Effectiveness of Guided Imagery Intervention on Factors Associated With Maternal Stress and Preterm Birth

Preterm birth (PTB) is the leading cause of neonatal morbidity and mortality and has
tremendous health and economic costs for the infant, family, and society. There has been
little success in reducing PTB; rates are at an all time high. Of particular concern is the
major racial disparity in PTB rates; African American women have the highest proportion of
PTB compared to women of other races or ethnicities. There is growing evidence suggesting
that PTB may be the end point of sub-acute or chronic pathophysiological changes that occur
before clinical symptoms of preterm labor are present. There is also evidence to suggest
that psychosocial factors such as maternal stress and the related symptoms of fatigue,
anxiety, depression, as well as unhappiness about the pregnancy are associated with negative
birth outcomes. It is proposed that these behavioral factors could influence birth outcomes
through two possible pathways: (1) a neuroendocrine pathway in which maternal stress may
lead to early and/or greater activation of the maternal-placental-fetal endocrine systems,
with CRH playing a key role, thereby promoting labor; and/or (2) immunologic or
inflammatory pathways which may promote labor through pro-inflammatory mechanisms. Experts
agree primary prevention interventions are needed to address the issue of PTB. Guided
imagery (GI) has been effective in decreasing self-reported measures of stress, depression,
and fatigue as well as influencing neuroendocrine and immune measures in the general
population. However, there are only limited studies examining the effects of GI on maternal
stress, neuroendocrine measures, and/or birth outcomes, and there are no published studies
examining the effect of GI as a primary prevention intervention to improve birth outcomes by
reducing stress and related symptoms and influencing the proposed immunologic pathway to
PTB. The specific aims of this randomized clinical trial are (1) to test the effects of a GI
intervention on maternal stress (perceived stress), related symptoms (fatigue, anxiety,
depression, and unhappiness), neuroendocrine (CRH) and immunological mediators (IL-1β, IL-6,
Il-8, IL-10, IL-12, TNF-α, IFN-γ, G-CSF, GM-CSF), and birth outcomes (gestational age and
neonatal birthweight) in African American women; and (2) to test the proposed theoretical
model by examining predicted relationships among stress, fatigue, anxiety, depression,
unhappiness, patterns of neuroendocrine and immunologic factors, and birth outcomes. An
analysis of covariance (ANCOVA) model will be used to test for group differences between the
GI and control groups. To test the proposed theoretical model descriptive statistics,
graphical methods and pairwise correlations will be calculated for all baseline data and
canonical correlation analysis will be used to look for relationship among groups of the
baseline variables. Demonstrating the effectiveness of an economical, easy to distribute and
use, intervention on the psychosocial factors associated with PTB and the proposed pathways
leading to adverse birth outcomes has tremendous health, social and financial benefits. This
project will provide baseline data for further research to test the biobehavioral efficacy
of this intervention in larger samples with multiple races/ethnicities as well as test the
model during the postpartum period for maternal well-being and infant development.

Inclusion Criteria:

- Being pregnant between 14-17 weeks gestation

- Being African American

- 18 years of age or older

- able to read, write and understand English

- verbalize a source of social support

- self-report of no change in level of stress management strategies used within the
last month.

Exclusion Criteria:

- carrying multiples

- have had cervical cerclage

- currently use oral corticosteroids

- have uterine or cervical abnormality

- have dissociative disorders, borderline personalities or psychotic pathology

- have medical and/or pregnancy complications known to impact cytokine levels (e.g.,
gestational diabetes)

- currently use GI techniques.