activity and motivational interviewing, for women facing perinatal depressive symptoms.

Keywords: pregnancy, depression, motivation, mindful, physical activity

Perinatal depression is a common yet potentially devastating condition, defined herein as major depressive episodes and/or depressive symptoms occurring during pregnancy and in the first year postpartum (Kimmel et al., 2019; O’Connor et al., 2019). Although estimates of prevalence vary and are limited by under-diagnosis, the American College of Obstetrics and Gynecologists (ACOG) suggests that more than one in seven women in the United States experience perinatal depression (ACOG, 2018). Research suggests physical activity may be as effective as typical clinical treatments in improving depressive symptoms in a variety of populations (Kvam et al., 2016). However, engagement in physical activity is often challenging for individuals with depression due to reduced self-regulation and self-efficacy (or one’s belief in one’s ability to manage symptoms), which can make it difficult to plan and follow through with activity goals (Son et al., 2009). One type of gentle physical activity that may help address these depressive symptoms is prenatal yoga, which may be more attractive to some individuals with depressive symptoms than other forms of physical activity (Kinser et al., 2012). Previous studies suggest that this type of mindful physical activity is acceptable and feasible for women with depressive symptoms (Cramer et al., 2013; Kinser et al., 2013; Uebelacker et al., 2017a) and may target self-regulation (Battle et al., 2015). This approach offers promise as an intervention for pregnant women to reduce levels of depression, anxiety, negative affect, and stress (Kinser et al., 2012; Kinser & Lyon, 2014).

Despite previous research that prenatal yoga may be helpful for depressive symptoms, the evidence is unclear whether and how to help women stay motivated and engaged in this activity. As such, our team developed the Mindful Moms intervention, which added nurse-led motivational interviewing (MI) to target self-management and engagement. Motivational interviewing techniques are often used by health care providers to promote and strengthen motivation for positive behavior changes in patients (Arkowitz & Burke, 2008; Rollnick & Miller, 1995), including managing obesity, sedentary lifestyle, and substance use (Lundahl et al., 2013). In this qualitative study, our primary aim was to enhance understanding of motivation related to managing perinatal depressive symptoms in the context of the Mindful Moms intervention involving mindful physical activity and MI.

Methods

Study Design

We used a phenomenological qualitative approach to study design and data analysis. Semi-structured, individual interviews were conducted with participants. The full study protocol and description of the intervention is reported elsewhere (Kinser et al., 2019). Briefly, the Mindful Moms intervention includes a brief nurse-led MI-informed discussion, followed by 12 weeks of weekly group-based 75-minute prenatal yoga classes and self-directed home-based physical activity. In that first discussion, the research nurse engaged the participant in MI-informed conversations to promote self-awareness, set physical activity goals, and instill habits of self-directed care. The prenatal yoga classes were taught by certified prenatal yoga instructors using a manual of standardized practices for consistency across classes and instructors. Participants were provided with a handbook of yoga poses and other safe physical activities for self-directed home activity.

Sample and Setting

Women who participated in the Mindful Moms intervention through the parent study were included. Inclusion criteria for the parent study were as follows: English-speaking pregnant woman no more than 28 weeks gestation at enrollment; ≥ age 18; self-report of depressive symptoms prior to pregnancy; current depressive symptoms at a moderate-to-severe level, as defined by a score ≥10 on the Patient Health Questionnaire (PHQ9); self-identify as Black or White (to match demographics of archival comparison group in parent study); absence of suicidal ideations, psychosis, or mania; absence of pregnancy complications or physical conditions making physical activity inadvisable; and, not engaged in a regular mindfulness-based physical activity routine during the current pregnancy. Women were recruited for the parent study using IRB-approved flyers and brochures, by word-of-mouth from health care providers, and by active recruitment in clinic waiting rooms. Participants were invited to engage in the semi-structured interviews for the current qualitative study when they were approximately six weeks postpartum. Interviews occurred in a quiet setting of the participant’s choice, such as a coffee shop or a room at the university. Given that participants were engaged in active childcare of young infants, several interviews were held by phone at the participant’s request.

Data Collection and Procedures

All interested women engaged in an informed consent process and provided written consent as part of the parent study procedures. Interviews were conducted by one consistent individual who was not the study interventionist, using a semi-structured interview guide with open-ended questions. Examples of questions used are: “Can you describe the experience of having depressive symptoms during your pregnancy or since you have had your baby?” “What is your general impression about the Mindful Moms intervention?” Interviews were recorded and transcribed. At the completion of the interview, participants were thanked and received a $25 gift card as compensation for their time.

Data Analysis

Four members of our research team engaged independently and together as a group in the active iterative process of data analysis using the following steps: read all transcripts from every interview for a general sense of the data; identify quotes from participants which seemed to be relevant, rich, and reflective of the phenomenon of motivation for self-management of depression and code the quotes; re-read the transcripts to confirm quotes were derived appropriately from the content; and group quotes into code-based categories to identify themes for closer examination (Cohen et al., 2000; Giorgi, 2005). Field notes about body language and interview setting provided clarification and substance to the interview transcripts. After independent analysis, the team met three times to engage collaboratively in multiple rounds of the iterative analysis process to confirm and clarify themes that arose from the rich data. The team used several strategies to ensure trustworthiness of the findings (Lincoln & Guba, 1986). Credibility (the confidence that identified themes accurately represent participants’ experiences) was addressed through peer debriefing in which colleagues unrelated to the study reviewed the data and confirmed the findings. Dependability (consistency of findings) was ensured by having several authors engage in independent analysis of the data prior to the group process. To ensure confirmability (avoidance of researcher bias) and replicability, we maintained an accurate audit trail of decisions made regarding coding and thematic development during all in-person analysis sessions (Rodgers & Cowles, 1993). Although transferability can be difficult to achieve when dealing with specific phenomena, this criterion was addressed in our efforts to provide “thick description”, or description of a phenomenon in such detail that the reader may have the ability to consider transferability of findings to other people, settings, or times (Lincoln & Guba, 1986). Data were analyzed in an iterative, spiral process that enabled constant questioning and reinterpretation by the research team members, in an attempt to face and minimize personal biases.

Results

Participants

Women who completed all aspects of the intervention and data collection in the Mindful Moms parent study (n=27) were invited to participate in the postpartum interviews; twenty-five women elected to participate. The two women who did not participate were lost to follow-up. Participants’ mean age was 29 with a range of 19–39; 18 identified as White and 6 identified as Black. Most women had at least a college degree (n=16), were working full-or part-time (n=15) and were either married or unmarried but living with a partner (n=21). This was the first pregnancy for nine of the women.

Themes

Data analysis revealed several common themes among participants that relate to the phenomenon of interest (motivation for self-management of depressive symptoms). These themes are represented in Figure 1 and are supported by participants’ quotes.

Figure 1.

Figure 1.

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Key themes about motivation for managing depressive symptoms

Recognized Need for Self-Care:

Participants recognized the need for self-care in the face of their depressive symptoms, often thanks to family members, friends, or providers. One participant reports not realizing she was depressed until her family member took a photograph of her. I’m thinking I’m dealing with everything but … when she showed me the pictures, I was like ‘what? Who’s that? One participant did not recognize her symptoms until completing a provider survey …when I started filling out the surveys I was like wow, I actually have a lot of symptoms. Participants were relieved to participate in the Mindful Moms intervention to prevent worsening symptoms. One participant noted I was having a lot of really sad days, I was really weepy…so when [the research nurse] approached me, I was like yea-I definitely need something to help me get through this pregnancy. Another participant reflected on her early pregnancy. I pretty much had no motivation and I was kind of just laying around doing nothing. So it started to obviously take a negative toll on my life and my relationship…I thought that yoga might help. A participant with prior postpartum depression stated My midwife was the one who told me about the study and I wanted to try anything that might help me this time around. Another participant with prior negative experiences during pregnancy reported Instead of playing catch up, [I wanted] to… face it head on.

Practice of Yoga Provided Embodied Experience of Symptom Management:

The intervention provided an embodied experience that allowed for depressive symptoms relief and a time for self-care. A resultant confidence and competence through yoga helped participants manage depressive symptoms and connect to self-needs. For example, one participant discussed the importance of the physical act of yoga. There was something about the actual movement where I felt like my body was capable and could do something. The mindfulness aspect of yoga helped another participant. That’s probably part of the benefit of yoga is that it forced me to confront myself- things I may not be experiencing consciously but are just under the surface. Many participants also noted that the weekly yoga classes gave them time and space for self-care. One participant noted I thought it’s great to have a reminder-take care of yourself every week. To take a minute and have some time- not alone- but just for yourself. Participants also noted that the positive experiences that occurred in yoga class led to other life changes. One participant noted When you do something like yoga, it kind of affects other parts of your life…the healthy things feed into each other. Another participant joked I’d be having a bad day, and I’d come out of class and my life would be puppies and kittens and rainbows and sparkles.

Sense of Connectedness and Safe Space:

One of the most beneficial aspects of the intervention was the safe space and shared experiences with other participants. For example, one participant remarked For the first time in my life, I now understand what people mean by the sisterhood bond…After being in this class, I understand how important it can be to be around other women and support each other. Another participant agreed. I think the best thing was just being surrounded by other women who were not only pregnant, but they understood the kind of depression and anxiety that I had dealt with. This sense of being understood without needing to talk was reported consistently by several participants, and seemed to be an important motivator for returning to classes. Participants discussed that the support from other women in the study helped normalize their experience: it didn’t feel as overwhelming and helped me manage the depression- it didn’t feel so heavy.

Participants also commonly expressed that the yoga class and the teacher created a safe space for sharing their experiences. A participant commented about the class. It was this safe space where you know you could be honest about how you felt and we would all support each other. The yoga teacher was highly important. She definitely was good at creating that safe space every single time we came- where we felt safe to open up and share our stories, and that’s really important. Another participant noted I think she was my favorite part of the study, the things that she said, the way that she said them, the advice that she gave. The teacher’s role in creating a safe space to relax and to be themselves was clearly important.

Compassionate Accountability:

Participants highly valued the accountability and motivation provided by the study structure and staff. One participant noted …to actually have interaction with people who were so supportive and kind and friendly and…but then to also be able to discuss sort of on a deeper level what’s going on is so important. Participants mentioned the supportive value of the nurse-led motivational sessions. For example, a participant shared …that day I did a lot of sharing, crying about things, getting them off my chest. I felt really supported during that and throughout the study. Another participant discussed the benefit of the MI sessions with the research nurse. It was good to have someone from the outside to check in and share things with and someone to offer a plan to potentially help. It was really encouraging, and it made me hopeful. Participants observed that the accountability enhanced improvements in symptom self-management. One participant disclosed I think I needed a reason to be accountable and so the study definitely did that for me. Another participant noted It helped motivate me and made me accountable to the team. A few participants followed-up these comments with concerns about maintaining physical activity post-study. For example, some suggested that it would be helpful to create a mom’s group or other structure through social media, to motivate each other to continue. These quotes highlight the perceived value of having support with motivation for self-care.

Overarching Theme: Gained Self-Confidence and Empowerment with Decreased Depressive Symptoms:

As represented in Figure 1, participants gained a sense of empowerment and self-confidence in managing depressive symptoms, thanks to the combination of recognizing a need for help, experiencing the physical and emotional benefits of yoga in a shared space with other pregnant women, and experiencing accountability/ motivation through the intervention. Increased self-confidence and decreased depressive symptoms were positive reinforcement and motivation for returning to the weekly classes. For example, one participant discussed the source of her increased self-confidence during the study. I was doing something for me, but I was also doing something for the baby, and I think it made me feel good about myself. Another participant described the importance of self-care. I think it’s made me a better mom, a better wife, and it just made me a better person because I’m taking care of myself. Several participants mentioned that had learned coping mechanisms that stuck with them after the intervention ended. One noted …[the intervention] taught me some coping mechanisms… I’m breathing better. Another participant shared I’ll run away from my screaming toddler and baby for a minute and go stand in the corner and do a tree pose. It actually really, really helps. Other participants reported increased confidence with symptom management. One noted I feel confident that if I start seeing any signs [of depression] popping up, I will know what to do. Another participant shared I feel more confident this time around, I know who to go to and the resources available to me. Quotes such as Little by little, it’s just making my life better, I can keep going, were repeated throughout the postpartum interviews, suggesting that many women were confident about continuing self-management.

Clinical Implications

Several themes from the qualitative interviews arose related to the phenomenon of interest, motivation for self-management of symptoms. Self-awareness of current symptoms and encouragement from others (e.g., provider, family member) motivated participants to seek help for their depressive symptoms. Participants reported having an embodied experience of relief from symptoms with the Mindful Moms intervention that reinforced their motivation for engagement. A sense of safe space and shared experiences with fellow intervention participants was identified as important for maintaining motivation for participation. Participants reported that accountability to the study was a helpful motivator for continuing with the yoga classes. Together, these four themes comprised an overarching theme whereby women reported an increased sense of empowerment and self-confidence in managing their depressive symptoms.

Our findings suggest participants deem physical activity to be helpful for depressive symptoms and they appreciated the Mindful Moms focus on the specific needs of pregnant women. These findings are consistent with previous research that demonstrated benefits of mindful physical activity in managing depressive symptoms (Cramer et al., 2013; Kinser et al., 2012; Kinser et al., 2014; Reza et al., 2018; Rimer et al., 2012). Other studies have found that pregnancy-specific exercise groups were helpful in motivating women to engage in physical activity (Harrison et al., 2018) and that empowering pregnant women with coping skills can prevent negative sequelae of perinatal depression (Garcia & Yim, 2017).

Participants stated that a key aspect to success of the Mindful Moms intervention was encouragement of the kind yoga teacher and study staff, leading to an increased sense of self-confidence and increased engagement in self-care. This is consistent with the literature; two recent qualitative studies of yoga for depression in other populations found that one of the most important factors to success was the presence of a kind and warm yoga instructor (Lee et al., 2019; Uebelacker et al., 2017b). Although not overtly discussed by participants, it is likely the MI techniques used by study staff to engage women in self-management conveyed a sense of warmth and caring; it was this warmth and encouragement that participants reported helpful for addressing ambivalence and low-motivation, two prominent characteristics of depression (Keeley et al., 2014).

Several opportunities for future research became apparent during this study. The concept of intervention aftercare warrants future attention, given that several participants lamented loss of accountability and support upon the end of the intervention. Future studies may consider referring participants to MI-trained nurses, obstetricians, and pediatric providers; Providers trained in MI skills are well-equipped to guide their patients to relevant behavior changes, resulting in substantial improvement in patients’ depressive symptoms (Keeley et al., 2014; Keeley et al., 2016). Some participants reported work and family responsibilities made it difficult to attend every class and complete weekly goals. Further research into cost effectiveness of mindful physical activity interventions is warranted, particularly for supporting coverage of such interventions by managed care organizations.

This study has several limitations and strengths. Because this was a pilot trial, the sample is small; hence, future larger-scale studies are warranted to enhance generalizability of the results. Women self-selected to enroll in this study; thus they might be more motivated to change their behaviors than women who did not enroll. A key strength is use of a qualitative design enabled us to gain a depth of insight into factors influencing women’s initial and ongoing participation in Mindful Moms.

Findings suggest that the Mindful Moms intervention, a combination of nurse-led MI and group- and home-based mindful physical activity, is a promising approach to targeting the challenging issue of motivating women to manage depressive symptomatology during pregnancy. Nurses who work with childbearing women may consider learning MI techniques to encourage mindful physical activity. Nurses should be aware of some of the non-specific aspects of interventions that women find to be helpful when engaging in a mindful physical activity intervention, such as having a warm and supportive staff, having a safe environment in which to discuss difficult topics, and being involved in group activities with other women experiencing similar symptoms.

Suggested Clinical Implications.

  • Nurses should be aware that mindful physical activity may be an important self-management strategy for women experiencing perinatal depressive symptoms

  • Motivational interviewing is a technique that can be learned and used by nurses to engage women in self-management of depressive symptoms

  • The combination of motivational interviewing and mindful physical activity can empower women to manage perinatal depressive symptoms

  • Participants in the Mindful Moms intervention stated that they felt motivated to engage in self-management thanks to the safe space and opportunities to share experiences with other women experiencing similar symptoms

  • Nurses can provide additional motivation to women managing their depressive symptoms by providing a sense of accountability in a warm, kind environment

Acknowledgements

The authors wish to acknowledge Suzanne McGinnis for her assistance in the preparation of the figure for this manuscript.

Funding (Financial Disclosure)

Research reported in this publication was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development/ National Institutes of Health under Award R15HD086835-01A1 (PI: Kinser).

Contributor Information

Amy Rider, School of Nursing, Virginia Commonwealth University, Richmond, VA.

Suzanne E. Mazzeo, Department of Psychology, Virginia Commonwealth University, Richmond, VA.

Patricia A. Kinser, Department of Family and Community Health Nursing, Virginia Commonwealth University School of Nursing, 1100 E. Leigh St., Richmond, VA 23298.

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