Psychology Presentation : Critical Analyses Of the Article

Women and Birth 26 (2013) 82–86

Women’s experiences of participation in a pregnancy and postnatal group incorporating yoga and facilitated group discussion: A qualitative evaluation

Frances Doran a,*, Julie Hornibrook b,1

a School of Health and Human Sciences, Southern Cross University, PO Box 150, Lismore, NSW 2480, Australia b Member of Council of Women, Lismore and District Women’s Health Centre Inc., PO Box 1020, Lismore, NSW 2480, Australia

A R T I C L E I N F O

Article history:

Received 20 March 2012

Received in revised form 14 June 2012

Accepted 22 June 2012

Keywords:

Pregnancy

Postnatal

Yoga

Community

Group

A B S T R A C T

Background: This paper reports on a small qualitative research study which explored women’s

experiences of participation in a pregnancy and postnatal group that incorporated yoga and facilitated

discussion. The group is offered through a community based feminist non-government women’s health

Centre in Northern NSW Australia.

Question: The purpose of the research was to explore women’s experiences of attending this pregnancy

and postnatal group.

Methods: An exploratory qualitative approach was used to explore women’s experiences of attending

the group. Fifteen women participated in individual, in-depth face-to-face interviews. Interviews were

recorded and transcribed verbatim. Thematic analysis was undertaken to analyse the qualitative data.

Findings: Six themes were developed, one with 3 subthemes. One theme was labelled as: ‘the pregnancy

and motherhood journey’ and included 3 sub-themes which were labelled: ‘preparation for birth’,

‘connecting with the baby’ and ‘sharing birth stories.’ The other five themes were: ‘feminine nurturing

safe space’, ‘watching and learning the mothering’, ‘building mental health, well-being and connections’,

the ‘‘group like a rock and a seed’ and ‘different from mainstream’.

Conclusion: This research adds to the overall body of knowledge about the value of yoga in pre and

postnatal care. It demonstrates the value of sharing birth stories and the strong capacity women have to

support one another, bringing benefits of emotional and social well-being, information, resources and

support derived from group based models of care.

Crown Copyright � 2012 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives. All rights reserved.

Contents lists available at SciVerse ScienceDirect

Women and Birth

jo u rn al h om ep age: w ww.els evier .c o m/lo c ate /wo mb i

1. Introduction

This paper reports on the results of an exploratory qualitative study, which aimed to explore women’s experiences of attending a pregnancy and postnatal group offered as part of a community based feminist non-government women’s health Centre in rural northern NSW. The group aims to provide women with a positive, joyful and safe space; teach breath control, relaxation, and build strength through yoga; explore options in relation to birthing and parenting and develop a support network.

A formal quantitative evaluation to determine the effectiveness of the group in achieving its aims was undertaken in 2010. Results of 45 completed postal surveys indicated the group is highly effective in meeting its aims. An article demonstrating the results has been submitted by the authors for publication. The evaluation

* Corresponding author. Tel.: +61 02 66 203888; fax: +61 02 66 203022.

E-mail addresses: [email protected] (F. Doran), [email protected]

(J. Hornibrook). 1 Tel.: +61 04 0289 1169; fax: +61 02 6622 7268.

1871-5192/$ – see front matter . Crown Copyright � 2012 Published by Elsevier Australia (a division of Reed

http://dx.doi.org/10.1016/j.wombi.2012.06.001

also included a qualitative component of individual interviews with group participants, which aimed to explore in more depth women’s experiences of attending the group. This paper reports on this qualitative phase of the evaluation.

2. Literature review

Community based feminist women’s health centres emerged in the 1970s in NSW in response to women’s dissatisfaction with mainstream biomedical care.1 Their aim is to improve the health status of women by providing a unique, holistic, women-centred approach to primary health care. Practice is underpinned by a feminist, preventive framework which values women’s own knowledge and experience and facilitates the sharing of women’s skills, knowledge and experience to empower personal and social aspects of their lives.1

These Centres in NSW offer a range of different services to women across the lifespan, including supporting women during pregnancy and motherhood. Groups offered for women during and following pregnancy can complement mainstream care2 and

International Books Australia Pty Ltd) on behalf of Australian College of Midwives. All rights reserved.

F. Doran, J. Hornibrook / Women and Birth 26 (2013) 82–86 83

provide a level of social support not readily provided for childbearing women.3

Other holistic models of care that have emerged to support childbearing women include ‘‘Centering Pregnancy’’, which was developed in America in the 1990s4 and has since been adapted for Australia.5 Women meet within a group setting during pregnancy and in the early postpartum period and participate in facilitated discussion. It is a model of care that empowers women with information and resources to choose health-promoting beha- viours.6 Women have the opportunity to build supportive relationships and networks through sharing knowledge, ideas and experiences with other women and with midwives facilitating the groups.5

3. Setting

This background illustrates the context of the holistic post natal and pregnancy group, which has been evaluated. The group offered as part of a community based women’s health centre is based on feminist values. It commences with gentle yoga, meditation and breath work. This is followed by morning tea, check-in, birth stories, facilitated discussion and/or an education session by a guest speaker. Attendance is flexible and women pay a nominal fee. For women postpartum, babies are integrated in the group. The group has been co-facilitated by the same yoga teacher and midwife since inception in 2003 and each has over 25 years experience in her field of expertise.

4. Methods

Within the initial quantitative evaluation women completed a postal survey and were asked to tick a box if they would be willing to voluntarily participate in an individual interview, with the aim of exploring their experience of attending the group. This was the qualitative phase of the evaluation. Eligible women were contacted by the researcher. Interviews were conducted at a mutually agreed location and place. Interviews were digitally recorded. The only exclusion criteria related to participation of <5 groups.

Individual in-depth interviews were chosen as the most appropriate method to meet the research aim and as an ideal way to create a milieu to tap into the woman’s lived experience, knowledge and understanding. Conversing for some time in a relaxed environment allows for an in-depth understanding of a part of that person’s life and experience.8 A list of topics with open ended questions guided the interviews (Table 1).

5. Ethics

Ethics approval was gained from Southern Cross University Ethics Committee (ECN-10-150) to conduct the research.

6. Informed consent

Before commencement of the interview information about the purpose of the interview was explained to the woman, as was her right to withdraw at any time, without affecting participation in

Table 1 Guide for interviews.

� Background – demographics � Experiences/benefits derived from the group � Ways participation in the group influenced women in relation to pregnancy, birthing choices, parenting and social networks

� Group process

the group. Levels of confidentiality were explained such as the use of pseudonyms and aggregating of age and number of children in published results. A consent form was then signed by each participant.

7. Data analysis

Simple descriptive statistics were used to detail the participant characteristics. Interviews were transcribed verbatim and themat- ic analysis was undertaken. Data were entered using the NVivo computer qualitative analysis package. Broad headings were initially named by the researcher. Common word or phrases were given a numerical score and listed under an appropriate heading. For example, an initial heading related to the main benefits of participating in the group. Under this heading were words such as emotional support, social support, birth preparation, resources, yoga, and sharing resources. Two researchers then independently reviewed the list of headings and grouped concepts together to develop categories. The researchers then discussed these catego- ries and developed themes. Finally, the researchers met with the group facilitators (who had been provided with the list of preliminary headings, concepts and categories) to discuss and reach consensus on themes that most accurately reflected and captured the women’s words. Consensus was reached, with six themes identified.

8. Results

8.1. Findings

Of the 45 completed surveys, 23 women indicated their willingness to be interviewed. However, 3 women were ineligible and 5 were not contactable. Fifteen women were interviewed and time ranged from 20 to 90 min. Women were keen to tell their stories and needed minimal prompting.

8.2. Participant characteristics

Of the 15 participants interviewed 14 women were born in Australia, one identified as Indigenous and one was born in the Pacific. Ages ranged from 22 to 45 years with an average age of 32 years. All participants had a Technical and Further Education (TAFE) or university qualification, with an average of 1.6 children with the age of the youngest child ranging from 6 weeks to 21 months. One woman had participated in the group for both her pregnancies.

8.3. Themes

Six themes were identified, one of which incorporated three sub-themes. The themes are outlined below:

1. ‘the pregnancy and motherhood journey’ with sub-themes of ‘Preparation for birth’, ‘connecting with the baby’ and ‘sharing birth stories’;

2. ‘feminine nurturing safe space’; 3. ‘watching and learning the mothering’; 4. ‘building mental health, well-being and connections’; 5. ‘group like a rock and a seed’ and 6. ‘Different from mainstream.’

8.3.1. The pregnancy and motherhood journey

‘The pregnancy and motherhood journey’ emerged as a theme and 3 sub-themes were identified within this journey: ‘preparation for birth’, ‘connecting with the baby’ and ‘sharing birth stories’.

F. Doran, J. Hornibrook / Women and Birth 26 (2013) 82–8684

Marie had attended the group for both her pregnancies and her words capture the essence of the value of sharing in the group:

‘‘To be in a group of women going through exactly the same thing as you at all different stages, but everyone was going through that journey together, and so . . . it was beautiful the 1st

time and then the 2nd time some things were even more so.’’

8.3.1.1. Preparation for birth. All women spoke of the ways in which the group helped them to prepare for the birth, either emotionally or physically. Claire joined the group so that she ‘‘could do yoga and know that is was safe while I was pregnant.’’ Dominique commented: ‘‘I just really wanted to get centred ‘cos (previous baby) was caesarean. . . I really wanted. . . to get my body in practice through yoga.’’

Yoga helped some women to gain stamina and strength both physically and emotionally. Crystal reflected that ‘‘the breathing and meditation side ended up being the most important part.’’ Visualisations and meditation were beneficial in finding balance and a sense of strength. Claire commented that ‘‘yoga was really good. . . did lots of meditation.’’ Hannah also thought ‘‘yoga is great. . . [yoga teacher]. . . does all this empowering stuff where you visualise

yourself as a really strong woman. . . like a warrior kind of thing.’’

8.3.1.2. Connecting with the baby. ‘Connecting with the baby’ was a sub-theme of the pregnancy and motherhood journey that emerged through the reflective practice of the yoga. Imogen thought that the ‘‘yoga really helps you have a connection with your child and your body.’’ Polly commented on the skills of the yoga teacher and her ‘‘very good understanding of the needs of pregnant women. . . very good for feeling, for bonding with your unborn baby.’’

8.3.1.3. Sharing birth stories. ‘Sharing birth stories’, was identified as a sub-theme and seen as valuable by participants in preparing for the birth of their own baby and handing on unique women’s culture and knowledge. This is well reflected in Gail’s comment: ‘‘One of the most essential parts is the birth stories.’’ Regina ‘‘found more benefit in just going round the circle and hearing other birth stories. I loved hearing

the birth stories. . . it sort of prepares you for what was to come.’’ Reece was pleased the information was being passed on: ‘‘the girls who had their babies after me said they remembered things from my birth stories

that helped them.’’ Liana ‘‘was quite fearful of the whole labour, birth’’ but she said hearing other birth stories and how women dealt with things helped her with some of that fear.

8.3.2. Feminine nurturing safe space

All women perceived the group as a safe feminine space in which they felt nurtured to regain a sense of self and confidence. As Marie commented ‘‘you felt really nurtured in that space of yoga and the meditation ritual.’’ Marie thought that both facilitators just ‘‘provide a very loving caring environment for us.’’ Karen enjoyed ‘‘the creation of that space for women to be.’’ Imogen commented that she always ‘‘felt safe. . . can speak. . . safe to cry there.’’ Dominique valued the group in the early postpartum period as she found it ‘‘really scary to venture out into the world’’ with a baby and a small child.

For some women the group enabled a time and space for them to focus on being pregnant. Imogen felt the group was an important space in which ‘‘pregnancy was normalised.’’ For Reece who was experiencing relationship problems, the group for her was ‘‘my little pocket I got every week, where I could enjoy being pregnant because I felt like I was missing my pregnancy with all the

stuff going on.’’ Imogen, a mother of two children described the welcome experience of arriving at the group after doing the ‘‘bus drop off’’ and the ‘‘pre-school drop off. In the beginning when you come in. . . you lie out for relaxation and let the rest of the world drop

away for a while.’’

8.3.3. Watching and learning the mothering

Women spoke of the opportunity the group provided for women for watching and learning the mothering. Hannah’s comment captures the essence of learning about mothering skills:

‘‘Even having the women and the babies in the circle was interesting . . . because you could see what was going on with women who were pregnant, watching the mums . . . watching the mothering. . . was really important as we don’t get enough of that in our culture; being around mums when they are pregnant.’’

Regina liked the opportunity to talk to other mothers: ‘‘It was good. When he was born I always used to pay attention to the women

who had babies. . . good to be able to talk to other mothers.’’ Ivy linked the watching the mothering to the opportunity to learn, especially for the ‘‘wondering ‘doey’ eyed first timers to see a real live screaming ‘pooing’ little person and also to let them to be clucky. . . works really

well that subtle level of learning – observing other women.’’ However, some women found the yoga challenging with the babies, as highlighted by Imogen’s comment: ‘‘not so sure about the yoga – like there are 2 scripts running.’’ Gail reflected on these challenges in that ‘‘sometimes a bit of patience is needed.’’

8.3.4. Building mental health, well-being and connections

‘Building mental health, well-being and connections’ was identified as a theme as women readily described their feelings of anxiety, depression and isolation of being a new mother. When Claire first joined the group she ‘‘had chronic anxiety about everything. . . I couldn’t do anything. . . started seeing a psy-

chologist. . . yoga was really good. . . did lots of meditation. . . it

helped a lot.’’ Reece, Karen, Dominique and commented on challenges they

were experiencing early postpartum and the importance of the group in relation to helping them emotionally and in coping with postnatal depression. Reece reflected that the group ‘‘gave me something to get out of the house for. Even though he still wasn’t

sleeping, and was crying. . . I think definitely that played a role in me

not cracking. It kept me from going insane; just having those people

around you.’’ Karen felt she was bordering on postnatal depression and commented how the group helped her during this period: ‘‘You know if you’re having a crap time. . . then you see ‘oh, it’s just not me’. I think isolation’s a key factor in [postnatal]

depression. . . it’s a killer. . . that group is definitely one way to be

supported.’’ Dominique ‘‘reckoned it [the group] staved off a bit of post natal depression.’’

The value of support gained within the group was highlighted. Marie commented that ‘‘everyone’s there with you. . . you’re sitting in a group of people who’re going through the same thing. . . so the

compassion, empathy, advice, it’s beautiful; you can be supportive for

other people.’’ Liana commented on the importance of support: ‘‘definitely once I had [the baby]. . . that social aspect became more important. . . connecting with those mums. . . that’s when you started

swapping numbers.’’ Regina had recently moved to the area and reflected that she ‘‘had no one around here . . . so it was nice to just get out and see other women every week.’’ Imogen commented that her ‘‘favourite part is sitting down in the morning tea – we are all in a circle and we can tell each other how we’ve been and just being able to

say that and support each other through.’’ The value of connection in the morning tea was identified by

several women. Ivy thought that ‘‘the morning tea afterwards was a great way to meet other women.’’ Some women commented that they would like more opportunity to connect with other women. Hannah felt ‘‘sometimes it would have been good to share a bit more on what’s going on for me.’’ Polly also suggested a ‘‘check-in week. . . (could). . . give women more chance to connect.’’

F. Doran, J. Hornibrook / Women and Birth 26 (2013) 82–86 85

8.3.5. Group like a rock and a seed

The metaphor of the group like a rock was coined to reflect structure and familiarity of the group and the way it provided a sense of certainty. Marie’s words capture the group structure well: ‘‘You’ve got the 2 sections, the yoga and the talk. . . it allows some women to do just the 1st half or just the 2nd half – when it comes to

mothers bringing their babies back and telling their stories.’’ Claire commented that is was ‘‘good to have that structure. . . even if I was late – feel comfortable knowing what we were doing. . . and . . . what

was going to happen.’’ The metaphor of the group as a seed was coined to reflect the

group as a source of information and resources for mothers. Imogen reflected on how it helped her develop resources: ‘‘the talks afterwards – helps having tools in your tool belt to deal with

knowledge about services, resources, to pull out when things do get a

bit tough.’’ Jeanette found value in resources and knowledge to help with her birth plan: ‘‘Relaxation and feeling more empowered about the impending birth came from yoga and facilitated discussion –

knowledge came from meeting other women at that group.’’ Educational resources were important for Crystal: ‘‘having info on the pamphlets; that’s another really good thing.’’

8.3.6. Different from mainstream

Some women described the group as different from mainstream antenatal care, general yoga groups and Mothers groups. It provided a high level of support and enabled of women to express themselves through their own stories. Imogen commented that ‘‘yoga enabled me to have a connection with my body and child. . . which is really

important and really overlooked in the mainstream medical side of

obstetric care and the emotional journey of the woman.’’ Karen stated that ‘‘when I was first pregnant I went to pregnancy/yoga in Sydney but they didn’t have the group afterwards so you just went there and did

your yoga and left.’’ Jeanette compared the group to the ante-natal classes at the hospital: ‘‘Well up there [the hospital clinic] it’s all about the birth really, all about what to expect during birth while you’re in

hospital, whereas down here [the group] it’s all about just support

really. . . they do have the topics but I found more benefit in just going

round the circle and hearing other birth stories.’’

9. Discussion

The qualitative outcomes of the group described in this paper indicate the value of the group in providing yoga and facilitated discussion to support women during pregnancy and in the early post natal period. Yoga is one of the complementary therapies that is acceptable and beneficial during pregnancy. A South Australian study found that over 70% of obstetricians and midwives considered yoga and meditation safe during pregnancy and that over 65% had formally referred a patient for use of one of the complementary therapies.8 Yoga is useful for reducing depression9 and both yoga and relaxation contribute to improving mental health through reducing anxiety,10 as described by women in this study.

Group participants interviewed in this study were reflective of yoga users. A large study of correlates of yoga users (n = >3000) found they are more likely to be females with higher levels of education and average age of 39.5 years, compared to non-yoga users.11 All women in this study had either a TAFE or University level education in an area that overall has a higher socio-economic disadvantage compared to the NSW average.12 As yoga confers many benefits to participants the question remains how the group could be better accessed by women with lower levels of education and likely higher levels of social disadvantage, to improve equity and access of services.

The emergent themes highlight some key points of understand- ing such as the value of a feminine nurturing safe space. The style of the group fits readily with the philosophy of women’s health centres,

which aim to create a safe space for women. Similar to other holistic models of care such as ‘‘Centering Pregnancy’’6 the format enables women to participate in facilitated discussion and develop a support network with other group members. These group models of care enable an opportunity to build supportive relationships through sharing women’s knowledge, ideas and experiences with other women and within the safety and knowledge of a midwife/yoga teacher facilitating the groups.5,13 The style of the group fosters connections that support women as mothers, enables shared stories, and values women’s experiences. Compared with traditional antenatal care with its medical focus, women who attend group based antenatal care are more likely to continue to meet regularly.14

Women valued the opportunity to share their birth stories and to listen to other women’s stories with benefits related to birth preparation, labour and anxiety reduction. These findings are in line with results from research on storytelling as part of group programmes during pregnancy, which indicate the value as a potential real life teaching tool in childbirth. Through storytelling opportunities for social support, a sense of connection with other women and enhanced perceptions of emotional well-being during pregnancy are enabled.15 Sharing of birth stories can also be a powerful way to share and honour women’s knowledge about childbirth for expectant mothers. The group offers an opportunity for women to pass on this woman-to-woman legacy.16

Building mental health and well-being is a significant finding of the analysis and demonstrates that supported women’s culture contributes to the ability of women to find their way through the passage of pregnancy to parenthood in a positive, calm way, thus enhancing well-being for mothers and newborns. Potentially this reduces the risk of mental distress and post-natal depression during such a major transition in life. Further research is warranted to explore these links with implications for ways to improve support for women’s mental health and well-being. The 2010 Women’s Health Policy identified women’s reproductive health, including maternal health, as a national health priority that needs to be considered within the social and cultural context of women’s lives.17

This study draws attention to value and significance of social support and connections to improve health within a social context.18

10. Limitations

The purpose of this small qualitative study was to explore women’s experiences of participation in a pregnancy and postnatal group that incorporated yoga and facilitated discussion. The results of this study highlight the value of the group in supporting women holistically through pregnancy and in the early postpartum period. The results are applicable to this well educated group of participants and cannot be generalised to a broader population. In an attempt to enhance the trustworthiness of the data and to ensure the themes reflected the meaning of the transcripts, a team approach was taken to ensure a comprehensive process of thematic analysis. In this study potential for interview bias was offset by using skills of an experienced interviewer who was able to make the interviewees feel at ease so they could speak honestly and reflect on their experiences.19 The study on the value of this group did not extend to assessment of birth outcomes or an association between breathing techniques and labour process or the prevalence of postnatal depression. Larger research studies are needed to strengthen the evidence base.

11. Conclusion

This research adds to the overall body of knowledge about the value of group yoga and facilitated discussion in pre and postnatal care. It demonstrates the strong capacity women have to support one another, to be like ‘a rock and a seed’ for each other, bringing

F. Doran, J. Hornibrook / Women and Birth 26 (2013) 82–8686

the benefits of emotional and social well-being, information, resources and support derived from group based models of care set in a feminist framework. Given the positive impact gained by participating women it would be valuable to further research key themes identified and explore strategies to attract women from all walks of life, not only those of higher education levels.

Acknowledgements

To the group facilitators, the Midwife and the Yoga Teacher for constant guidance, support and enthusiasm; the group partici- pants; the research team and the funding body, NSW Health, which supported the project.

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