Abstract
Women with a high-risk pregnancy on hospitalized bedrest engaged in relaxation interventions, including guided imagery, visual imagery, and listening to music. Qualitative interviews gathered their perspectives on the effects of hospitalized bedrest on well-being and the subjective experiences related to the relaxation interventions. Benefits identified included improved physical well-being and sleep. Such relaxation interventions were concluded to have the potential to positively influence the occupational well-being of this population, resulting in more positive outcomes for mothers.
Women with high-risk pregnancies restricted to bedrest may experience threats to well-being (Heaman & Gupton, 1998; Maloni, 2011). Approximately 1 million women in the United States are prescribed bedrest for high-risk pregnancy annually, despite the lack of evidence supporting its effectiveness (Maloni, 2011). Bedrest may actually induce further complications for the pregnant mother, including impaired muscle functioning; decreased bone mass; increased risks for blood clots; and amplified feelings of depression, loneliness, and stress—all of which can also be detrimental to pregnancy outcomes (Heaman & Gupton, 1998; Maloni, 2011). Associated negative outcomes for the unborn baby include effects on growth and maturation as well as susceptibility to a range of long-term diseases (Viltart & Vanbesien-Mailliot, 2007).
Seligman (2011) defined well-being as consisting of the following indicators: positive emotions, engagement, relationships, meaning, and achievement. Lack of engagement in meaningful occupations during bedrest poses a barrier to the experience of optimal well-being as articulated by other models that have suggested emotional, spiritual, social, physical, and intellectual dimensions (Hettler, 1976; Substance Abuse and Mental Health Services Administration, 2016). Activity restrictions also constitute a barrier to occupational participation that inevitably leads to occupational disruption (Whiteford, 2010), posing a risk to the health of the mother and the unborn baby.
Among the interventions that address well-being are those designated as complementary and alternative medicine (CAM) strategies, such as relaxation techniques. Relaxation techniques include methods designed “to produce the body’s natural relaxation response, characterized by slower breathing, lower blood pressure, and a feeling of increased well-being” (National Center for Complementary and Integrative Health , 2016, para. 4). Relaxation reduces arousal in the cortical regions of the brain, potentially calming the nervous system and conserving and restoring energy (Jacobs & Friedman, 2004), positively affecting stress, depression, sleep disturbances, and other ailments (National Center for Complementary and Alternative Medicine, 2016). Relaxation interventions have resulted in prolonged gestation and positive labor outcomes (Janke, 1999) and improved sleep during pregnancy (Tsai et al., 2011).
Listening to soothing music for relaxation has been found useful during pregnancy (Tsai et al., 2011; Yang et al., 2009) and has proven effective for promoting sleep and alleviating anxiety and muscle tension (de Niet et al., 2009). Guided imagery includes prompts to engage in deep diaphragmatic breathing exercises and progressive muscle relaxation, and it may incorporate visual imagery evoked from imagination or recalled from actual events (Apóstolo & Kolcaba, 2009; Kaufman, 2007). Guided imagery has been found to produce positive results for breastfeeding and lactation (Feher et al., 1989) as well as reductions in blood pressure, heart rate, and endocrine levels (Urech et al., 2010). Visual imagery may elicit a relaxation response (Moffatt et al., 2010) and facilitate relaxation during labor, leading to shorter duration of labor and an increased number of vaginal deliveries (Saisto et al., 2001). In the occupational therapy literature, Flynn et al. (2016) found that a guided imagery intervention yielded a considerable reduction in stress in pregnant adolescents.
In summary, research indicates that relaxation interventions produce positive outcomes for antepartum mothers and to pose a possible alternative to hospitalized bedrest as a primary intervention in light of the lack of evidence and potential negative health effects of the associated restrictions. However, the use of these interventions with this population has received scant attention in the literature, and there is a need to produce evidence regarding the effectiveness of relaxation and other interventions for this population.
Method
Design
A qualitative constructivist approach (Creswell, 2013) was used to gather subjective experiences of women on hospitalized bedrest for high-risk pregnancy regarding their participation in relaxation interventions. Qualitative approaches are deemed useful to investigate the effectiveness of health care interventions by gathering participants’ perspectives regarding their experiences of the intervention. In this case, the constructivist approach was used to frame an inquiry that would encourage participants to articulate their experiences of and their views regarding the meaning of participation in the interventions in relation to well-being (Al-Busaidi, 2008). Approval was obtained from the Towson University institutional review board and the scientific review committee of the participating hospital. The audio-recorded guided imagery CD was developed and recorded by the author, and it integrated evidence-based language that has been shown to produce a relaxation response among pregnant women (Jallo et al., 2008).
Trustworthiness was supported through the use of verbatim transcription of audio-recorded semistructured interviews, supplemented by field notes, and observation. Rich descriptions of experiences were elicited through multiple interviews, rephrasing of questions, and prompting for detailed and thorough accounts. Triangulation provided corroborating evidence through member-checking throughout the interview process to ensure that the understandings obtained were accurate and credible. In addition, an external audit supported the accuracy of the data analysis (Creswell, 2013).
Participants
The study took place on the antepartum unit of a regional medical center in a metropolitan area. Twelve female participants were selected with criterion sampling (Creswell, 2013). All patients admitted to the unit were screened, and inclusion criteria included an active prescription for hospitalized bedrest due to a high-risk pregnancy, a projected length of stay of at least 5 days, and willingness and ability to provide informed consent. Exclusion criteria included the presence of a medical condition that could jeopardize the pregnancy with participation in the study. The participants ranged in age from 20 to 41 yr, and the gestational age at commencement of the study varied from 22 to 30 wk. The length of time on hospitalized bedrest varied from 1 to >7 wk.
Data Collection
The central research question posed in the study was as follows: What are the experiences of antepartum, high-risk mothers regarding relaxation interventions and their effects on mothers’ well-being? After the provision of informed consent consistent with the institutional review boards of the supporting institutions, participants engaged in semistructured interviews conducted by the occupational therapist principal investigator (PI). The interview protocol was devised to determine participants’ perceptions of their occupational engagement before and after being placed on bedrest, their current subjective well-being, and their previous experiences with relaxation techniques.
Guidance for participation in relaxation interventions was provided by an audio CD, scripted instructions, or an Internet link. Graduate occupational therapy student researchers under the direct supervision of the PI provided live instruction in each technique at the onset of the study. The use of a CD audio program that integrated evidence regarding specific prompts for this population (Jallo et al., 2008) further supported the client-centered context of the intervention (Law et al., 1995). Accordingly, verbal prompts included those intended to evoke feeling state imagery noted to promote relaxation as an important prerequisite for effective imagery (Jallo et al., 2008). Careful attention was paid to the selection of appealing music, and the narrator used a calm and soothing voice to prompt participants to visualize images intended to elicit positive emotions, such as loving, healing light surrounding the unborn baby (Naparstek, 2003).
Participants were prompted to engage in all three relaxation interventions over 5–7 days, and they kept a log recording dates and times of participation as well as reactions to the practices. The music was adapted from a musical CD titled The River (DeMaria, 2003), with permission from the artist. The guided imagery intervention consisted of a prerecorded CD including soothing music and scripted verbal instructions for a 25-min guided imagery experience. The visual imagery intervention included an Internet link to a 30-min slideshow of soothing images accompanied by music. The music intervention included only the prerecorded CD with 30 min of soothing music.
Follow-up interviews were cofacilitated by the PI and graduate students and took place 5–7 days after the initial visit. Participants engaged in one, two, or three interviews, depending on length of stay, which was unpredictable because of various circumstances regarding the commencement of labor. During the interviews, participants were asked to describe their experiences with each of the relaxation interventions, with prompts provided to elicit rich descriptions of experiences. Two to four audio-recorded follow-up interviews were conducted, depending on length of stay and availability, with a goal of reaching data saturation (Glaser & Strauss, 1967).
Data Analysis
Data analysis commenced with verbatim transcription of interview data, which were analyzed to identify significant themes following a process of analytic induction (Le Compte & Preissle, 1993). Line-by-line analysis was conducted by teams of two graduate student researchers to compare and come to an agreement regarding emerging initial themes, which were then collapsed into more general encompassing thematic categories. The PI and graduate student researchers then collaborated to link the emergent categories of information to larger, more meaningful themes (Creswell, 2013) in relation to the research questions. After the themes were finalized, a textural description was compiled and presented to a faculty member not involved in the research, who served as an external audit, along with the transcriptions for feedback to ensure the accuracy and saliency of the analysis.
Results
Participants chose among the relaxation intervention options for daily practice rather than consistently engaging in all three. Four of the 12 participants reported listening to the soothing music for relaxation, 4 of 12 participants used visual imagery, and all participants engaged in guided imagery. Participant experiences were characterized in relation to physical well-being, emotional well-being, and sleep.
Physical Well-Being
Before participation in the relaxation interventions, participants reported lower body soreness from inactivity, headaches, and general discomfort from the position of the babies. Participants indicated improved physical well-being after participating in the relaxation training, with 2 women relating that they found music to be particularly helpful. Specifically, participants relayed that the soothing music helped them to “reduce tension” and “relax [their] muscles.” One participant stated, “I didn’t feel so stiff [after listening to the music].” Two participants revealed that the guided imagery helped alleviate painful contractions, and 2 women shared that they thought their babies positively responded to the guided imagery, as evidenced by a perception of calming of the movement in their wombs. As noted by 1 participant, “[The guided imagery CD] was relaxing; I could feel the baby was really settled.”
Emotional Well-Being
Each participant reported some degree of emotional discomfort, and all described it as more severe than their physical discomfort. One participant shared that being on bedrest was “miserable” because “everything was out of [her] control”; specifically, she indicated that she felt upset about not being able to attend her baby shower, and she noted that she was experiencing financial stress because of loss of work. Another participant observed that she left things at work in a state of “chaos” because of her unexpected hospital admission. Other participants indicated emotional discomfort due to missing their families, inability to fulfill roles in the home, feelings of isolation, and worry over their pregnancy outcomes. As 1 participant noted, “[Bedrest is] not having freedom to do anything. It’s like being stuck . . . basically sitting back and watching the world go by and not being able to do anything.” Moreover, participants reported features of the hospital context that were perceived as barriers to well-being, exemplified by 1 participant who commented that “During the day there are so many distractions. Even if I try to take a nap, somebody is always coming in, and the phone is always ringing.”
Participants reported that listening to music for relaxation was effective for improved emotional well-being, noting that the soothing music “helped [them] to relax,” “reduced [their] anxiety . . . and stress,” and helped take their minds off of their pregnancy complications. One woman elaborated, “I felt more relaxed, calm, and happy [after listening to the music].” One participant shared that she listened to the music after hearing concerning news related to her pregnancy, and she stated that this relaxation strategy distracted her from her situation, “cleared her head,” and decreased her stress level. One participant similarly stated, “It was nice just to not focus on the baby” because she found that most topics of her conversation were centralized to the baby, which she perceived as stressful.
Guided imagery also reportedly improved participants’ perceptions of emotional well-being. Several participants reported experiencing a “mental release” from the stress of bedrest during guided imagery, attributed to having guided instructions provided to facilitate relaxation. One participant indicated that guided imagery was particularly helpful for improving her mood and relieving tension that she felt from the stresses of both pregnancy and activity restriction. Another participant perceived it as helpful for reducing her anxiety. One participant, also referring to guided imagery, emphatically stated, “Oh, I feel so much better! I just feel happy!” Another participant elaborated a bit: “I think it [guided imagery] was very positive. It was very relaxing, especially toward the end of my stay here because . . . my mind was racing with going home . . . the CD really helped [me to] relax.” The visual imagery intervention was also described by 1 participant as helpful because it “took [her] mind off of things” by allowing her to focus on something other than her symptoms and to feel less stressed.
Facilitated Sleep
Adverse physical and emotional symptoms were reported to have negatively affected many of the participants’ sleeping patterns before engaging in the study, including problems falling asleep and staying asleep. Several participants indicated that “racing thoughts” kept them up at night. One participant elaborated, “My mind is constantly thinking, and eventually I fall asleep, but it’s like 2:00 or 3:00 in the morning.” Others described difficulties maintaining normal sleeping patterns because of the unfamiliar hospital environment, including frequent disruptions of sleep throughout the night by hospital staff. In addition, others repeatedly reported napping during the day because of boredom from lack of occupational engagement. One woman said that being in bed all day interfered with her sleeping patterns: “I’m not doing anything [during the day], so at night I’m not tired.”
The majority of the participants indicated that the relaxation strategies were helpful for facilitating sleep. One participant shared that she was surprised to have slept so well during her first night on bedrest, stating that the guided imagery CD “put [her] to sleep in minutes” and that the positive relaxation effects kept her from “tossing and turning so much.” Another participant stated that the guided imagery CD helped her to fall asleep and that she felt she had gotten “more total hours of sleep than [she had] in a while.”
Participants frequently reported that the guided imagery CD helped to “ease their mind” and that they were able to fall asleep easier and sooner. All of the participants who participated in the music intervention reported positive perceptions of this technique for facilitating sleep. One woman shared her perceived feelings of peacefulness after listening to music at night, stating that it made her feel “definitely more relaxed.” She described that the relaxing music took “the focus away” from her pregnancy complications and bedrest, which allowed her mind to relax at night. Another participant agreed, stating that listening to the relaxing music had made a “dramatic change” in her sleep patterns and that it was successful for facilitating the onset of sleep and for staying asleep.
Discussion
The results indicate that women with high-risk pregnancies who are on hospitalized bedrest experience threats to well-being in relation to the associated restrictions. Physical and emotional side effects reported in association with bedrest were consistent with findings in the literature (Da Costa et al., 2010; Maloni, 2011; Pires et al., 2010). Relaxation interventions were experienced as effective for improving dimensions of well-being and enhancing sleep, including producing feelings of calm and facilitating the onset and duration of sleep. Guided imagery and listening to music interventions were experienced as positive in regard to improving subjective well-being.
Participants in this study articulated the experience of threats to well-being in terms of broad categories of physical well-being, emotional well-being, and sleep. Available models of well-being (Hettler, 1976; Seligman, 2011; Substance Abuse and Mental Health Services Administration, 2016) have identified additional dimensions that did not emerge in this study, and sleep hygiene has often been subsumed under the dimension of physical well-being. In addition, the subjective experiences of well-being are not typically confined to one dimension, representing a more holistic and dynamic pattern. Yet, the analysis of the narratives depicting the perspectives of these participants yielded these categories of themes and reveal that women on hospitalized bedrest for pregnancy do experience distress and discomfort that pose real and present risks to their own health, potentially contributing to negative birth outcomes. Also, the data revealed that the participants did experience positive benefits from the menu of relaxation interventions provided, with a reduction in perceived features of stress from even a brief period of practice.
Limitations
Limitations of the study include the lack of data obtained regarding various demographic characteristics of the sample, including race, ethnicity, and cultural background, in light of the Centers for Disease Control and Prevention report on the use of CAM in the United States (Clarke et al., 2015) indicating various patterns of use among different racial and ethnic groups. Additional limitations include the lack of consistent participation in relaxation interventions across the participants.
Three intervention options were provided, and observations were gathered regarding the choice of intervention to determine which were experienced more positively. This method represented a limitation in terms of attaining data saturation, varied perspectives, and rich and thick descriptions across conditions. However, provision of options for participant choice was also viewed as an opportunity to learn about their preferences regarding intervention engagement and the barriers posed by the hospital context. Accordingly, participants revealed that many distractions in the hospital impeded their ability to engage in a relaxation intervention, yielding helpful information for structuring future studies. In addition, the durations of the experiences varied for several reasons, with participants engaging in the relaxation for a varied number of times.
Implications for Occupational Therapy Practice
The American Occupational Therapy Association (AOTA) has reported that occupational therapists can “teach relaxation strategies” (Gupta et al., 2012, p. 3), which the researchers noted may promote health and well-being among clients faced with uncontrollable situations in which their opportunities for participation are limited. AOTA supported their position about the use of relaxation strategies and other forms of CAM in occupational therapy practice, asserting that “occupational therapy practitioners may use CAM in the delivery of occupational therapy services when they are used as preparatory methods or purposeful activities to facilitate the ability of clients to engage in their daily life occupations” (AOTA, 2011, p. 3).
To date, few published studies have addressed the participation of this population in occupational therapy interventions designed to promote relaxation and enhance well-being, despite findings that high-risk pregnancy and associated bedrest can be detrimental to optimal well-being on several levels (Barlow et al., 2007). The temporary activity restrictions imposed by prescribed bedrest may be characterized as occupational disruption, as described by Whiteford (2010), representing a barrier to occupational engagement and the opportunity to flourish, as described by Seligman (2011). Relaxation strategies have been identified as a relevant occupational therapy intervention to support health and well-being (Gupta et al., 2012), suggesting that it is important to continue to investigate the potential benefits of such interventions and contribute to the base of evidence regarding safe and effective treatments for antepartum mothers.
Therefore, it is pertinent to consider the following key points:
In light of the lack of evidence supporting bedrest and other medical interventions to prolong gestation, it is important that occupational therapists continue to explore safe and effective approaches to address the important physical and mental health issues related to preterm birth.
Relaxation interventions show some promise for addressing the deleterious effects of stress during bedrest for high-risk pregnancy.
Contributions to the evidence base for practice necessitate the development and implementation of evidence-based protocols for the application of relaxation interventions in occupational therapy practice.
Conclusion
The results suggest that relaxation techniques are perceived as beneficial for the physical and emotional well-being and sleep quality of women on hospitalized bedrest for high-risk pregnancy, warranting further investigation of the efficacy of these interventions to support an evidence-based foundation for the integration of these approaches in a holistic practice of occupational therapy.