Mindfulness Intervention for Perinatal Grief: A Pilot and Feasibility Study in Rural India

Purpose:

India is among the ten countries that contribute 67% of all stillbirths globally.  The 2009 national stillbirth rate of India was estimated at 15-24.9/1000 births.  However, there are great variances in stillbirth rates within the country, with rates of 66/1000 births or higher in Central India.  A small rural hospital in Central India even reported a stillbirth rate of 330 in 2006.  At this hospital in 2010 and 2011 the stillbirth rate was 103 and 118, respectively. While still high, this sharp decrease occurred with the use of cardiotocograph and increases in staff available for emergency Cesarean sections.  (Unfortunately, mothers typically present for delivery after failing to give birth at home.)  

After experiencing stillbirth, these women suffer significant perinatal grief.  Factors that contribute to perinatal grief include traditional social norms, and perceived lack of social support.  An understanding of women’s perceptions and social norms for women in this context guided the development of a culturally rooted intervention designed to positively impact their ability to cope, utilizing mindfulness modalities. 

Mindfulness based stress reduction (MBSR) is an empirically supported 8-week intervention effective in helping individuals cope with clinical and non-clinical problems.  There are five facets of mindfulness: observing, describing, acting with awareness, non-judging of inner experience, and non-reacting to inner experience.  Mindfulness has been defined as a state of moment-to-moment awareness without judging one’s experience.  A state which can be cultivated with practice.  The purpose of this pilot study was to explore the feasibility and fit of a mindfulness-based intervention for perinatal grief, among poor, rural women in Central, India.

Methods:

Data were collected in two phases.  Phase one (N = 16) involved qualitative data collection to explore concept acceptability, receptivity, and modality.  Phase two involved the actual implementation of a subsequently developed mindfulness-based intervention and was delivered to women in a village referred by snowball technique from a phase one participant. It consisted of a brief version of the 8-week intervention delivered to 22 participants over two lengthy sessions, one week apart, with daily practice between sessions. (None of the participants in phase one participated in phase two.) Pretest included a validated perinatal grief scale, Cronbach’s alpha for this sample = 0.95 (n = 13). Pre and posttest included validated scales for mindfulness, satisfaction with life, social support, religiosity, depression, and anxiety; Cronbach’s alpha ranged from 0.68 to 0.84 (n = 6). Program evaluation consisted of twelve Likert-type items and three open-ended questions.

Results:

Phase one: Key informant interviews (n = 10) were conducted with a doctor, a staff nurse and women of reproductive age that had experienced stillbirth (< 1 year to 17 years prior).  A focus group (n = 6) was conducted with women of reproductive age who had a stillbirth history (< 1 year to 8 years since event).  Data indicated concept acceptance and acknowledged need for an intervention.  High receptivity for the proposed intervention was indicated by enthusiastic response and requests for immediate intervention delivery.  Intervention modality was carefully explored and helpful suggestions for cultural adaptation received for didactic materials.  Phase two: Participants in the first session (n = 13) had experienced stillbirth within the last one to seven years; with an average of 19.31 months (SD 21.34) since the event, and had high levels of perinatal grief; mean perinatal grief index score 106.39 (SD 22.68) where ≥ 91 indicates a high degree of grief.  Nine women who had experienced stillbirth attended the second session, however, only six of these women had attended the first session and were eligible to complete the posttest.  Statistically significant changes were noted on paired t-tests (n = 6) for Overall Religious Coping (p = .025) and Describing (p = .024).  All participants indicated daily practice of mindfulness skills. Pilot evaluation results indicate strong modality fit, women’s appreciation of what they had learned and their intent to attend 8-weekly sessions if given the opportunity to participate in the full intervention.  However, we also learned that women lacked the ability to follow through on their desire to attend, due to intervening life events and family expectations.

Conclusion:

Perinatal grief, particularly prolonged perinatal grief such as noted in this sample, puts women at risk for mental health issues, somatic symptoms, and decreased function.  This prolonged grief places these Indian women at further risk for domestic violence and displacement from her family or community, and other social issues, particularly if she has failed to produce a child, preferably a son.

            Stigmatization of mental health and reproductive issues plus a strong cultural belief in the inter-relatedness of mind, body, and spirit, in addition to a lack of mental health resources points to mindfulness as a possible solution. This mindfulness-based intervention utilizing yoga and meditation was well suited and well received among these women suffering with perinatal grief.  However, delivery of the intervention proved problematic.  It is not feasible for these women to attend weekly sessions, even when provided in the village, within walking distance.  Their time is structured by familial duties; work dictated by environmental variations, such as harvesting; and community events, such as weddings and festivals.  Additionally, the women lack autonomy, therefore, to attend a session was considered only after all other obligations and family concerns had been satisfied.          

Although the sample size in this pilot limits interpretation of the quantitative findings, the preliminary reliability and relationship tests suggest that the tools will adequately measure and show significance in a larger study.  Additionally, mindfulness is a culturally acceptable intervention. However, while results are promising, a full MBSR intervention is not feasible.  Though the women are enthusiastic about the intervention, note that they need it, and want it, given the realities of their lives the rigorous schedule of MBSR will be impossible to deliver.  Given our results we have continued wrestling with how to deliver the intervention to women in this rural Indian context, and have come upon a one-day intensive mindfulness intervention that may be adaptable yet effective.  Additionally, we intend to provide childcare and run a concurrent mother-in-laws group to better accommodate the limited autonomy and resources of these women.  Also, moving to this intensive one day format we feel it is critical to conduct individual follow-up sessions with participants and plan to accomplish this by partnering with local staff nurses and nursing students doing their community health rotations.  The follow-up sessions will be used to reiterate mindfulness concepts, monitor progress, promote continued practice of mindfulness skills, and receive feedback.  This partnership will be instrumental to the success of implementing and sustaining the intervention in the future.