Elsevier

Psychoneuroendocrinology

Volume 104, June 2019, Pages 174-184
Psychoneuroendocrinology

The SMART Moms Program: A Randomized Trial of the Impact of Stress Management on Perceived Stress and Cortisol in Low-Income Pregnant Women

https://doi.org/10.1016/j.psyneuen.2019.02.022Get rights and content

Highlights

  • Pregnant women in CBSM show lower perceived stress in pregnancy and post partum.

  • Interaction effects found for CBSM on cortisol by ethnicity and pregnancy anxiety.

  • Non-Latina women in CBSM have a lower CAR at three months post partum.

  • High prenatal anxiety women in CBSM show steeper decline in their diurnal cortisol.

Abstract

Background

Dysregulations in maternal hypothalamus-pituitary-adrenal function and the end product, cortisol, have been associated with a heightened risk for stress-related health complications during pregnancy and post partum. Given the adverse health impact that maternal cortisol may have on expectant mothers and their infants, empirically-based prenatal interventions are needed to target optimal management of stress and its biological effects in at-risk pregnant women, a primary example of which is cognitive behavioral stress management (CBSM). This randomized-controlled trial examined the effects of a prenatal CBSM intervention on reduction in perceived stress and regulation of salivary cortisol patterns [i.e., overall cortisol output (area under the curve), cortisol awakening response (CAR), diurnal slope] during pregnancy and the early postpartum period, as compared to a control group.

Methods

One hundred low-income pregnant women (71% Latina; 76% annual income < $20 K) with low or high anxiety during pregnancy were randomized (stratified by anxiety) to either an eight-week CBSM group intervention (n = 55) or a control group (n = 45). They provided seven salivary cortisol samples (four am samples, 12 pm, 4 pm, and 8 pm samples on one collection day) at baseline (1st trimester; < 17 weeks of gestation), after their prenatal program (2nd trimester), and also in the third trimester and at three months post partum.

Results

Women receiving CBSM had lower perceived stress levels throughout pregnancy and early post partum compared to women in the control group (p = .020). Among women with high prenatal anxiety, those in CBSM showed a steeper decline in their diurnal cortisol at three months post partum compared to those in the control group (p = .015). Further, non-Latina women in CBSM had a lower CAR at three months post partum compared to non-Latina women in the control group (p = .025); these randomization group differences on the CAR were not observed among Latina women.

Conclusions

These findings provide preliminary support for the efficacy of prenatal CBSM interventions in improving stress outcomes among low-income pregnant women and suggest the need to test the effects of these interventions on a larger scale for improving maternal and infant health outcomes long-term.

Introduction

Stress is generally considered an adaptive response to challenges in the environment, but chronic dysregulations in biological stress-related systems have been associated with adverse health outcomes (Chrousos, 2009). Stress during pregnancy has been associated with a range of health problems for women, including increased anxiety and postpartum depressive symptoms (Dunkel Schetter et al., 2016; Yim et al., 2015). It has also been linked to adverse birth outcomes, namely preterm birth and low birthweight, which are associated with long-term neurodevelopmental impairments in children (Van den Bergh et al., 2017). Of particular concern are low-income women, who are prone to experiencing psychosocial stressors during pregnancy such as poverty, little or no prenatal health education, single parenthood, and are at greater risk for prenatal health complications and adverse birth outcomes (Lefmann et al., 2017; Reynolds et al., 2013). Therefore, studies examining biological mechanisms underlying the impact of prenatal stress on maternal and infant health in low income populations are needed.

The stress hormone cortisol has been associated with a heightened risk for stress-related health complications during pregnancy and the postpartum period (Hodyl et al., 2017; Zijlmans et al., 2015). Cortisol is the end-product of the hypothalamus-pituitary-adrenal (HPA) axis, is released by the adrenal glands, and is considered one of the main markers of the biological stress response (Fries et al., 2009). A dramatic change in HPA axis regulation and cortisol secretion occurs during pregnancy with cortisol levels rising throughout pregnancy, which plays an important role in fetal organ development, and returning to pre-pregnancy levels after childbirth (Mastorakos & Ilias, 2003). Diurnal variation is still observed during pregnancy, though reduced, with cortisol levels being highest in the morning and lowest at the end of the day (Mastorakos & Ilias, 2003). Although the rise in cortisol during pregnancy is normative, studies show that higher concentrations of maternal cortisol during pregnancy are related to adverse birth outcomes, including increased rates of preterm births, a higher need for infant resuscitation assistance at birth, and infant brain cell damage (Hodyl et al., 2017; Zijlmans et al., 2015). In addition to overall cortisol secretion, researchers have examined women’s cortisol awakening response (CAR), a normative increase in salivary cortisol from the time of awakening to 30 min after waking (Pruessner et al. 1997). A higher CAR during pregnancy has been associated with shorter gestational periods (Buss et al., 2009) and a blunted or flat CAR with increased risk for postpartum depression (Scheyer & Urizar, 2016). Furthermore, flatter diurnal cortisol slopes (i.e., smaller decrease in cortisol levels across the day) during pregnancy have been associated with increased anxiety and impaired sleep in mothers and with low birthweight in infants (Bublitz et al., 2018; Kivlighan et al., 2008). Although low-income and ethnic minority women experience unique stressors (e.g., unemployment, racial discrimination) that place them at greater risk for prenatal health complications and poor birth outcomes (Lefmann et al., 2017; Reynolds et al., 2013), fewer studies have examined income/ethnicity differences in cortisol patterns and their relation to adverse health outcomes for mothers and their infants. Pregnancy studies show that African American women (regardless of income level) demonstrate a more blunted CAR and flatter diurnal cortisol patterns compared to non-Hispanic whites, which in turn have been associated with a greater risk for preterm birth in this population (Glynn et al., 2007; Simon et al., 2016). Collectively, these findings suggest that altered cortisol patterns (i.e., higher cortisol concentrations, higher/flat CAR, flatter diurnal cortisol slope) negatively affect mothers and their infants, and highlight the pressing need to develop and test prenatal interventions that target optimal management of stress during this critical period.

Health providers of pre- and postnatal care are becoming more aware of the need to create clear guidelines for the management of stress during pregnancy (ACOG, 2006). The Institute of Medicine (IOM) Report on Preventing Mental Disorders prominently states the need for research on preventive interventions and has endorsed group cognitive behaviorally-based interventions as one of the best methods and empirically-supported modalities for helping to prevent stress-related disorders (National Research Council & Institute of Medicine, 2009). Over the past 15 years, there has been some progress in examining the effectiveness of cognitive behavioral stress management (CBSM) interventions (i.e., combination of cognitive coping and relaxation training) on regulating biological markers of stress, such as cortisol. Previous randomized studies have shown group-based CBSM interventions to be effective in producing short-term reductions (i.e., 2 to 10 week follow-up period) in stress and cortisol levels in patients with stressful medical conditions, such as HIV and breast cancer (Antoni, 2013; Antoni et al., 2005). One of the few studies to examine the effects of a prenatal CBSM intervention on cortisol demonstrated lower cortisol levels among mothers at high risk for depression at 18 months post partum (Urizar & Muñoz, 2011). Despite these promising results, limited resources and training have precluded the translation of the IOM’s recommendations for systematically evaluating the effectiveness of group-based CBSM interventions in regulating stress and cortisol levels among low-income pregnant women who are in most need of these programs. In fact, despite the disproportionate number of premature births and low birthweight babies observed among low-income mothers, less than one quarter of these women report actively engaging in stress management during pregnancy due mainly to a lack of awareness of how important managing one’s stress levels can be for the health of the mother and her baby (Birdee et al., 2014). Given these disparities in birth outcomes and dissemination of preventive interventions, studies are needed to reach underserved women during pregnancy and provide them with the necessary skills and knowledge to facilitate stress management.

The current randomized-controlled trial examined whether a prenatal CBSM intervention, in comparison to a control group, was effective in reducing perceived stress levels and regulating salivary cortisol patterns among low-income pregnant women prospectively assessed throughout pregnancy and the early postpartum period. CBSM effects on perceived stress and cortisol were examined by ethnicity and prenatal anxiety levels.

Section snippets

Participants and study design

Women were recruited from six public-sector prenatal centers in southern California during their first to second trimester of pregnancy between 2011 and 2013. These prenatal centers serve a predominantly low-income population representative of the surrounding neighborhoods (38% below poverty level; U.S. Census Bureau, 2014). Women were recruited by research staff who approached them in the waiting room during their prenatal clinic visits, through print-based advertising (brochures, flyers), or

Participant characteristics

A description of the study sample by randomization group is shown in Table 1. Women in both groups were similar on all sociodemographic characteristics, including gestational age, as well as baseline levels of perceived stress and cortisol (all p > .05). On average, women in CBSM attended five out of eight classes (63%), with 56% attending at least half of the classes (range = 1-8 classes). The most common reasons for women missing a CBSM class included having competing time demands, having a

Discussion

The goal of this randomized controlled trial was to examine the effects of a prenatal CBSM intervention, compared to a control group, in reducing perceived stress and regulating salivary cortisol patterns (i.e., overall cortisol output, CAR, diurnal slope) in low-income pregnant women during pregnancy and the early postpartum period. Findings showed that women receiving CBSM had lower perceived stress levels during pregnancy and early post partum compared to women in the control group. Although

Conflict of interest

The authors declare that there are no conflicts of interest.

Acknowledgements

Guido G. Urizar Jr. is a Professor in the Department of Psychology, California State University, Long Beach. Ilona S. Yim is a Professor in the Department of Psychological Science, University of California, Irvine. Christine Dunkel Schetter is a Professor in the Department of Psychology, University of California, Los Angeles. Anthony Rodriguez participated in this work in the Department of Psychology at UCLA and is now at the Rand Corporation in Boston, MA. This study was conducted as part of a

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