A Yoga Therapist’s Toolkit for Pregnancy During a Pandemic—And Beyond
Originally published in Yoga Therapy Today, a publication of the International Association of Yoga Therapists.
Shared with permission.
Lately, I have been reflecting on the COVID-era impact on the prenatal journey for moms and families. When my studio restarted in-person sessions a few months ago, a pregnant mom attended one of my classes. This woman works full-time while supporting her family at home, which includes the responsibility of stewarding her kids through remote schooling. She shared how she needed a space to step away and reconnect to herself and her little one inside. “I feel with this pregnancy I am not able to just sit and connect to baby, or even myself,” she lamented. “This pandemic has been exhausting.” I recognize her need to find a space of stillness and reconnection as she prepares to usher forth new life. More requests have been coming from pregnant people looking for private sessions with the yoga therapists and teachers at my studio.
I began teaching yoga in 2003. In 2004, I was pregnant. My own prenatal yoga path was an integral part of the beginnings of my professional yoga career. I have been teaching prenatal yoga for more than 15 years, and I developed one of the only prenatal yoga teacher trainings combined with a doula training program in the United States. With the growth of my private yoga practice, I began to work more one-to-one with pregnant clients, especially those who had experienced trauma. COVID-19 is a collective traumatic experience, and it has created a diverse range of stressors. This article offers an expansive lens on pregnancy, the COVID era, and yoga therapy.
Unequal Effects, Unequal Burdens
The impact of this pandemic on our mental and physical well-being cannot be underestimated. However, some groups are being affect- ed disproportionately. In March 2021, the American Public Media Research Lab revealed in its The Color of Coronavirus project report that Black and Indigenous Americans continue to suffer the greatest losses, nationally experiencing a COVID-19 death toll of about 1 in 555 and 1 in 390, respectively—compared to 1 in 665 for White Americans.
The gender gap is real, as well. A commentary in the February 13, 2021, Fortune magazine addressing how to help women come back to work notes, “In September, when schools resumed, many of them with remote learning, 80% of the 1.1 million people who exited the workforce were women. In December, women accounted for all net job losses, while men achieved some job gains.”
Understandably, these impacts have extended to our mental health. Also in February 2021, Nature published an article regarding the research around depression and COVID: “More than 42% of people surveyed by the U.S. Census Bureau in December reported symptoms of anxiety or depression in December, an increase from 11% the previous year.” Another study completed in 2021 highlighted that pregnant women showed a more pronounced increase in depression, anxiety, and negative affect than nonpregnant women did. This COVID-era research collected data anonymously from 6,894 pregnant and postpartum women in 64 countries in 2020 and uncovered the extent of elevated posttraumatic stress, anxiety/ depression, and loneliness in these groups around the world. The study concluded with a call to action to public health and hospitals to pay attention and create programs to support pregnant and postpartum women. I extend this call to yoga therapists and yoga centers.
Studies have been ongoing regarding the impact of COVID on pregnancy. These studies, such as “Pregnancy and COVID: What the Data Say,” also published in Nature in 2021, have exposed the two major vulnerabilities that exist for pregnant people:
It’s no surprise that respiratory viruses pose a threat to pregnant women, whose lungs are already working harder than usual. As the uterus grows it pushes up against the diaphragm, reducing lung capacity and taxing an oxygen supply divided between mother and fetus. On top of that, pregnancy dials down the immune system so as not to harm the baby. That makes women more susceptible to complications from infection.
The Necessity of Caring for the Whole Self
In the midst of the pandemic, I felt pressed to quickly publish a book I had been working on for 3 years. Regardless of whether I had an agent, editor, or publisher, it was the exact right moment to spread awareness of how we can use time-honored wisdom to care for all dimensions of ourselves in times of peril as well as times of peace. I wrote Care of the Whole Self: Yoga-Inspired Tools for Befriending the Self to turn attention to how our body needs our full participation to foster wellness in all aspects of our lives. With a few simple daily acts, we can move toward self-regulation and find ourselves more centered, more able to skillfully respond to our hyper-stressed lives. The tools I shared are based on the wisdom of yoga and Ayurveda, as well as on breath, movement, and meditation. By honoring seasons, cycles, and specific times of the day, one can create lifestyle habits that optimize well-being and aid in nourishment. Although I didn’t write the book specifically for the pregnancy journey, the framework inspired by the panchamaya kosha (five sheaths of being) model, yoga therapy, and Ayurveda are important in the therapeutic approach I offer for pregnant people.
The therapeutic application of the tools of yoga is a skill that I believe healing practitioners can develop to great effect by working with pregnant clients. For anyone who wants to work with pregnant people, it is important to understand the natural changes that pregnancy brings throughout the physical, energetic, mental, and biophysical/hormonal dimensions. Understanding prenatal development is equally important, as it cultivates an understanding of why certain poses at certain times are not recommended so we can develop respect for the process of creation and the considerations around nourishment. It is the responsibility of yoga professionals working to support pregnant clients’ specific needs to have a baseline understanding of the imbalances that can be generated during pregnancy.
Navigating Pregnancy During the Pandemic
The application of yoga therapy is a top-down (using the mind/thoughts to informed the body/senses) and a bottom-up (using the body/senses to inform the thoughts in the mind) approach that offers many possible pathways. So, where do you begin?
People navigate their pregnancies in many ways. Some want to just keep going and “fit” the pregnancy in. Some become completely baby-focused. Some have no choice; that is, they need to keep working their two jobs, raising their children, and, well, surviving. Recently, I had a pregnant client experiencing a high level of stress as she was struggling with being kind to her changing body and with how her once-active yoga practice was changing. Yoga invites the ability to explore the vrittis (thought whirlpools) of the mind and the body; she and I worked with affirmations and mudra (gestures) within the practice to invite qualities of softness and kindness toward herself.
Pregnancy is a vulnerable time (energetically, mentally, and physically), and when you add the risk of a potentially life-threatening virus like COVID-19, it is natural that many mamas have become hypervigilant and isolated, for their own protection. Another recent survey found that 61% of parents had “significant concerns” about their mental health.
When pregnant people read the U.S. Centers for Disease Control’s website statement for pregnant and recently pregnant people, it is hard to imagine not feeling anxious about the increased risks for severe illness from viral infections like COVID-19. However, one important detail to remember is how protected baby is. There have been several accounts with Mom having COVID and giving birth, and baby is COVID-free. Why? This shines a tremendous spotlight on the powerful role of the placenta as a defense between the vulnerable baby and the external environment. The virus rarely crosses between mother and baby, but there have been reports of damage to the placenta from the pregnant person suffering from COVID-19; this is one way in which harm can occur for the little one(s). The placenta is an amazing organ of protection between the fetus and the external world, and in some cases, antibodies for COVID-19 were found in the umbilical cord as well as the placenta. It should be noted, however, the study of epigenetics is revealing that the placenta is not all-powerful and that severe illness or hardship experienced by either parent can have multigenerational effects.
Given all this information, it’s understandable that pregnant women are on high alert and feel a sense of threatened safety in the face of a deadly pandemic. “I have become hypervigilant, isolated and confused around what decisions are best for baby and me,” remarked a pregnant client in my yoga therapy practice.
The process of pregnancy is complex and multifaceted—and a lot of things can happen in those 40 weeks. We are just beginning to understand the relationship of chronic stress, depression, and mood on development in utero and later in life. Experiencing depression during pregnancy is a cause for concern on various fronts, from baby’s gut-biome health, to birth weight, to the child’s later mental health.
Pregnancy and Mental Well-Being Through the Trimesters
The mental toll of being pregnant during the COVID era is now occurring alongside the significant hormonal shift every mama undergoes. This can affect each person uniquely.
Many mothers experience significant fatigue during the first trimester because a majority of the body’s resources are focused on creating life, which takes considerable energy. This is a vulnerable stage of pregnancy, during which I recommend limited yoga and movement. The tools of pranayama and meditation can be very helpful, as can gentle Hatha Yoga and/or Restorative Yoga. I recommend not offering active practices, especially when the person is new to yoga, until after the 12th week of pregnancy. Miscarriages often happen during this time (see this report). It may also be inadvisable to raise the core body temperature excessively, especially in women who did not previously regularly participate in the kinds of activities that have this effect.
During the second trimester, the many hormones being produced by the placenta and elsewhere tend to settle into something of a steady state, and for many pregnant women a period of well-being arrives. Movement and thoughtful core strengthening often feel great and are much needed as the body is transforming. For example, the lumbar spine takes on a greater load and accommodates this by becoming more lordotic (increasing the lumbar curve to support the growing baby). The baby’s movement and positioning within can affect the frequency and urgency for urination in the mama. In addition, diaphragm movement is limited, so the breath tends to feel more challenged. Mama’s body is working for two, so there is naturally an increase in heart rate and blood pressure. The center of gravity, which in most women tends to be between the navel and lumbar area, moves forward (think of how the navel is pushed out), and coordination can be affected. Fall risk is a consideration during any asana practice. Due to the focus a mama’s body has diverted to this growing new—and essentially “other”—life-form within, her immune system is suppressed in significant ways. Special attention needs to be paid to nutrition, hydration, and possible exposures to serious infection.
In the third trimester, hormones continue to do their work to progress the pregnancy. Estrogen and progestogen levels peak at around 32 weeks of gestation, affecting digestion (heartburn may be one consequence), increasing water retention (swelling, potentially throughout the body), and supporting the baby’s growth (pressure on the mother’s hips and lower back). Nourishment may need to be adjusted by incorporating, for example, less spicy foods. Massage and elevation of the feet and legs can be helpful, as can embracing a daily routine of cat/cow to support an optimal birthing position for baby. This final stretch of pregnancy can also be full of excitement and anticipation. Many pregnant people need accommodation in the workplace during this trimester, and advocating for oneself is a powerful act of self-care.
Because of its impact on the mental health of those who have given birth, the so-called fourth trimester, the 12 weeks following birth, must be acknowledged. At 32 weeks’ gestation, estrogen and progestogen are at their highest levels; during the weeks following birth these levels they plummet to the lowest they will be until menopause. This dramatic drop begins with the birth of the baby and removal of the placenta. At least 1 in 7 women experience post-partum depression, and it is vital to educate the village of the pregnant family’s support system about the signs, creating space for dialogue and acknowledgment.
Thankfully, yoga is a wonderful self-care tool for pregnancy. A 2015 systematic review of randomized control trials (originally written in Japanese) concluded that “prenatal yoga may help reduce pelvic pain. It may also improve mental condition (stress, depression, anxiety, etc.), physical condition (pain and pleasure at the delivery, etc.), and perinatal outcomes (obstetrical complications, delivery time, etc.)” (see here for an English-language abstract of the review).
Yoga (Yoke/Unite) and Pregnancy— All About Bonding
Yoga therapy focuses on building connection; for pregnant mamas, an additional layer must be acknowledged. Patanjali’s Yoga Sutras invite the theory that a path of embodying the state of yoga (absolute peace) lies in having a relationship with the inner seer. In addition to fostering connection to themselves, mamas also need to cultivate their connection to the life they are growing. Bonding is essential for healthy relationships, and it starts in the womb. When a yoga practitioner works with pregnant people, they must not forget to offer tools to the mothers for bonding with themselves and with the little one(s) inside.
A study in the May-June 2016 issue of The Annals of Saudi Medicine revealed that prenatal bonding practices helped improve a baby’s mental health: “Teaching attachment skills to mothers increased the attachment between the mothers and their infants, and consequently, improved infant mental health. Thus, teaching attachment skills should be incorporated into routine prenatal care.”
Yoga therapy is a powerful domain to cultivate the skill of fostering connection through education and practice. If you are interested in working with pregnant people, it is important to go to the very heart essence of yoga and recognize that mama is not only pursuing a relationship with herself, or in yoga terms the atman, but also with the little one(s) inside. The necessity of bonding cannot be overlooked as an essential part of any yoga therapy practice that works with pregnant clients. The gift of yoga is its adaptability to meeting the needs of the individual and the collective. May you be inspired to amplify the therapeutic application of yoga to meet the needs of pregnant people as we all begin to emerge from the pandemic.
Resource Library
If you are interested in learning more about pregnancy, yoga, and neurodevelopment, consider these books as a starting place.
Yoga Mama, Yoga Baby: Ayurveda and Yoga for a Healthy Pregnancy and Birth by Margo Shapiro Bachman
The Birth Partner: A Complete Guide to Childbirth for Dads, Partners, Doulas, and All Other Labor Companions by Penny Simkin
Nurture: A Modern Guide to Pregnancy, Birth, Early Motherhood—And Trusting Yourself and Your Body by Erica Chidi Cohen
Pregnancy, Childbirth and the Newborn: The Complete Guide by Penny Simkin, Janet Walley, Ann Keppler, Janelle Durham, and April Bolding
Preparing for Birth with Yoga by Janet Balaskas
Brain Health from Birth: Nurturing Brain Development
During Pregnancy and the First Year by Rebecca Fett
Yoga for Pregnancy, Birth and Beyond: Stay Strong, Sup- portive, and Stress-Free by Francoise Barbira Freedman
Care of the Whole Self Through Daily Rituals for Pregnancy
Morning Rituals: Rise, Acknowledge, and Breathe
This practice cultivates bonding through breath awareness. It begins with a gentle warming of the core. It also helps mamas cultivate a mindset of santosha (content- ment with the present moment) for entering the day.
After rising from sleep, sit on the side of the bed or anywhere you are com- fortable. Place your attention and your hands on your belly. Feel free to invite your partner into this ritual. Inhale and feel the space of the womb expand; as you exhale, feel yourself hugging the little one(s) inside. Repeat for 5–10 breath cycles.
As you continue to breathe, acknowledge your own heart beating and the heartbeat of your little one(s) inside. Allow yourself to feel a sense of awe and wonder for this growing life and your powerful role in bringing it into the world.
Afternoon Rituals: Pause, Reflect, and Rest
The energy it takes to make life is amazing, but it usually also means that mama’s needs can take a back seat. The body prioritizes the growing life within, so it’s impor- tant to acknowledge that fatigue is to be expected, and thus create small spaces of rest and restoration throughout the day.
Afternoon is an ideal time to focus on hydration with water, fruit (not juices, which lack crucial fiber), vegetables, or other nourishing foods. Now con- sider lying down for 15 minutes on your left side to maximize blood flow to the uterus and support digestion (this piece on the Lifehack website explains why this is likely a good idea: www.lifehack.org/356391/ this-why-you-should-sleep-your-left-side-backed-science). Alternatively, you might elevate your feet and allow your lower back to relax. Close your eyes, and take time to check in and simply rest. This offers the growing life within you a valuable lesson: It is not always about running through the day, doing doing doing. You may discover that even 5 minutes can invite a much-needed pause that will carry you through your day.
Evening Rituals: Release, Massage, and Quiet
Hip-flexor releases are often needed among pregnant mamas, as the lower back and psoas take on additional physical stress. A daily practice that includes gentle chakravakasana (cat/cow) flow and some variations of anjanayasana (crescent moon pose or low lunge) is helpful and valuable.
Massage the hands, face, and/or feet. When massaging the feet, refrain from massaging the pinky toe and ankle, as they are stimulating points for giving birth. Use your favorite oil for the massage. I highly recommend a belly massage, too. Consider inviting your partner to participate in massage time!
Allow your evening to be a quiet space for yourself. Curate your activity by limiting screen time; consider journaling, listening to calming music, reading children’s books out loud, or writing letters to your little one(s) inside.
Pregnant moms can begin and end the day by bonding with themselves and with their growing babies. The art of yoga can foster the cultivation of this connection. This ability to draw oneself with full attention into the present moment reminds us all of “Atha yoganusasanam” (Yoga Sutra 1.1). That is, “With our full presence, the art of yoga is revealed.”