MINDFUL DIGITAL PROGRAM

RESEARCH ARTICLE
Mindful Digital Program–based Interventions and Their Role
in Pregnancy and Fetal Outcomes
Jaideep Malhotra1
, Narendra Malhotra2
, Madhuri Patil3
, Neharika Malhotra4
, Ruchika Garg5
Abstract
The joint family system provides a support system especially for children, young parents, and parents-to-be and is a major factor in their survival,
health, education, development, and protection. It has the major potential to provide stability and support when there are problems.The joint
family system even in India is on the decline, and nuclear families are on the rise both in urban and rural areas.This has left the pregnant woman
with little or no family support to fall back on, which can be a cause of stress and thus affect the outcome of pregnancy. Moreover, during the
COVID, the medical support was also limited, which has added to the distress.
Stress in the mother can result in hypertensive disorders of pregnancy with resultant low birth weight babies, preterm delivery, adverse
neurodevelopmental outcomes for the child, and developmental delays in babies, and all these need to be avoided.
iMumz pregnancy, the baby care and parenting digital program, has sought to address these issues by partnering closely with pregnant
women, offering a wide range of assistance and activities for maternal well-being in the comfort of their own homes. This study captures the
responses and pregnancy outcomes of the women who have used the iMumz pregnancy digital program during pregnancy.
Materials and methods: This longitudinal study (panel study) was conducted on 512 primigravidas. The study group included 255 pregnant
women who opted for a digital holistic health program:“Baby Care Program”(BCP), while the control group consisted of 257 pregnant women
who received no such interventions.
The BCP included mindfulness meditation, 3 hours of yoga and breathing practices every week, 2 hours of harmonizing music every week,
1 hour of baby bonding activities every week, and 1 hour of personalized diet and pregnancy education each week. The data were collected
at 15 and 35 weeks of pregnancy and then from 1 month until 6 months of postdelivery.
Results: The study showed a statistically significant improvement in sleep patterns and stress levels. It also showed a statistically significant
decrease in the incidence of preterm delivery and low birth weight and a better maternal–fetal bonding or attachment (MFA) in the BCP study
group compared to the control group. After initiation of BCP activities in the App, 88% of the patients reported a significant reduction in stress.
The BCP study group also reported a higher sense of mastery in coping with postpartum blues. Eighty percent of the control group reported
postpartum blues as compared to 19% of the BCP users. Moreover, 81.4% of the BCP study group reported more sense of control in managing
their pregnancies, despite the stressful COVID environment.
Conclusion:The BCP activities, such as meditation, yoga and breathing exercise, harmonizing music, baby bonding activities and personalized
diet, and pregnancy education, have helped pregnant women to reduce their stress levels with improvement in sleep quality, increased a sense
of control over diet and nutrition, and educated about MFA.
The use of BCP has also positively correlated with better early childhood development and milestones.
Keywords: Baby Care Program, Baby blues, Fetal development, Mother–fetal attachment, Nuclear family, Pregnancy, Stressors.
Journal of South Asian Federation of Obstetrics and Gynaecology (2021): 10.5005/jp-journals-10006-1909
Introduction
Traditionally,oursocialstructureandculturesupportedthetransition
ofwomentomotherhood.Thepregnantwomeninthepastwithjoint
family system were surrounded by knowledgeable women, family,
andclosefriends,whosupportedthistransitionwithaffirmationand
greatexcitement.Wealsoknowthatpregnantwomenweretreated
differently, given the best food, and protected from stress and hard
physical work. The joint family system also played a major role in
the survival, health, education, development, and protection of the
children in the family and helped in providing expecting mothers
with stability and support when they most needed it.1,2
The current
trend of changing family dynamics to a nuclear structure along
with limited medical support during the COVID pandemic had led
to more stress and anxiety during pregnancy. It has been observed
that approximately 70% of women experience either prolonged
depression or a phase of baby blues,3
which can have an effect on
thematernal–fetalbondingandalsoinfluencesleeppatterns,ability
to perform daily tasks, and quality of life in the pregnant women.
© Jaypee Brothers Medical Publishers. 2021 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
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1
ART Rainbow IVF, Agra, Uttar Pradesh, India
2
Global Rainbow Healthcare, Agra, Uttar Pradesh, India; Dubrovnick
International University, Dubrovnik, Croatia; IAN Donald School,
Mumbai, Maharashtra, India
3
Patil’s Fertility and Endoscopy Clinic, Bengaluru, Karnataka, India
4
Rainbow IVF Hospital, Agra, Uttar Pradesh, India; Patankar Hospital,
Pune, Maharashtra, India
5
Department of Obstetrics and Gynecology, SN Medical College, Agra,
Uttar Pradesh, India
Corresponding Author: Jaideep Malhotra, ART Rainbow IVF, Agra,
Uttar Pradesh, India; Dubrovnik International University, Dubrovnik,
Croatia, e-mail: jaideepmalhotraagra@gmail.com
How to cite this article: Malhotra J, Malhotra N, Patil M, et al. Mindful
Digital Program–based Interventions and Their Role in Pregnancy and
Fetal Outcomes. J South Asian Feder Obst Gynae 2021;13(3):170–175.
Source of support: Nil
Conflict of interest: None

Mindful Digital Program–based Interventions and Their Role in Pregnancy and Fetal Outcomes
Journal of South Asian Federation of Obstetrics and Gynaecology, Volume 13 Issue 3 (May–June 2021) 171
The data were collected at 15 and 35 weeks of pregnancy
and then from 1 month until 6 months of postdelivery. Both
quantitative and qualitative data were collected using a descriptive
mixed-methods design. In the first data-gathering touchpoint, the
primigravida milestones were collected from weeks 10 to 12.
In the 15th and 35th weeks, the maternal psychosocial indices
were mapped on three scales, namely the Perceived Stress
Reactivity Scale (PSRS), Pittsburgh Sleep Quality Index Scale (PSQI),
and Cranley’s Maternal–Fetal Attachment Scale (CMFAS).
Participants also responded to a 45-item self-reported
questionnaire on their emotional state, postpartum blues,
breastfeeding, sense of control, and their observations of the baby.
This method of data collection was selected because it not only
provides freedom for participants to express their views but also
helps in validating results. Moreover, this method was the easiest
to conduct during the COVID pandemic.
Results
This study to probe the role of the BCP mindful digital program–
based interventions on pregnancy and fetal outcomes threw up
interesting insights across several dimensions.
The mean gestational age at delivery and the weight of the
baby was significantly more in the study group as compared to the
control group (Table 2). The incidence of preterm deliveries was
significantly lower in the study group as compared to the control
group (Table 2). There was no statistical difference in the normal
vaginal delivery or emergency caesarean section between the two
groups, but the rate of elective caesarean section was much higher
in the control group as compared to the study group though it did
notreachstatisticalsignificance(Table2).Onemustrememberthat
there is still an 8% chance that the null hypothesis is true for the
rate of elective cesarean section being more in the control group.
The data on the birth weight of the babies revealed that the
BCP study group notched a mean of 3.1 kg as against the control
group’s2.4 kg(Table2).Morethan86%ofbabieshadabirthweight
greater than 2500 gm in the study group as against 67% in the
control group (Fig. 1).
When the data were analyzed for preterm deliveries, it was
observed that the incidence was much lower in the BCP group
(12%) as compared to controls (32%) (Fig. 2).
Eighty-two percent of mothers in the BCP group revealed that
theywereabletoadoptdietswithidealnutrition,comparedto46%
in the control group, based on the dietary information and recipes
that were made available to them on the BCP.
The study group of BCP mothers reported better sleep during
pregnancy. On the PSQI scale, there was a significant difference
between mothers using the BCP activities vs those in the control
group (Table 3). Patients reported better sleep (87%) as compared
to their pre-BCP sleep, which was attributed to the in-App activities
of BCP (Fig. 3).
It is a known fact that bonding with and shaping the baby’s
temperament, also known as maternal–fetal attachment (MFA),
begins right from the time of conception.4
The baby can hear and
absorb mother’s emotions and feelings in the womb. Mother is a
powerful engineer in shaping the baby’s traits and personality just
withherstateofmind,calmness,andmentalstability.Herexposure
to good nutrition, music, exercises, and meditation improves her
coping up strategies and reduces stress.
SeveralstudieshaveshownthateducatingmothersonMFAcan
enhancethemother’smentalhealthandattachmenttotheinfant.5
During the past several decades, great strides have been made in
improving the outcomes of pregnant women and their babies.
The Baby Care Program (BCP) digital intervention was designed
and developed to help mothers to improve MFA and help them
to cope with stress. Thus, one can help pregnant women from all
walks of life with the use of technology to experience the benefits
of the age-old practices of maternal well-being.
Simple elements like “music” impacted a mother’s state of
mind and outcomes in pregnancy.6
Chansoria, Konanki, and Tiwari
in a single-center, randomized, open-label controlled trial of
primigravida mothers aged 19 to 29 years concluded that prenatal
musicexposureofthemothersignificantlyandfavorablyinfluenced
neonatal behavior.7
Thebodyofresearchonmindfulinterventionsisthecornerstoneof
theBCPApp,leadingtoitsdigitalframeworkthatinvolvesthefollowing:
• Meditation and sleep guidance
• Harmonizing music
• Talk to baby and storytelling (baby bonding activities)
• Yoga and breathing exercises
• Diet and pregnancy information
The vision of this app, which was established in July 2019, is to
help the expectant mother develop and sustain a healthy, holistic
lifestylethatbeginsinthepreconceptionperiodandcontinuestothe
postpartumperiod.Thisappisamembership-basedplatform,which
has a repository of 800 plus actionable activities under meditation,
music, yoga, and unique baby bonding exercises for women to be
physically and mentally healthy and connect with the baby.
The primary aim of this study was to test the efficacy of
mindfulness activities and maternal bonding with the unborn
baby with regard to postnatal outcomes in primigravidas. The
secondary aim was to determine the influence of ongoing, real-
time consultative mentoring for the primigravida on lowering the
day-to-day maternal stress and other secondary effects.
Materials and Methods
This longitudinal study (panel study) was conducted on 512
primigravidas.Thestudygroupincluded255pregnantwomenwho
opted for a digital holistic health program: “Baby Care Program”
(BCP), while the control group consisted of 257 pregnant women
whoreceivednosuchinterventions.Table1showsthetotalnumber
of women in the study and control groups in different age-groups.
The study group was offered the BCP that included the
following:
• 8 minutes of daily guided mindfulness meditation.
• 3 hours of yoga and breathing practices every week.
• 2 hours of harmonizing music every week.
• 1 hour of baby bonding activities every week.
• 1 hourofpersonalizeddietandpregnancyeducationeveryweek.
Table 1: Subjects as per age-group
Age
Study group
(n = 255)
Control group
(n = 257)
20–30 158 135
30–35 62 78
35–40 23 43
>40 2 1

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Table 2: Results of the pregnancy outcomes
(Baby Care Program)
Study group (n = 255)
Control group
(n = 257) p
Mean gestational age at
delivery (weeks) 38.5 36 0.02
Mean birth weight (gm) 3130 2490 0.004 (a)
Preterm delivery 30 (12%) 82 (32%) 0.0005 (a)
Mode of delivery
Normal vaginal delivery 141 (55%) 129 (50%) 0.8
Elective cesarean section 40 (16%) 69 (27%) 0.08
Emergency cesarean section 74 (29%) 59 (23%) 0.4
Birth weight
<2500 gm 36 (14%) 80 (31%) 0.01 (a)
≥2500 gm 219 (86%) 177 (67%) 0.01 (a)
a
p <0.05 univariate analysis between groups; p value and significance
Fig. 1: Birth weights for control and study groups
Fig.2:Pretermdeliveryandnormaldeliveryforcontrolandstudygroups
A very important issue of maternal stress was also explored in
this study using the PSRS. The BCP study group also self-reported
significantly lower stress levels (14%) as compared to the control
Table 3: Responses on psychological scales: PSQI, PSRS, and Cranley’s
MFA scale
Control group
(n = 257)
Baby Care Program
Group (n = 255) p
PSQI score
15th week 4.3 4.1
35th week 5.1 2.8 0.018 (a)
PSRS score
15 weeks 1.5 1.4
35 weeks 2.2 0.52 0.032 (a)
Cranley’s MFA scale
15 weeks 76 74
35 weeks 82 108 0.003 (a)
a
p <0.05 univariate analysis between groups; p value and significance
Fig. 3: PSQI scale response for control and study group
group (79%). In the study group, 70% attributed to the reduction
in stress levels to the activities they did under the BCP program.
ThePSRSscorewassignificantlyhigher(2.2)inthecontrolgroup
as compared to 0.52 noted in the BCP study group (Table 3). The
study group performed better (Fig. 4) at 35 weeks of pregnancy.

Yoga,breathingexercises,andmeditationshelpedinincreasing
lung capacity, controlling the breathing pattern, and alleviating
labor fears. This helped the pregnant women in having a normal
vaginal delivery and in accepting/tolerating pre- and postpartum
symptoms and body changes.
Moreover, the real-time digital education on widespread
pregnancy-related concerns, such as diet, fetal development,
growth,symptoms,maternalbondingcheckups,andscans,helped
to reduce anxiety and manage nutrition especially during the
pandemic,whenaccesstohealthcareisrestricted.AstheuseofBCP
increased the parental bonding with the baby, it led to exclusive
breastfeeding that has several advantages.
Discussion
The iMumz pregnancy, a baby care and parenting app, has
beautifully amalgamated the treasure of traditional methods
of maternal and fetal wellness, runs past the stringent litmus of
science, and is serving the same methods digitally, via activities
easy for pregnant women to perform in their own comfort zone.
The objective of the digital app is to help the expectant mother
to develop and sustain a healthy, holistic lifestyle right from the
preconception period to postdelivery.
Sleep patterns, ability to perform daily tasks, and quality of
life in the pregnant woman are affected by systematic variations
caused by hormonal, emotional, mental, and physical factors.9
Sleepdeprivationleadstoadecreaseinthefunctionoftheimmune
systemandfunctioningofthehypothalamus,pituitary,andadrenal
glands.10
Even as the pregnant woman tries to cope with this state
during pregnancy, fears related to the upcoming childbirth add to
heranxieties.Inastudy,80%ofpregnantwomenreportedanxieties
around the process of birth.11
The pregnant woman’s state of mind affects the development
of the unborn baby’s cognitive and noncognitive skills: when she
is calm and at peace, the baby reaps significant benefits and she
experiences higher self-esteem and a sense of personal control.12
The opposite leads to increased incidences of intrauterine growth
retardation,pretermlabor,prolongedlabor,fetalheartratedecline,
low birth weight, increased rate of caesarean section, postnatal
neurobehavioralproblems,anddevelopmentaldisorder.Moreover,
itwasalsoobservedthatheightenedmaternalanxietyincreasedthe
This was further validated by the subjective self-reports. With
regardtofearsrelatedtochildbirth,BCPusersreportedsignificantly
lower fear of labor (24%) as compared to the controls (12%).
The BCP study group also reported a higher sense of mastery
in coping with postpartum blues. The control group reported
significantly higher (80%) postpartum blues as compared to 19%
of the BCP users. Moreover, 81.4% of the BCP study group reported
that they felt a sense of control and confidence in managing their
pregnancies, despite the stressful COVID environment.
In the current context of fast-paced urban lives, a raging
pandemic, uncertainty of the future, has multiple stressors on
expectant mothers. In the general population, mothers have
reported that they spend an average of 17 minutes on themselves
while the BCP reported a range of 2 to 4 hours. This, they said,
was despite the increased workload and diminished support due
to the lockdown. The question is how one can expand the use of
scientificallyprovenmindfulness,relaxation,andplannedactivities
for self-care to the entire pregnant population.
On the Cranley’s MFA 24-item scale that has five subscales to
measure the construct of MFA during pregnancy,8
the Cranley’s
MFA scores positively correlated with the amount of available
social support and negatively correlated with the amount of stress
perceived. The BCP study group scored 108 as compared to the
control, which scored 85 (Fig. 5).
The content analysis validated the above in which 97% of the
BCP users reported higher levels of bonding and an understanding
oftheirbaby’sneedscomparedto19%inthecontrolgroup.Ninety-
three percent of BCP users reported a deep understanding of the
importance of MFA compared to 34% of in the control group (the
remaining did not have any knowledge of MFA). In addition, 93%
of BCP users reported a marked increase in attachment with their
babies after regularly practicing BCP baby bonding activities.
Being informed and having easy access to query resolution led to
expectant mothers reporting lower levels of anxiety.
Seventy-four percent of the study group also reported that
the BCP in-App activities helped to stimulate baby’s movements
in the womb. The use of the BCP app resulted in a lower incidence
of postpartum blues and depression and positively correlated with
early childhood development—both mental (brain development,
physiological) and physical (birth weight, motor skills, milestones).
It also helped in improving baby–mother bonding.
Fig. 4: PSRS scale response for control and study group
Fig. 5: Cranley’s MFA score for control and study groups

Journal of South Asian Federation of Obstetrics and Gynaecology, Volume 13 Issue 3 (May–June 2021)
174
for reducing stress scores, coping with pregnancy, and the overall
well-being of antenatal mothers.17
All these were available in the
interactive BCP app.
Bowlby’s (1951) pivotal work on attachment suggested
that the absence of a close and sustained bond with a mother
(or mother figure) has irreversible mental health consequences on
the child.18
Fowles and Horowitz (2006) support this, describing
infant development to be sensitive to the quality of mother–child
interaction in the first postpartum year.19
Children of mothers with prenatal maternal depression (PMD)
showed cortical thinning, particularly over the frontal lobes and
this may be a risk marker for depression in the future. Another
study found that the microstructure of the amygdala, indexed by
fractional anisotropy, may be altered in newborns of mothers with
PMD.18
ItwasalsoobservedthatPMD-exposedinfantshadincreased
functional connectivity between the amygdala and several frontal
regions.19
TogethertheseresultssuggestthatexposuretoPMDmay
influence the development of the frontal cortex and particularly,
amygdala–prefrontal circuits, with implications for the future as
altered amygdala–prefrontal connectivity has been implicated in
pediatric depression.20–22
Thus prenatal maternal mood and stress
levels have a direct and persisting effect on her child’s psychology
and support an “in utero-programming” hypothesis for depression
in childhood and adolescence.
Today, pregnancy and birth are treated as medical events
rather than as normal life events and the woman is always under
stress between her two prenatal visits that everything is “okay” in a
nuclearfamilysetupwheretheage-oldcultureofsocialandmental
support of joint family is not there. Today with medicolegal issues,
the obstetrician exaggerates the risks of pregnancy and birth and
increases women’s fears for themselves and their babies. This adds
to the stress of the expectant mother that results in an exaggerated
concern for safety, “intervention-intensive” pregnancy, as well as
labor and childbirth. Moreover, the pandemic has increased the
stress of the pregnant woman as her visits to the obstetrician have
also decreased, which makes her worried about the well-being of
her child.
A large number of studies have confirmed that a woman’s
active involvement with the fetus benefits both the woman and
her unborn child.23,24
We have explored how this attachment can
be assisted and facilitated by providing her with well-researched
activities that she can engage in through the BCP. The BCP not only
provides activities but also sets up an engagement framework to
intimate, involve, and continuously encourage the completion of
the same. We must remember that everything that happens once
a baby is born is the outcome of all that has happened during
the pregnancy. One can help pregnant women with the use of
technology to experience the benefits of the age-old practices
of maternal well-being. The iMumz BCP App was designed and
developed for precisely this purpose.
Conclusion
The women’s ability to negotiate this journey of pregnancy and the
postpartum period will determine the well-being of the mother
and child. The physical and emotional changes of pregnancy and
then the experience of labor, birth, and breastfeeding play vital
roles as women make the transition to motherhood. To make this
journeyofpregnancyandlaborfruitfulforthemother,bothphysical
and psychological prenatal care systems contribute in a powerful
associationbetweenplasmaandamnioticcortisollevels,suggesting
thatwomen’sdistressmayaffectchildren’soutcomesviaepigenetic
regulation of glucocorticoid pathway genes in the placenta.13
A recent study found that pregnant women experience more
anxietyantepartumascomparedtopostpartum.14
Astudybasedon
the Avon Longitudinal Study of Parents and Children indicated that
maternal prenatal anxiety predicted persistently higher behavioral
and emotional symptoms across childhood with no decrease of
effect into adolescence. Elevated prenatal anxiety (top 15%) was
associated with a twofold increase in the risk of a probable mental
disorder. Results were similar with prenatal depression that had a
directandpersistingeffectonthechild’spsychiatricsymptomsand
supported an in-utero programming hypothesis.14
Consistent with the Developmental Origins of Health and
Disease model, prenatal distress was found to be associated with
heightened psychiatric risk, suggesting a “third pathway” for the
familial transmission of disease beyond shared genes and the
postnataleffectsofmaternalpsychopathologythatinfluencesfetal
neurobehavioral development.
The woman needs to develop a strong attachment with her
baby in natural and normal ways. She needs to be supported for
this to alleviate her fears about the progress of pregnancy, labor,
and birth so that she takes good care of herself and her baby.
TheBCPhasbeenseentohaveadirectandindirecteffectonthe
mother developing a closer connection with her baby. A milestone
study by Tsao, Hsing, Wang, and Huey-Ming Guo established that
there is a relationship between mindfulness and MFA during
pregnancy.15
A pregnant woman needs to be made aware of the
need for her to connect to the fetus. Furthermore, cultivating an
open and nonjudgmental attitude toward one’s pregnancy stress
is important in addressing the relationship between the mother
and her baby.
Astudyonmaternalbondingthroughpregnancyandpostnatal
life aimed to build a prognostic model of bonding quality based
on sociodemographic factors and postnatal factors (e.g., weeks
of gestation, breastfeeding problems, and crying behavior.).16
It
was hypothesized that both the quality and intensity of maternal–
antenatalbondingwouldincreasethroughthecourseofpregnancy
until the early postnatal period. Furthermore, it was expected that
not only mother–fetal bonding in trimesters 1 through 3 would
predict mother–infant bonding at 8 weeks postpartum.16
It is a known fact that preparation for a safe and easy birth is
determined by what the mother does throughout pregnancy. Thus
preparing for birth needs to start early in pregnancy and childbirth
educationplaysaveryimportantroleinassistingthewomenonthis
journey. This education will help the women manage normal fears
about pregnancy, labor, and childbirth, develop strong bonding
with the baby, and also develop confidence in themselves about
the process of birth. This also helps the women embrace the belief
that she herself is responsible for the health and safety of herself
and her baby.
During the COVID pandemic, it was difficult for face-to-face
talks and counseling, which increased the stress in these pregnant
women.TheBCPapphashelpedtheseanxiousmothersinchanging
their attitude, having a deeper understanding of pregnancy
and childbirth, and becoming stress-free during their journey
of becoming a mother. Moreover, calmness and peace do not
emanate from outside and with momentary pleasures alone but it
isinfluencedbytheinternalstateofbeing.Yoga,music,meditation,
breathingexercise,andcounselinghavebeensignificantlyeffective

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way and allow her to negotiate the pregnancy successfully and
ultimately her transition to motherhood.
TheBCPactivities,suchasmeditation,sleepguides,harmonizing
music, talk to baby and baby bonding activities, yoga and breathing
exercise,dietary,andpregnancyinformation, have helped to reduce
stress, educated about MFA, increased a sense of control over diet
and nutrition, and improved the mother’s quality of sleep, which
ultimately has a bearing on the baby’s temperament.
These results have important implications not only for
pregnant women and their unborn children but also for healthcare
professionals working in antenatal and postnatal services,
technologyvisionariesandurbanplanners,andfuturegenerations.
Italsoputsthespotlightonareturntotraditionsthatwereprevalent
forages.Theirrediscoverywithscientificvalidationandtheirbrand-
new method of digital delivery. In these times of social distancing,
isolation, and stress during the pandemic, the BCP has helped
in the remote assistance in pregnancy care. The BCP is one such
contemporary prenatal care app that helps women to accomplish
the tasks of pregnancy, labor, and birth and has the potential to
help women’s transition to motherhood.
Abbreviations
BCP: Baby Care Program
PSQI: Pittsburgh Sleep Quality Index
PSRS: The Perceived Stress Reactivity Scale
CMFAS: Cranley’s Maternal–Fetal Attachment Scale
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