1199949
research-article2023
WHE0010.1177/17455057231199949Women’s HealthRabinowitz et al.
Meta-analysis
The role of catastrophizing in chronic
cyclical pelvic pain: A systematic
review and meta-analysis
Women’s Health
Volume 19: 1–16
© The Author(s) 2023
Article reuse guidelines:
sagepub.com/journals-permissions
https://doi.org/10.1177/17455057231199949
DOI: 10.1177/17455057231199949
journals.sagepub.com/home/whe
Emily P Rabinowitz1 , MacKenzie A Sayer1
and Douglas L Delahanty1,2
Abstract
Background: Dysmenorrhea (painful menstrual cramps) is one of the most common gynecological complaints in women
and girls. Dysmenorrhea may be a condition itself or a result of another medical condition, including endometriosis
and chronic pelvic pain. Research examining the relationship between menstrual pain ratings and catastrophizing has
produced mixed results.
Objective: To review and meta-analyze the relationship between catastrophizing and pain ratings of chronic cyclical
pelvic pain.
Design: Cross-sectional, longitudinal, and intervention studies that reported the relationship between menstrual/
pelvic pain and catastrophizing were included. Study populations had to include healthy menstruating persons or
persons with a condition associated with cyclical pelvic pain including primary dysmenorrhea, endometriosis, and/or
chronic pelvic pain.
Data sources and methods: A systematic search of articles published since 2012 on PubMed, PsychInfo, CINHAL,
and Medline was conducted in January and rerun in November of 2022. Search terms included cyclical pelvic pain,
dysmenorrhea, endometriosis, pelvic pain, and catastrophizing. Data extraction was completed independently by two
extractors and cross-checked for errors. A random-effects meta-regression was used to synthesize the data using
restricted maximum likelihood.
Results: Twenty-five studies examining 4,540 participants were included. A random effects model found a metacorrelation between catastrophizing and pain of r = .31 (95% confidence interval: .23–.40) p < .001. Heterogeneity was
large and significant (I2 = 84.5%, Q(24) = 155.16, p < .001). Studies that measured general pelvic pain rather than cyclical
pelvic pain specifically and those that used multi-item rather than single-item measures of pain had significantly higher
correlations. Age and depression did not moderate the relationship between catastrophizing and pain.
Conclusion: A systematic review and meta-analysis found that catastrophizing had a small but significant positive
association with pain ratings. Patients experiencing cyclical pelvic pain may benefit from interventions targeting the
psychological management of pain.
Registration: This meta-analysis was registered in PROSPERO on 14 January 2022. Registration number: CRD42022295328.
Plain Language Summary
Severity of period pain is associated with catastrophic thinking
••
1
Dysmenorrhea, known as menstrual cramps or period pain, is a common symptom and condition for women of
reproductive age. Medical and surgical treatments often do not effectively reduce dysmenorrhea. Understanding
the psychological processes that reinforce dysmenorrhea may help in developing better treatments. One important
epartment of Psychological Sciences, Kent State University, Kent,
D
OH, USA
2
Northeast Ohio Medical University, Rootstown, OH, USA
Corresponding author:
Douglas L Delahanty, Department of Psychological Sciences, Kent State
University, 317 Kent Hall, Kent, OH 44240, USA.
Email: ddelahan@kent.edu
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons
Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use,
reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and
Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
2
••
••
Women’s Health
psychological process is catastrophizing, a thinking style in which people “catastrophize” or engage in negative
thinking about how bad pain is or might become.
In this study, we reviewed 25 studies of women with menstrual pain and statistically combined their results. We
found that pain severity was significantly associated with higher catastrophizing. We also found that the association
between pain and catastrophizing was higher in the studies that assessed general pelvic pain rather than cyclical
pelvic pain specifically and those that used multi-item rather than single-item measures of pain. The relationship
between pain and catastrophizing was not affected by diagnoses, age, or level of depression.
Our results suggest a significant association between catastrophizing and menstrual pain ratings. Patients experiencing
dysmenorrhea may benefit from interventions targeted at addressing catastrophizing.
Keywords
catastrophizing, dysmenorrhea, menstrual pain, pelvic pain
Date received: 3 January 2023; revised: 7 August 2023; accepted: 22 August 2023
Introduction
Dysmenorrhea (painful menstrual cramps) is one of the
most common gynecological complaints in women and
girls.1–3 Among women of reproductive age, rates of dysmenorrhea range from 16% to 92%, whereas the prevalence of severe dysmenorrhea ranges from 2% to 29%.4
Primary dysmenorrhea (PD) occurs in the absence of an
identified organic disease, whereas secondary dysmenorrhea (SD) refers to cramps/pain attributed to an identifiable condition.1 One common cause of SD is endometriosis,
a chronic condition affecting 6% of women in the United
States, over half of whom report struggling with menstrual
pelvic pain/cramping.5 Other conditions associated with
SD include uterine fibroids (leiomyomas), adenomyosis,
interstitial cystitis, chronic pelvic pain (CPP), and pelvic
floor myalgia.6 While dysmenorrhea is often associated
with (and confused with) CPP, CPP is a broad chronic pain
diagnosis that refers to both noncyclical pain (i.e. pain that
is not dependent on the menstrual cycle) and persistent
cyclical pelvic pain (i.e. pain due to endometriosis or dysmenorrhea).7 As the primary aim of this meta-analysis is to
examine the role of catastrophizing in chronic cyclical pelvic pain (CCPP), and given inconsistent definitions used in
prior research, we included studies of individuals with primary and secondary dysmenorrhea and CPP (unless it was
stated that individuals with dysmenorrhea or cyclical pain
were excluded). Furthermore, for simplicity of reading, we
refer to these studies as including individuals with CCPP.
Current medical and surgical management of CCPP is
limited by side effects and nonresponse.8–10 For example,
a systematic review of clinical trials for the treatment
of CCPP due to endometriosis found that 17%–34% of
women experienced pain recurrence at follow-up time
points.8 Experiencing CCPP in adolescence and early
adulthood is associated with developing chronic pain later
in life; this, combined with existing treatment limitations,
further underscores the necessity of developing effective
treatments for the management of CCPP.11,12
One reason for the limited success of medical or surgical management of CCPP may be due to the failure of
these treatments to address psychological factors that contribute to and maintain cyclical pelvic pain. Like many
chronic pain conditions, there is a high comorbidity of
CCPP and psychopathology, specifically depression.10,13,14
For instance, almost a third of women with CCPP due to
endometriosis also meet the criteria for depression.14
Despite this significant comorbidity and the existence of
effective psychotherapy for many forms of chronic pain,15
research examining psychological interventions for CCPP
is lacking in quantity and quality.16,17 A systematic review
of 11 studies of psychological interventions for CCPP due
to endometriosis found that interventions containing mindfulness, psychoeducation, or cognitive behavioral therapy
appear to be effective at improving both coping with pain
and symptoms of depression and anxiety, but findings
are limited by the small number of studies included and
methodological concerns.17 Another systematic review
found only four studies of psychological or behavioral
interventions for women with CCPP of unknown etiology,
and the results of these interventions were inconclusive.16
In one small open trial for patients with CCPP due to PD,
Payne et al. implemented five sessions of mind-body and
cognitive-behavioral group therapy (including one session
on “automatic pain thoughts and de-catastrophizing”);
patients showed significant reductions in menstrual pain
and catastrophizing, suggesting that catastrophizing may
be a mechanism for reducing CCPP.18
Catastrophizing is defined as the tendency to “overestimate the likelihood of a negative event, and also believe
that the negative event will be catastrophic.”19 A form of
negative repetitive thinking, catastrophizing is linked to
rumination, magnification, and helplessness/hopelessness
in response to negative stimuli.20 Originally introduced
as one of the cognitive distortions associated with depression, catastrophizing is significantly associated with
perceived pain intensity and pain-related disability.21,22
Rabinowitz et al.
Catastrophizing is one of the major mechanisms in psychological models of chronic pain. For example, the fearavoidance model of chronic pain posits that maladaptive
beliefs about pain, including catastrophizing, trap patients
in a cycle of fear and avoidance that ultimately increases
pain intensity and disability.23 Alternatively, Petrini and
Arendt-Nielsen hypothesize that catastrophizing may be
understood as an inhibitory emotional regulatory process as
defined under the Behavioral Inhibition and Activation
Systems (BIS/BAS) model.24 In this way, individuals
engage in catastrophic thinking to avoid experiencing or
managing pain.24 Intervention research suggests that reductions in catastrophizing may precede reductions in pain and
disability, further highlighting the clinical utility of addressing catastrophizing in chronic pain populations.25,26
Because CCPP involves repeated, unavoidable, and
predictable pain, women with CCPP may engage in anticipatory catastrophic thinking as they approach their period;
during their period, women may also catastrophize menstrual pain itself. Both anticipatory and concurrent catastrophizing likely lead to increased pain from menstrual
cramps. Over a third (35%) of women with CCPP due to
PD and 58% of women with CCPP due to endometriosis
have clinical levels of catastrophizing (defined as a score
of 30 or above on the Pain Catastrophizing Scale), suggesting that catastrophizing is a common maladaptive
cognitive process in this population.27 Some researchers,
supported by neuroimaging and pain threshold findings,
posit that repeated exposure to severe cyclical pelvic pain
each month may lead to changes in the brain systems that
process and cope with pain.28–31 For example, women with
CCPP due to dysmenorrhea compared to healthy controls
showed altered central pain processing as evidenced by
more sensitivity to thermal pain and increased activation
of the entorhinal cortex, a region associated with the anticipation of pain.32,33 Evidence also suggests that engaging
in catastrophic thinking may inhibit successful pain modulation, possibly by triggering anticipatory anxiety or
increasing attention to painful stimuli.34,35 In further support of this anticipatory effect, women with severe CCPP
have a stronger emotional reaction to menstrual-related
words in a modified version of the Stroop task during the
late luteal (premenstrual) phase compared to during the
mid-follicular phase (after menstruation).36 Thus, catastrophizing represents a critical mechanism through which
women’s anticipation, expectation, attention, and worry
about menstrual pain may be increased, potentially leading
to increased experiences of pain.
Catastrophizing may also be a mechanism that explains
the association between sexual trauma and dysmenorrhea.
Women with a history of sexual assault are 1.60 times
more likely to have pelvic pain and 1.20 times more likely
to have dysmenorrhea compared to women with no history
of sexual assault.37 Sexual trauma may intensify the experience of cyclical pelvic pain because pain is localized to
3
the pelvic and genital region, and this pain could serve as a
reminder of the past traumatic experience.38,39 Women
with a history of sexual trauma may catastrophize both
their menstrual pain and their negative emotional reactions
to and/or memories of trauma, creating a negative feedback loop that increases pain.38
In addition to the role that it plays in exacerbating pain
ratings, catastrophizing is also associated with the maintenance and exacerbation of depression, which, as previously mentioned, is common in patients with CCPP.10,13,14
In both nonpelvic chronic pain and CCPP samples, symptoms of depression are related to higher levels of catastrophizing, suggesting that the relationship between pain
ratings and catastrophizing may be stronger in individuals
experiencing depression.22,27
The present meta-analysis
While both theory and available data suggest a significant
positive correlation between catastrophizing and CCPP, the
magnitude of this relationship is unclear. A study of women
with CCPP due to endometriosis found a correlation of
r = .67,40 whereas another study of women with CCPP due
to CPP more broadly found a correlation of r = .52.41 Other
studies reported correlations closer to r = .30.42–44 It is
unclear if this variability in effect size is due to differences
in study design, medical diagnosis examined, levels of
depression, or other methodological differences such as the
instrument used to assess pain or measure catastrophizing.
Because CCPP is both a condition and a symptom of a wide
variety of gynecological conditions, identifying which subpopulations have a stronger relationship between catastrophizing and pain ratings may improve recommendations
for which patients would benefit from an intervention to
address catastrophizing.6,45
Consequently, the present analysis is the first to directly
examine the unique effects of catastrophizing on pain ratings in patients with CCPP. We also examine the extent to
which this relationship is impacted by study methodology,
medical diagnosis, age, depression, or history of sexual
trauma.
Objectives
1. To calculate the meta-correlation between catastrophizing and pain severity ratings in women with
CCPP.
Hypothesis 1: We hypothesized that catastrophizing and pain severity would be significantly, positively related.
2. To examine if the relationship between catastrophizing and pain ratings was moderated by the
instrument used to measure catastrophizing, measure of pain severity, medical diagnosis, and age.
4
Women’s Health
Hypothesis 2: We hypothesized that the relationship between catastrophizing and pain ratings
would not be moderated by assessment instrument,
pain, medical diagnosis, or age.
3. To test if the relationship between catastrophizing
and pain severity ratings was moderated by levels
of depression or history of sexual trauma.
Hypothesis 3: We hypothesized that levels of
depression and prior exposure to sexual trauma
would moderate the relationship between catastrophizing and pain severity such that catastrophizing
would be more strongly correlated with pain ratings in individuals with higher levels of depression
and in those with a sexual trauma history.
Method
The following procedures were preregistered on
PROSPERO in January 2022 (CRD42022295328) and
follow PRISMA and MOOSE reporting guidelines.46,47
The PRISMA and MOOSE checklists can be found in
supplemental materials.
Search strategy
A search of articles published after 2011 was conducted on
PubMed, CINHAL, Medline, and PsychInfo in January
and rerun in November of 2022. We used the following
search terms to broadly capture articles addressing catastrophizing and CCPP: cyclical pelvic pain, dysmenorrhea, endometriosis, pelvic pain, and catastrophizing. A
similar search strategy was used in a systematic review of
treatments for CCPP.48 Consistent with prior reviews and
the age range for the prevalence of dysmenorrhea and CPP,
we used an age range of 6–64.4,49 While there has yet to be
a meta-analysis specifically evaluating catastrophizing
and cyclical pelvic pain, a large systematic review published in 2006 identified psychosocial factors as important
correlates of pelvic pain.50 Later, review papers published
in 2010–2011 identified psychological variables including
catastrophizing as key mechanisms of pelvic pain.7,51,52 In
addition, a prior meta-analysis of the association between
PD and psychopathology indicated that only a minority of
studies on PD were published prior to 2012.13 Due to
increasing emphasis on psychosocial factors in CPP after
2011, and the large literature captured in our search of
reproductive health conditions, we limited our search to
articles published in the last 10 years (2012 and later).
Study selection
Articles retrieved from the initial searches of all databases
were compiled into Covidence, a web-based platform that
streamlines the production of systematic reviews.53 Two
blind reviewers completed title/abstract and full-text
reviews of articles to determine eligibility according to criteria. Disagreements were resolved by article discussion.
Exclusion reasons were documented in Covidence.
Eligibility criteria
Inclusion and exclusion criteria are specified in Supple
mental Document 1. Briefly, included studies had
(1) samples of menstruating persons with CCPP or a
condition known to cause cyclical menstrual pain (dysmenorrhea, endometriosis, adenomyosis, leiomyomata
(fibroids), interstitial cystitis, CPP, and pelvic floor
myalgia) and (2) measurement of both catastrophizing
and pain. Conditions known to cause CCPP were taken
from current guidelines for the differential diagnosis of
secondary dysmenorrhea.6 Because we planned to measure the impact of pain measurement and specific CCPP
conditions on the relationship between catastrophizing
and pain, we included studies that measured both specific cyclical pelvic pain and those that measured broader
pelvic or urogenital pain. Healthy samples were included
if they measured dysmenorrhea specifically.
Data extraction
Two independent reviewers double-entered study data
regarding study design, location, participant demographics, methodology, and effect size estimates into a customized Qualtrics form.54 Whenever possible, an article’s
original sample descriptions were used (i.e. “women with
Primary Dysmenorrhea” was coded as PD); if reviewers
were unclear of the conditions specified, they also examined study descriptive data to determine if additional
conditions were included in the sample. If articles
reported on a longitudinal study, the correlation coefficient from the first timepoint was used. In case-control
designs, the correlation within the cases relevant to the
study was used. Whenever possible, the correlation
between dysmenorrhea and catastrophizing was extracted.
When not available, data from other pain measures were
used (such as ratings of CPP). If multiple pain indices
were reported, we used the scale with the highest reliability and validity (e.g. the Brief Pain Inventory compared
to a single item VAS). If necessary, correlations for the
catastrophizing subscales were averaged to create an
effect size estimate for the total scale. If a study used only
the pain subscale of a health-related quality of life
(HRQOL) instrument, the sign of the correlation was
inverted such that higher catastrophizing was related to
worse pain-related HRQOL. Effect sizes were converted
to Pearson’s r correlations using standard formulas for
Spearman’s rho,55 chi-square,56 and odds ratios.57 If an
Rabinowitz et al.
included study did not provide sufficient information for
an effect size estimate, the corresponding author was
contacted. If the author did not provide the necessary
information prior to the completion of the review, the
study was excluded due to lack of data availability.
Assessment of risk of bias
The Appraisal tool for Cross-Sectional Studies (AXIS), a
20-item critical appraisal tool, was used to evaluate the
quality of each study.58 Each study was evaluated by
independent raters, and disagreements were processed
identically to data extraction. Because current guidelines
caution against using summary scores to rate study quality, we reported the ratings for each study on each of the
20 items.59
Meta-analysis
Data analysis was conducted using the “meta” and “metafor” packages in RStudio (https://www.r-project.org).
Meta-regressions used mixed effects models to estimate
the meta-correlation between catastrophizing and pain
rating.60,61 Our review used Pearson’s r correlation coefficient because it is the recommended approach for metaanalysis.60,61 Heterogeneity between the studies’ effect
sizes was assessed using the Q and I statistics as well as by
examining the forest plot.62 We also created a funnel plot
to evaluate for publication bias. For the meta-regressions
with categorical moderators (i.e. medical condition, study
design), a minimum of 10 studies per category was
required.61,63 When less than 10 studies existed, a narrative
review was conducted.
To conduct the moderation analyses on depression, the
sample symptom mean was extracted from each study.
However, because there was significant variability in
instruments used for symptom measurement, mean values
were converted to standardized scores using a common
metric derived from an item response theory analysis.64 A
standardized metric is available for 11 depression instruments including the Beck Depression Inventory (BDI),
Center for Epidemiologic Studies Depression Scale (CESD), and Hospital Anxiety and Depression Scale (HADS).64
Studies that used an instrument not included in the standardized metric were not included; a total of 10 studies were
needed to conduct the meta-regression. As part of our narrative review, we documented if studies assessed anxiety
symptoms to explore other potential moderators.
Results
A systematic search using PubMed, PsychInfo, CINHAL,
and Medline yielded 9,294 studies. After removing duplicates, 4,838 studies were screened at title-abstract review,
5
947 were screened in full-text review, and 25 were included
in the final analysis (see Figure 1 for PRISMA Diagram).
Of the studies excluded at full-text review, 92% (N = 852)
were excluded for not measuring catastrophizing, 3.6%
(N = 33) were excluded for nonoriginal data (i.e. post hoc
analyses of data already in the review), and 3% (N = 28)
reported to measure both catastrophizing and pain but did
not report sufficient data or respond to data inquiries.
Finally, 0.7% (N = 6) of studies were excluded because
their study population did not meet inclusion criteria, and
0.3% (N = 3) of studies were excluded for not measuring
pain.
Study characteristics
Descriptive information for each study is presented in
Table 1 and summarized in Table 2. Most studies were
observational (N = 16), followed by intervention (N = 8)
and case-control designs (N = 1). Thirteen studies assessed
general pelvic pain (using instruments such as the Brief
Pain Inventory), whereas 12 studies specifically assessed
cyclical pelvic pain (e.g. ratings of menstrual pain/cramps).
Thus, we conducted two meta-analyses: 1) an overall correlation with all 25 studies and 2) a meta-correlation
including studies of cyclical pelvic pain specifically. There
was also significant heterogeneity in the diagnoses
included in the samples of the studies; only five studies
had a sample solely comprised of participants with PD;
thus, we were unable to conduct a separate meta-correlation for these studies. However, 11 studies included participants with endometriosis, allowing for additional
examination of this condition.
There was considerable variability regarding what
measurement tools assessed pain ratings. Among the studies that used multi-item instruments, the most common
was the Brief Pain Inventory (Table 2). Yosef et al.43
described using a VAS CPP rating that participants “were
asked to specifically differentiate from dysmenorrhea,
deep or superficial dyspareunia, dyschezia, or back pain.”
The data for dysmenorrhea specifically were not available.
Excluding the above paper did not significantly impact the
overall meta-correlation (r = .31 (95% confidence interval
(CI): .22–.40), p < .001) I2 = 85.2%, Γ = .17, Tau2 = .03,
H = 2.60, Q(23) = 154.92, p < .001), thus we kept it in the
analysis. Catastrophizing was most frequently measured
by the pain catastrophizing scale (PCS, N = 19, Table 2).
Analysis of heterogeneity
A fixed-effects model demonstrated that there was considerable heterogeneity across all studies, I2 = 84.5%,
Q(24) = 155.16, p < .0001, and H = 2.54. The forest plot
(Figure 2) also demonstrated significant heterogeneity
across studies. Thus, we conducted a random-effects
6
Women’s Health
Figure 1. PRISMA flow diagram showing inclusion and exclusion of relevant studies.
model to estimate the meta-correlation and to account for
this heterogeneity.63 Significant heterogeneity was also
observed in the fixed-effects model of the studies of cyclical pelvic pain (N
=
12): I2 = 89.3%, Q(11) = 102.90,
p < .0001, and H = 3.06.
Meta-correlation
A random effects model found that the overall meta-
correlation was r = .31 (95% CI: .23–.40), p < .001. The
variance of the true effect size (Γ)2 was. 03 and Γ was
Country
United Kingdom
USA
USA
Australia
USA
Country
USA
Croatia
Ireland
Canada
Sweden
USA
Country
UK
Canada
Multiple
Study
Abokhrais et al.40
As-Sanie et al.41
Bridger et al.65
Bryant et al.66
Chao et al.67
Study
Chen et al.68
Cosic et al.69
Durand et al.70
Flynn et al.71
Grundström et al.72
Hellman et al.73
Study
Horne et al.74
Jarrell et al.75
Kapadi and Elander76
Cross-sectional
Intervention
Intervention
Study Design
Case-Control
Cross-sectional
Intervention
Cross-sectional
Longitudinal
Cross-sectional
Study Design
Intervention
Cross-sectional
Intervention
Cross-Sectional
Intervention
Study Design
Table 1. Summary of included studies.
PD
Patients needing laparoscopy, including
endometriosis and CPP
CPP, excluding endometriosis
Condition(s)
Dysmenorrhea with or without Silent Blatter
Pain
CPP and suspicion of endometriosis
CPP, excluding endometriosis + PD
None
None
Dysmenorrhea
CPP, endometriosis
Condition(s)
CPP
CPP
CPP
Endometriosis, abdominal and/or pelvic floor
myofascial dysfunction
adenomyosis, pelvic adhesions, ovarian remnants,
vulvodynia
Endometriosis
Condition(s)
145
61
305
N
147
37
24
892
147
678
N
14
170
6
219
27
N
24.55 (7.87)
33 (7.5)
30.3 (8.15)
Age
Mean or Median (SD)
24.35 (6.21)
25
37.7 (7.9)
N/A
26.9
28 (7.6)
Age
Mean or Median (SD)
41.5 (7.95)
36 (14)
49
34.8 (11.3)
35.76 (9.08)
Age
Mean or Median (SD)
N/A
N/A
64.71%
Contraception
(% usage)
0%
54%
100%
31.3%
0%
N/A
Contraception
(% usage)
N/A
N/A
N/A
N/A
36.36%
Contraception
(% usage)
Menstrual pain VAS
6.79
(1.55)
MPQ-SF
2.97
(2.04)
Menstrual VAS*
5.15
(3.85)
Pain Measure
M (SD)
Menstrual VAS
73.10
(13.60)*
Pain sensitivity
questionnaire
4.6
BPI-severity
47.08
(17.05)
Menstrual pain VAS
5.51
(1.80)
*Yes/no pain during
menses
51.02% Yes
*Average menstrual
pain NRS
N/A
Pain Measure
M (SD)
SF-36 Pain subscale
42.12
(23.50)
BPI-severity
5.55
(2.0)
MPQ total
6.67
(2.56)
BPI
5.06
(2.22)
BPI
N/A
Pain Measure,
M(SD)
CSQ-C
18.63
(8.90)
PCS
23.58
(13.6)
PCS
27.3
(12.93)
Catastrophizing Measure
M (SD)
PCS
15.46
(9.80)
PCS
9.66
PCS
26.17
(10.93)
PCS
16.78
(11.72)
PCS
20.38
(13.37)
PCS
18.3
(12.8)
Catastrophizing Measure
M (SD)
PCS
26.93
(15.39)
CSQ-C
20.96
PCS
27.8
(11.48)
PCS
N/A
PCQ
26.04
(12.61)
Catastrophizing Measure,
M (SD)
.52
.63
(Continued)
.49
.53
.11
r
.19
.34
.23
.45
.14
.05
r
.43
.48
-.07
r
Rabinowitz et al.
7
Japan
United Kingdom
Canada
Country
USA
Brazil
USA
Australia
USA
Country
Canada
China
Italy
Kato42
Keogh et al.77
Keizer et al.78
Study
Payne et al.18
Poli-Neto et al.79
Schrepf et al.80
Sewell et al.81
Tomakowsky et al.82
Study
Yosef et al.43
Yu et al.83
Zarbo et al.44
Cross-sectional
Cross-sectional
Longitudinal
Study Design
Cross-sectional
Longitudinal
Longitudinal
Intervention
Intervention
Study Design
Cross-sectional
Longitudinal
Cross-sectional
Study Design
Endometriosis
Dysmenorrhea
CPP including endometriosis
Condition(s)
Pelvic and/or urogenital pain
CPP, dysmenorrhea, dyspareunia, noncyclical
pelvic pain, lower abdominal pain, dyschezia,
dysuria
Urologic CPP syndrome
CPP + dysmenorrhea, endometriosis
PD
Condition(s)
Lumbopelvic pain
PD
PD
Condition(s)
162
43
619
N
117
113
233
21
20
N
108
52
186
N
N/A
22.86 (1.98)
34.5 (7.6)
Age
Mean or Median (SD)
36.12 (16.60)
29
40.5
28.2 (6)
20.9 (2.2)
Age
Mean or Median (SD)
40.4 (12.6)
21.92 (5.81)
18.99 (1.59)
Age
Mean or Median (SD)
N/A
0%
N/A
Contraception
(% usage)
N/A
N/A
N/A
0%
0%
Contraception
(% usage)
N/A
0%
N/A
Contraception
(% usage)
MPQ-SF total
23.04
(12.09)
*Menstrual VAS
6.77 (1.53)
VAS CPP2
5.8
(3.2)
Pain Measure
M (SD)
BPI-severity
4.74
(2.14)
Genitourinary pain
index-pain severity
18.8
(5.7)
Menstrual VAS
4
*VAS
76.4
(22.1)
Menstrual pain NRS
8
(1.12)
Pain Measure
M (SD)
Yes/no pain during
menses
41% yes
Menstrual pain VAS*
53.05 (20.85)
Menstrual VAS
3.84
(.95)
Pain Measure,
M(SD)
PCS
11.76
(12.77)
Cognitive emotion regulation questionnaire—short version:
catastrophizing subscale
5.07
(2.5)
PCS
Catastrophizing Measure
M(SD)
PCS
22.30
(14.78)
PCS
30
CSQ-C
14.1
(8.8)
PCS
32.8
(10.8)
PCS
19.75
(12.1)
Catastrophizing Measure
M (SD)
PCS
21.17
(10.28)
PCS
5.6
(4.9)
CSQ-C
9.83
(4.78)
Catastrophizing Measure,
M (SD)
r
.09
.12
.3
.27
.01
.34
r
.61
.38
.31
.56
-.23
r
CPP: chronic pelvic pain; N/A: not available; PD: primary dysmenorrhea; SD: standard deviation; BPI: Brief Pain Inventory; PCQ: Pain Catastrophizing Questionnaire; PCS: Pain Catastrophizing Scale; MPQ: McGill Pain Questionnaire;
SF-Short Form; CSQ-C: Coping Strategies Questionnaire- Catastrophizing Subscale; NRS: Numeric Rating Scale; VAS: Visual Analogue Scale.
*Study reported information for timing of assessment in relation to the menstrual cycle phase.
Country
Study
Table 1. (Continued)
8
Women’s Health
Rabinowitz et al.
9
Table 2. Study characteristics.
Study design
Cross-sectional correlational
Longitudinal correlational
Intervention
Case-control
Study location
USA
Canada
Australia
United Kingdom
Multiple
Brazil
Ireland
Italy
Japan
Sweden
China
Pain instrument
Single-item menstrual pain
Brief pain inventory
McGill pain questionnaire
Chronic pelvic pain single item
SF-36 pain subscale
Genitourinary pain index
Pain sensitivity questionnaire
Catastrophizing instrument
Pain catastrophizing scale
Coping strategies questionnaire-catastrophizing
Pain catastrophizing questionnaire
Cognitive emotion regulation questionnaire
N
%
12
4
8
1
48
16
32
4
8
4
2
3
2
1
1
1
1
1
1
32
16
8
12
8
4
4
4
4
4
4
12
5
3
2
1
1
48
20
12
8
4
4
19
4
1
1
76
16
4
4
N = 25.
estimated to be .16, I2 = 84.5% and H = 2.54, Q(24) =
155.16, p < .001. Among those studies that specifically
evaluated cyclical pelvic pain (N = 12), the meta-correlation was r = .21 (95% CI: .09–.33), p = .003. The variance
of the true effect size (Γ)2 was .03 and Γ was estimated to
be .16, I2 = 89.3% and H = 3.06, Q(11) = 102.90, p < .001
(see Supplemental Figure 1 for a forest plot of this
meta-correlation).
Moderation analyses
We first explored if the relationship between catastrophizing and pain ratings was moderated by differences in the
measurement of pain and/or measurement of catastrophizing. Because 76% of studies used the PCS, there was not
enough variability in measures to test whether the instrument for assessing catastrophizing moderated the relationship between catastrophizing and pain ratings. Eleven
studies used multi-item scales to measure pain and fourteen
used a single-item instrument. Studies that used multi-item
instruments had a higher correlation between pain and catastrophizing (r = .44) than studies that used a single-item
instrument measure of pain (r = .24, Qm(1,23) = 8.19, p = .01;
Table 3). Measurement differences accounted for 31%
of the variance in effect sizes. All the studies that evaluated
ratings of cyclical pelvic pain specifically (and all of the
studies that examined specifically PD) used single-item
measures. Studies that measured general pelvic pain had
higher correlations between pain and catastrophizing
(r = .43) than those that measured cyclical pelvic pain
specifically (r = .22, Qm(1,23) = 11.05, p < 01; Table 3).
Measurement of cyclical pelvic pain versus general CPP
accounted for 34% of the variance in effect size, and the
cyclical pelvic pain-specific correlation was significant
(p = .003).
As expected, many studies assessed women with a
variety of medical conditions including PD, urologic CPP
syndrome, and endometriosis (see Table 1). Because
endometriosis is a leading cause of CCPP, we examined
whether the correlation between catastrophizing and pain
was different for samples that included individuals with
endometriosis compared to those that did not; the moderation analysis was not significant (Qm(1,23) = 1.76, p = .20,
Table 3). There was also no significant effect of the average
age of the sample on the relationship between pain ratings
and catastrophizing (b = .01, SE = .01; Qm(1,21) = 2.30,
p = .14; Table 3).
Nine studies had sufficient data to convert average
depression levels to a standardized metric and examine the
impact of depression on the relationship between catastrophizing and CCPP (Supplemental Table 1). Although analyses required ten studies for adequate power, we conducted
exploratory moderation analyses to see whether existent
studies suggested a need to control for depression; the
moderation was not significant (b = −.003, SE = .02; Qm
(1,7) = .04, p = .85; Table 3).
History of sexual trauma was assessed in only three
studies, all of which used different definitions of sexual
trauma.41,43,80 Although not enough studies existed for
analysis, our narrative review found that the presence of
childhood and adult sexual trauma was positively associated with pain severity in two studies,43,80 and that those
with “major” childhood sexual abuse had significantly
higher pain catastrophizing levels than those with no abuse
or “mild” abuse history.41
Finally, while many studies assessed anxiety (Supple
mental Table 2), they used noncomparable measures, thus
preventing a moderation analysis using anxiety scores. In
our narrative review, we observed that higher anxiety scores
were significantly associated with both higher catastrophizing and pain ratings in nearly all studies (Supplemental
Table 2). In addition, as shown in Table 1, only 44% of articles (11/25) reported data on participants’ use of contraceptives, with many of the 11 studies simply limiting their
samples to participants not on contraceptives.
10
Women’s Health
Figure 2. Forest plot of all studies.
PR: Pearson’s r correlation coefficient, 95% CI is the 95% confidence interval around each correlation. Black boxes represent the correlation for
each study; size of each box indicates the influence of the correlation on the model. The solid black line indicates a correlation of zero. The dotted
line and the diamond indicate the meta-correlation.
Publication bias and study quality assessment
Examination of the funnel plot (Figure 3) indicated a relatively symmetrical distribution of the effect sizes, and
Egger’s regression test of asymmetry was not significant
(t = .19, df(22), p = .85), suggesting that the results of this
meta-analysis were not substantially impacted by publication bias.
AXIS ratings for each study are presented in Supple
mental Table 3. Very few studies conducted either an a
priori or post hoc power analysis. Furthermore, as can be
seen in Table 1, many studies had small sample sizes which
are susceptible to bias. Most studies were also conducted
in English-speaking countries and findings may differ in
other regions. Furthermore, few studies characterized participant refusals or missing data which may pose a risk of
bias. Some studies were missing basic data including
demographics and descriptive statistics, limiting the utility
and generalizability of those studies. Finally, most studies
recruited convenience samples receiving outpatient
gynecological services which may limit the generalizability of results to populations who are unable to obtain specialized medical care. However, the predominance of
heterogeneous clinical samples suggests that these results
would be relevant to gynecologists and other providers in
outpatient settings.
Discussion
The meta-correlation between catastrophizing and pain
ratings was r = .31 (p < .001), although there was significant heterogeneity across studies; 84.5% of the variability
in the effect sizes was due to between-study variability,
which is considered a high level of heterogeneity.84
There were higher correlations between pain and catastrophizing among studies that measured general pelvic pain
(r = .43) versus cyclical pelvic pain specifically (r = .22),
and those that used multi-item (r = .43) rather than
Rabinowitz et al.
11
Table 3. Tests of moderation.
Categorical Moderators
Test of Moderation
Heterogeneity
Statistics
Γ2 = .02
Γ= .14
I2 = 78.01%
H2 = 4.55
R2 = 30.78%
Γ2 = .02
Γ= .13
I2 = 76.61
H2 = 4.28
R2 = 33.72
Γ2 = .03
Γ= .17
I2 = 84.00%
H2 = 6.25
R2 = 0.00%
Moderator Present
Moderator Absent
Single-item measurement
k = 25
r = .24
k = 14
r = .44
k = 11
Qm(1,23) = 8.19
p = .01
Measured menstrual pain
k = 25
r = .22
k = 12
r = .43
k = 13
Qm(1,23) = 11.05
p = .003
Endometriosis
k = 25
r = .37
k = 11
r = .26
k = 14
Qm(1,23) = 1.76
p = .20
Continuous moderators
Age
k = 23
b = .0097
Qm(1,21) = 2.30
p = .14
Depression
k = 9
b = −.003
Qm(1,7) = .04
p = .85
Γ2 = .03
Γ= .17
I2 = 81.36%
H2 = 5.36
R2 = 6.19%
Γ2 = .03
Γ= .16
I2 = 77.43
H2 = 4.43
R2 = 0.00
CI: confidence interval; b: meta-regression coefficient for continuous moderators; k: # of studies; r: meta correlation.
Figure 3. Funnel plot.
PR: Pearson’s r correlation. The dotted line in the center indicates the
meta-correlation. The two diagonal lines indicate ±1.95 standard error.
Each study is plotted with a circle corresponding to its correlation on
the X-axis and Standard Error on the Y-axis. The absence of bias is
indicated by a balanced funnel within the SE line.
single-item measures of pain (r = .24). Average age and
depression scores did not moderate the relationship
between catastrophizing and pain.
Despite the prevalence of cyclical pelvic pain as a primary complaint and symptom across many reproductive
health conditions, only 12 studies (48%) measured cyclical
pelvic (i.e. menstrual) pain specifically, and only five
studies had samples composed solely of participants with
PD. While the heterogeneity of conditions in the studies
reviewed is not surprising given that CCPP is both a condition itself and a common symptom of many gynecological,
urological, and gastrointestinal conditions,6,45 our review
indicates a substantial need for more research into the relationship between catastrophizing and cyclical pelvic pain.
The correlation between catastrophizing and cyclical pelvic pain (r = .21) was lower than the correlation between
catastrophizing and pain in studies that assessed general
pelvic pain (r = .43), perhaps suggesting that the cyclical
pelvic pain samples lowered the overall meta-correlation
(r = .31). While the magnitude of our correlations is small,
it is consistent a prior meta-analysis of 49 studies which
found that the correlation between general chronic pain
intensity and catastrophizing was r = .29 (95% CI: .25–
.32).22 While some studies reported when (in the menstrual
cycle) the assessment was conducted, we were not able to
explore this as a possible moderator; it is likely that women
12
who were menstruating during the time of assessment may
have rated pain and catastrophizing differently than participants who were retrospectively responding. Despite
these limitations, the correlation between catastrophizing
and cyclical pelvic pain was still significant, providing justification for future investigation of this topic with better
methodology.
The observed correlation between pain ratings and catastrophizing was significant and consistent in magnitude
with other meta-analyses of adults experiencing pain.22
However, the relatively small correlation may be explained
by a number of variables including measurement variability, the use of single-item pain measurements, and potential conceptual overlap of pain and catastrophizing scales.
Measurement variability accounted for the largest percentage in effect size variability and may have affected the
overall correlation The relationship between catastro
phizing and pain was significantly lower in studies with
single-item assessments than studies that used multi-item
indices. The Initiative on Methods, Measurement, and
Pain Assessment in Clinical Trials (IMMPACT) recommends single-item numerical rating scales for the measurement of pain intensity while more comprehensive
measures are recommended for assessing “pain interference”85; for this reason, pain catastrophizing may have a
stronger relationship to pain interference than pain intensity. However, five of the 11 multi-item studies used the
pain severity subscale of the Brief Pain Inventory which is
an average rating of pain severity at its worst, least, average, and current level, a subscale that may produce similar
results as single-item measures of pain.86,87 It is also possible that the difference between single- and multi-item
correlations is a statistical artifact rather than a reflection
of true differences in the relationship between catastrophizing and pain because single-item pain ratings produce
less variability than multi-item scales.88 Alternatively,
there is conceptual overlap between measures of pain
interference and catastrophizing which may have inflated
the correlation for some studies. For example, the total
score of the McGill Pain Questionnaire used in three studies included four questions assessing the “affective” component of pain where individuals rate the extent to which
their pain is “fearful,” “punishing-cruel,” “tiring-exhausting,” or “sickening.”89 These items are likely highly related
to catastrophizing due to their similarity to anxiety, hopelessness, and helplessness. Nevertheless, we found that
both the single- and multi-item pain scales were significantly correlated with catastrophizing, which suggests a
robust association.
Unexpectedly, depression did not moderate the relationship between catastrophizing and pain ratings. This
may be due to small sample size or range restriction; the
standardized values of average depression scores ranged
from 57.1 to 67.8 units, which limited the ability to detect
moderation. However, the average depression scores
Women’s Health
included in our analyses are above the standardized
population average for this metric (M = 50, SD = 10).64
Therefore, our nonsignificant interaction term indicates
that catastrophizing impacts pain ratings similarly for
populations at varying levels of moderate-to-severe
depression. Our findings further suggest that catastrophizing is a useful treatment target even in patients with higher
levels of depression.13,14
The current review found only three studies that met
our inclusion criteria and evaluated trauma history. Two
studies reported that sexual trauma was associated with
increased pain severity and one study found that child
sexual abuse was linked to higher catastrophizing levels,
suggesting that those with a sexual trauma history may
have a stronger relationship between catastrophizing and
pain.41,43,80 Given the increasing calls for trauma-informed
reproductive health care and the impact that trauma has on
psychological mechanisms of pain, this review highlights
a major absence of trauma-informed research on CCPP.38,90
Strengths and limitations
To our knowledge, this is the first meta-analysis of the
relationship between catastrophizing and CCPP. Our
review searched four large databases, used a comprehensive definition of CCPP, and examined critical moderators.
While there is a significant range in the observed effect
sizes, this is likely reflective of the heterogeneous clinical
population with CCPP.6,45 In addition, small sample sizes
for the moderation analyses may have limited statistical
power to detect effects. Future research would benefit
from the inclusion of instruments to measure psychopathology and trauma exposure to examine these factors in
more depth. Furthermore, we were unable to account for
the effects of contraceptive use because the majority of
studies did not provide information on contraceptive use in
their samples. Also, because the majority (75%) of studies
used the PCS, we were unable to explore if the instrument
used to measure catastrophizing was a significant moderator. While the PCS remains a common and clinically relevant instrument in chronic pain research and practice,
theoretical and empirical work has begun to question the
extent to which the PCS accurately captures catastrophic
thinking processes as well as the construct validity of catastrophizing in general.20,24,91,92 Future research would benefit from improved measurement of catastrophizing and
other cognitive distortions.
Conclusion
In summary, we found that, among women with CCPP,
the overall correlation between pain ratings and catastrophizing was r = .31 and this relationship was consistent
across differences in medical diagnosis, age, and level of
depression. Because CCPP may be a risk factor for the
Rabinowitz et al.
development of future chronic pain disorders, addressing
the link between catastrophizing and CCPP may not only
reduce menstrual pain but also the likelihood of a chronic
pain condition later in life.12,93
Future research would benefit from improved assessment of catastrophizing, pain, history of sexual trauma,
and psychopathology. In addition, research could examine
the feasibility, efficacy, and scalability of mental health
interventions that address catastrophizing and may reduce
CCPP such as psychoeducation classes94 or brief smartphone-delivered interventions.95 Overall, our results reiterate the impact that mental health variables have on CCPP,
adding to the growing evidence for integrated behavioral
and reproductive health care.96
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Author contributions
Emily P Rabinowitz: Conceptualization; Data curation; Formal
analysis; Investigation; Methodology; Writing – original draft;
Writing – review & editing.
MacKenzie A Sayer: Conceptualization; Data curation; Investi
gation; Writing – review & editing.
Douglas L Delahanty: Conceptualization; Supervision; Writing
– review & editing.
Acknowledgements
Not applicable.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
publication was made possible in part by support from the Kent
State University Open Access Publishing Fund and support from
Kent State University Department of Psychological Sciences.
Competing interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Availability of data and materials
The data that support the findings of this study are available from
the corresponding author upon reasonable request.
Registration
This meta-analysis was registered in PROSPERO on 14 January
2022. Registration number: CRD42022295328 (https://www.crd.
york.ac.uk/prospero/display_record.php?RecordID=295328).
13
ORCID iD
Emily P Rabinowitz
https://orcid.org/0000-0002-1931-1824
Supplemental material
Supplemental material for this article is available online.
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1185405
research-article2023
WHE0010.1177/17455057231185405Women’s HealthSomerville et al.
Advancing Maternal Health Equity – Original Research Article
An evaluation of the feasibility and
acceptability of sister circles as an anxiety
intervention for pregnant Black women
Women’s Health
Volume 19: 1–16
© The Author(s) 2023
Article reuse guidelines:
sagepub.com/journals-permissions
https://doi.org/10.1177/17455057231185405
DOI: 10.1177/17455057231185405
journals.sagepub.com/home/whe
Keaton Somerville1 , Tiffany Rowell1, Robert Stadulis1,
Debra Bell2 and Angela Neal-Barnett1
Abstract
Background: Black women and their infants face heightened health risks during pregnancy, labor, and delivery that, for
many, cost them their lives. Such health risks during this critical period are linked to increased rates of anxiety among
Black pregnant and postpartum women. Black women also endure racism when seeking support from mental health
and healthcare providers, which further contributes to pregnancy and postpartum-related anxiety. Evidence on sister
circles has demonstrated that this indigenous form of healing may provide Black pregnant and postpartum women with
the support and skills needed to cope with stressors associated with mental and physical health concerns and racism.
Objective: Our study aimed to evaluate the feasibility and acceptability of the Birthing Beautiful Babies Sisters Offering
Support, a sister circle cognitive behavioral therapy-based stress and anxiety intervention for Black pregnant and
postpartum women.
Design: Our study employed a mixed-methods framework.
Methods: Descriptive analyses, paired samples t-test, and open and selective coding were conducted. We utilized the
following measures: Penn State Worry Questionnaire–Abbreviated, Kessler Psychological Distress Scale, PregnancyRelated Anxiety Scale, focus booklet, and focus group discussion.
Results: Participants reported experiencing moderate levels of worry and distress and low levels of pregnancy-related
anxiety prior to the start of the Birthing Beautiful Babies Sisters Offering Support intervention. Eighty women participated
in Birthing Beautiful Babies Sisters Offering Support. Eleven focus groups were conducted to assess their experience.
Participants reported a perceived increase in their knowledge about panic attacks and stress and ability to manage
stressors effectively. They found that all completed activities contributed to their development and application of skills.
They reported they enjoyed Birthing Beautiful Babies Sisters Offering Support because of the supportive environment,
openness, and emphasis on sisterhood. Participants provided helpful feedback about the structure and flow of the
intervention.
Conclusion: Limitations of the present study and future directions are discussed.
Keywords
anxiety disorders, Black women, maternal health, mental health, psychotherapy
Date received: 1 December 2022; revised: 10 May 2023; accepted: 14 June 2023
Introduction
Black women and their infants face heightened health risks
during pregnancy, labor, and delivery that cost many their
lives.1 For example, in the USA, Black pregnant women
are five times more likely to die from pregnancy-related
complications than White women.2 Similarly, Black
1
Kent State University, Kent, OH, USA
Birthing Beautiful Communities, Cleveland, OH, USA
2
Corresponding author:
Keaton Somerville, Kent State University, 600 Hilltop Drive, Kent,
OH 44242, USA.
Email: ksomerv5@kent.edu
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons
Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use,
reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and
Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
2
infants are twice as likely to die before their first birthday
than their White, Asian, and Hispanic counterparts.3
Furthermore, the awareness of these racial health disparities is a painstaking reality for Black women, which likely
contributes to the growing rates of pregnancy-related anxiety in this population.
Black women have a high risk of experiencing perinatal
and postnatal mood and anxiety disorders (PMADs), such
as anxiety, depression, obsessive-compulsive disorder, and
post-traumatic stress disorder.4 In recent decades, Black
pregnant women and mothers, including celebrities such
as Serena Williams and Taraji P. Henson, have become
vocal about the importance of mental health support for
this community.5,6 Despite their wants for mental health
care, Black women continually experience difficulty gaining access to quality providers that are both culturally
responsive and aware of their own implicit biases.7–9
Multiple studies have shown that mental health care providers may be uncomfortable talking about race-based topics or hold negative attitudes and beliefs about Black
Americans, which affects how they interact with their
patients and which treatments they provide.10,11 Regarding
receiving mental health care during pregnancy and birth,
Black women report greater provider mistreatment and
discrimination, based on insurance and race, than White
women.12–14 These stressful racialized experiences likely
also contribute to the growing rates of anxiety among
Black women.4,15–19
Sister circle interventions
One anxiety intervention that may be effective and
address the unique needs of Black women is sister circles. Sister circles can be defined as “support groups
that build upon existing friendships, fictive kin networks, and the sense of community among [Black]
females” (p. 1).20 Importantly, sister circles are unstructured, and they promote relationship-building.20 A Black
woman may be exposed to various forms of sister circles throughout her life that naturally develop within
her community and organizations.21 She may also be
exposed to more organized and structured sister circles
in her school or workplace. For example, sister circles
have been used to increase cultural values and beliefs,
improve academic performance, and reduce disruptive
behaviors in school among Black adolescent girls.22–24
Within collegiate and professional spaces, multiple sister circles were created to not only provide support but
also to serve as a form of resistance to the oppression
that Black women face daily.25–30
While these forms of sister circles were successful in
targeting their various goals, few studies have evaluated
the effectiveness of the sister circle format as a manualized, culturally relevant group intervention for Black
women. One example is the Prime-Time Sister Circles
Women’s Health
(PTSC) intervention.31 The PTSC used a cognitive behavioral modality integrated with the values and beliefs salient
to midlife Black women to reduce their health-risk behaviors. Findings from both the original and replication studies revealed increases in physical activity and reductions in
stress.31,32 Another example of a manualized sister circle is
the Sisters Offering Support (SOS) intervention developed
by Neal-Barnett et al.20 SOS was developed as an early
intervention for anxious professional Black women. It is
unique because it utilizes cognitive behavioral techniques
infused with cultural aspects to educate Black women
about anxiety, cognitive restructuring, and progressive
muscle relaxation.
Birthing Beautiful Babies Sisters Offering
Support theoretical framework
Considering the various uses of the sister circles for Black
women across the lifespan to address mental and physical
health risks and concerns, we believe that this format
would be beneficial for Black pregnant and postpartum
women experiencing stress and anxiety. To the best of our
knowledge, sister circles have not been utilized with Black
perinatal samples.
Thus, we developed the Birthing Beautiful Babies
Sisters Offering Support (BBB SOS) intervention to
address specific pregnancy and cultural concerns of this
population to reduce pregnancy-related anxiety. It is
grounded in cognitive behavioral therapy (CBT) because
it is one of the most effective treatments for anxietyrelated disorders.33 CBT emphasizes the importance of
changing thinking and behavioral patterns and improving
physical symptoms of anxiety through skill use.34 Within
the context of BBB SOS, the overarching goals of the
sister circle were to educate pregnant women about anxiety, stress, and panic attacks and help them challenge
maladaptive thoughts, learn how to manage their emotions, and engage in positive behavioral changes. In order
to maximize the potential effectiveness of the CBT
framework with the present study’s sample of Black
women, we followed recommendations from studies35,36
that encouraged the use of “gender-race-specific modifications and infusion” (p. 269).20
Since sister circles are peer-supported interventions, we
felt it was best to have women from the community serve
as facilitators. Specifically, we utilized Black perinatal
support persons (i.e. doulas) who were well-trained on all
aspects of the prenatal and postpartum periods and shared
the general experience of being a Black woman.
Furthermore, while the participants were learning common CBT strategies (e.g. visualization, goal setting, and
progressive muscle relaxation), there were also discussions about culturally relevant stressors, including racial
discrimination, stereotypical images of Black women in
the media, health, nutrition, hair care, and hair health.
Somerville et al.
Research indicates that stereotypical images of Black
women as strong, angry, and promiscuous are associated with increased anxiety.37–39 Further, in addition to
anxiety, Black women report high rates of obesity.40
BBB SOS provides prenatal yoga and nutrition, which
helps Black women combat their many health outcomes
and risks,41,42 including obesity, preeclampsia, and
hypertension, which are heavily influenced by poor diet
and limited exercise.43,44 Black women also experience
specific hair care needs and restrictions during pregnancy.45 BBB SOS provides solutions for Black women
with natural or relaxed hair that remedy hair-related
stress and anxiety.46 Research underscores that for
Black women, hair is culturally important and significant47,48 and a potential source of anxiety as textured
hair is associated with discrimination.49
Present study
The primary objective of this study is to evaluate the feasibility and acceptability of BBB SOS, a manualized culturally relevant stress and anxiety intervention for Black
pregnant and postpartum women using a mixed-methods
framework. Our research question is: will Black pregnant
and postpartum women perceive the BBB SOS sister circle
anxiety intervention to be helpful? We opted to use a
mixed-methods design as we believe the complementary
quantitative and qualitative data would (1) answer our primary research question and (2) provide substantial and
specific feedback to improve our intervention. In addition,
we hypothesized that (1) participants would report a perceived increase in knowledge about anxiety and panic
attacks and (2) participants would rate all session activities
and skills as helpful in reducing anxiety.
3
Table 1. Participant demographic information (N = 80).
Measure
Item
N (%)a
Trimester
First
Second
Third
Postpartum
1 person
2 people
3 people
4 people
5 people
6 people
7 people
8 people
9 people
Data unavailable
0
1
2
3
4
5
6
8
Data unavailable
US$25,0000
Data unavailable
Uninsured
Public
Private
Data unavailable
11 (13.8)
31 (38.8)
34 (42.5)
4 (5)
10 (12.5)
11 (13.8)
10 (12.5)
9 (11.3)
8 (10)
4 (5)
0
1 (1.3)
1 (1.3)
26 (32.5)
14 (17.5)
20 (25)
6 (7.5)
4 (5)
9 (1.3)
2 (2.5)
1 (1.3)
1 (1.3)
30 (37.5)
42 (52.5)
17 (21.3)
0 (0)
12 (15)
9 (11.3)
1 (1.3)
63 (78.8)
7 (8.8)
9 (11.3)
Household size
Number of children
Household income
Insurance
a
Method
Note percentages may not equal 100% due to rounded decimals.
Participants
Measures
Our convenience sample consisted of 80 Black pregnant
and postpartum women from an urban city in the Midwest.
The average participant was 26.72 (SD = 6.51) years old.
Participants were recruited from our community partners.
Our partners are a perinatal support program that was
developed to aid communities at risk for maternal and
infant mortality. Women enrolled in the perinatal support
program were invited by their doulas face to face and via a
call to participate in the in-person BBB SOS sister circle.
Our study and recruitment occurred pre-pandemic,
between 2017 and 2019. During this time, approximately
203 women received perinatal support services from our
community partner and were offered participation in the
study. One hundred and twenty-three (60.59%) did not
enroll in our study. Reasons for declining participation
were not recorded. Table 1 displays the complete demographic information of this sample.
Demographic survey. Demographic questionnaires were
used to collect information on participants’ self-identified
race, age, pregnancy status, number of children, and type
of insurance to describe the sample.
The following three measures of worry, stress, and
pregnancy-related anxiety were utilized only to confirm
that our sample was our target population and that we
could appropriately ask about their perceptions of the
feasibility and acceptability of our sister circle anxiety
intervention.
Penn State Worry Questionnaire–Abbreviated. The Penn State
Worry Questionnaire–Abbreviated (PSWQ-A)50 is an
8-item scale designed to measure worry severity. Given
that the present study’s sample is composed of Black
women, an additional item was added to assess participants’ level of worry about racism. Each item was scored
4
on a scale from 0 (not at all typical of me) to 5 (very typical
of me), which yielded composite scores ranging from 0 to
45. DeLapp et al.51 found the PSWQ-A to be a psychometrically sound brief measure of worry in Black Americans.
Kessler Psychological Distress Scale. The Kessler Psychological Distress Scale (K10)52 is a 10-item measure of
global distress experienced within a 4-week period. Specific items include questions about symptoms of anxiety
and depression. The items were rated on a scale from 1
(none of the time) to 5 (all of the time). Composite scores
can range from 10 to 50 and are derived from summing
item responses. Krieger et al.53 found the K10 to be a reliable and valid measure of distress in Black American men
and women.
Pregnancy-Related Anxiety Scale. The Pregnancy-Related
Anxiety Scale54 is a 10-item measure for expectant mothers that determines the severity of their worries about the
various aspects of pregnancy, labor, and delivery, and then
caring for a child. Items were scored on a scale from 1 (not
at all) to 4 (very much). Composite scores were calculated
by summing and then dividing the items’ responses by 10,
yielding a possible range from 1 to 4. This questionnaire
demonstrated high reliability and validity in a sample of
Black pregnant women.54
Focus group booklet. A focus group booklet was created and
piloted for this study. It contained questions assessing participants’ understanding of panic attacks and stress before
and after the intervention on a scale from 0 (nothing at all)
to 10 (a great deal). Items that measured participants’ perceived effectiveness of exercises and strategies covered in
each session were also included. Participants were asked to
rate their overall experience participating in the sister circle
on a scale from 0 (very negative) to 10 (very positive) and
comfortability with sharing with others within the sister circle on a scale from 0 (not so much) to 10 (very much so).
The final question asked participants if they would participate in a BBB SOS sister circle in the future.
Focus group discussion. An academic and community
research team formulated 10 focus group discussion questions. Questions centered on participants’ initial thoughts
when asked to participate in BBB SOS, experiences and
thoughts about exercises and activities utilized in the
group, the timing of sessions, comfortability with doulas,
identification in personal development, their experiences
versus expectations, any ideas for improvement, and initial
thoughts when asked to participate in BBB SOS.
Procedure
All study procedures were approved by the Kent State
University Institutional Review Board. As noted above,
Women’s Health
recruitment procedures were completed by our community
partner, a perinatal support program.
BBB SOS sister circle
Intervention training. Two Black female perinatal doulas
received in-person training from a licensed clinical psychologist to facilitate the BBB SOS intervention. They
were provided with a manual that contained all intervention materials and instructions to use as a training guide.
The training covered intervention goals and objectives,
data measures, and data collection procedures. The BBB
SOS curriculum was presented in detail. The clinical psychologist taught the intervention session by session, thoroughly covering session-specific content and materials,
including psychoeducational and activity components.
Prior to study implementation and independent of our
study specifications, our BBB SOS doula facilitators possessed mental health certifications (e.g. Qualified Mental
Health Professional and Community Health Worker) and
were up-to-date with their continuing education courses
as a part of their professional development. Therefore, we
determined an extensive CBT training was not needed.
Instead, the training included a brief CBT review and
emphasized administering CBT-based activities to our
target population. Finally, our BBB SOS doulas practiced
administration with the staff multiple times before study
implementation. Training took place over 3 months.
Intervention overview. BBB SOS was initially administered as an 11-week intervention. Staff and participants
gathered weekly for 2-h sessions in a local community
center. After two iterations, participant feedback led us
to condense the 11-week intervention to 7 weeks. Review
exercises and casual group discussions were shortened.
However, no exercises were removed in their entirety. The
remaining manuscript will focus mainly on our procedures
and data on the 7-week intervention. Descriptive data from
the 11-week intervention will be briefly discussed.
In the first session, doulas explained the general goals
of the research project. Then, written consent and participants’ demographic information (e.g. age, pregnancy status, and household income) were obtained during sign-in
by a Black female undergraduate or graduate research
assistant. Participants received a binder with the BBB SOS
group mission statement that read:
This is a place to speak your truth, to be heard, embraced, and
received in a loving, relatable way that supports, encourages,
and empowers Black women.
and a covenant we adapted from the Women of Color
Foundation with permission, that read:
I see your beauty
I sense your power
Somerville et al.
I celebrate your potential
I support your prerogative to sing your own song.
Participants were also given a copy of Soothe Your
Nerves: The Black Woman’s Guide to Understanding and
Overcoming Anxiety, Panic, and Fear55 as a complementary text to multiple intervention components. This text
uses anecdotes to discuss Black women’s experiences with
stress, anxiety, and panic attacks. These firsthand accounts
include Black women who are childless, pregnant, postpartum, and mothers, highlighting that the stressors of
Black women magnify during pregnancy and motherhood.
It also promotes a sense of “sisterhood” by normalizing
familiar and novel experiences. This is particularly helpful
for BBB SOS groups with few or shy participants. Second,
this text discusses and dispels harmful myths and stereotypes, such as the “Strong Black Woman” trope. Next, it
breaks down the stigma of therapy within the Black community and introduces the basic tenets of CBT. Finally,
CBT components and related strategies are explained and
recommended to promote healthy emotional functioning.
Doulas encouraged participants to read specific chapters of Soothe Your Nerves for assigned homework related
to specific BBB SOS sessions. Doulas also provide verbal
summaries of the text at the beginning of sessions so that
participants who did not have time to read or do not enjoy
reading can follow group discussions.
After participants were settled, the doulas checked in
with participants, completed introductions, and then introduced the BBB SOS guiding principles and group mission
statements. Later, they instructed participants to develop
their personal mission statement that allowed them to
establish their goals for participating in the sister circle.
Doulas ended session one by leading the group in reciting
the BBB SOS covenant, reinforcing the sisterhood dynamic
of the sister circle.
Sessions 2 through 5 began similarly: check-in and review
of Soothe Your Nerve text and review of group guidelines
and mission statement. During these check-ins, doulas would
discuss previous exercises, homework completion, and participation in BBB SOS strategies outside of the intervention.
Afterward, participants were provided with detailed psychoeducation about the emotional, cognitive, and biological
consequences of stress, anxiety, and panic attacks. Some
education on postpartum depression was also discussed with
participants, given its prevalence in this population.56
During these sessions, doulas led discussions about the
psychological impact of images and stereotypes of Black
women in the media. They encouraged the participants to
share their experiences with anxiety, racism, and racial
stress. In addition, doulas introduced and led evidencebased strategies to reduce anxiety, including goal setting,
progressive muscle relaxation, and visualization. Partici
pants also learned how to engage in cognitive restructuring
through a Build Your Own Theme Song (BYOTS) activity
5
that helped them use music to replace negative thoughts
with positive thoughts. Participants also received hair consultations, information about hair care needs during pregnancy, and a hair scarf wrapping demonstration.
In the latter half of sessions five and six, participants
participated in pregnancy yoga led by a certified instructor.
Session six was also devoted to educating participants
about nutrition using the U.S. Department of Agriculture’s
recommendations.57
Focus group. During the final session, participants celebrated their completion of the BBB SOS with a graduation party. A focus group discussion also occurred and
lasted approximately 2 h. It was led and audio recorded
by either a trained Black female graduate student (MA)
or a project coordinator (MA). Both women have previous work experience related to mental health concerns in
Black communities in the sampled area. These women did
not participate in any of the other BBB SOS sessions and
are not authors on this article. Their focus group training
was conducted by a licensed clinical psychologist (PhD).
The focus group interviewer took observational notes.
In addition to the focus group discussion, participants
also answered questions in paper focus group booklets. All
data were collected at the local community center, where
the BBB SOS sessions occurred. No other individuals
were present besides doula facilitators, undergraduate or
graduate students, and project coordinator, all of whom
were Black females.
Participants received a certificate, a US$50 Walmart
gift card, a yoga mat, and food storage containers for their
participation in the study. We also provided transportation
and onsite childcare to participants in need for all our sessions to reduce additional attendance barriers for pregnant
mothers. See the Online Appendix for a flowchart of the
BBB SOS Curriculum (Figure 1).
Supervision. We conducted fidelity checks weekly to
assess the doula-led intervention implementation. Checks
were completed live during the sessions by a Black female
undergraduate or graduate research assistant. A standard
CBT checklist was modified to assess group interventionspecific components such as guiding principles, facilitators’ knowledge, and group participation questions. Doulas
were provided a completed fidelity checklist and weekly
observational report. See Online Appendix for our fidelity
checklist. A licensed clinical psychologist also provided
weekly group supervision, which BBB SOS doula facilitators, doulas on separate projects, research assistants, and
project coordinators attended.
Statistical analysis
We conducted power analyses to determine an appropriate
sample size for our study.
6
Women’s Health
Recruitment by Doulas
Decision
Enrolled into BBB SOS
Session 1
Session 2
Check-in
Team & Group Introductions
Introduce Sister Circles,
Guiding Principles, & Group Mission Statement
Discuss Curriculum
Develop Mission Statement
Receive Soothe Your Nerves Text
Recite Sister Circle Covenant
Check-in
Review of Soothe Your Nerves Text
Review Guidelines & Group Mission Statement
Hair Struggles, Hair Care, &
Head Wrapping Demonstration
Recite Sister Circle Covenant
Session 3
Check-in
Review Guidelines & Group Mission Statement
Review of Soothe Your Nerves Text
Psychoeducation of Stress, Anxiety,
& Panic Attacks
Telling My Stress Story
Progressive Muscle Relaxation
Recite Sister Circle Covenant
Session 4
Session 5
Session 6
Check-in
Review of Soothe Your Nerves Text
Review Guidelines & Group Mission Statement
Psychoeducation Review
Images of Black Women Discussion
Recite Sister Circle Covenant
Check-in
Review of Soothe Your Nerves Text
Review Guidelines & Group Mission Statement
Review Images
Visualization Exercise
Progressive Muscle Relaxation
Prenatal Yoga
Recite Sister Circle Covenant
Check-in
Review of Soothe Your Nerves Text
Review Guidelines & Group Mission Statement
Visualization
Action Planning
Prenatal Yoga
Recite Sister Circle Covenant
Develop Mission
Session 7Statement
Receive Soothe Your Nerves text
Recite Sister
Circle Covenant
Check-in
Session
Evaluation
Graduation
Focus Group Booklet
Focus Group Discussion
Recite Sister Circle Covenant
Figure 1. BBB SOS intervention flowchart.
BBB SOS, Birthing Beautiful Babies Sisters Offering Support.
According to G*Power, approximately 34 study participants were required to detect an effect for our study-
specific hypotheses.58 Specifically, we evaluated a priori
power analyses for our paired t-tests, with an alpha of 0.05,
a power of 0.80, and a medium effect size.
Quantitative. Quantitative data analyses were conducted
using SPSS 25.0. Skewness and kurtosis data were
reviewed to assess normality according to Kline’s59 recommendation. Descriptive data analyses of participant
baseline worry, distress, and pregnancy-related anxiety
were analyzed. Participants’ baseline and post-knowledge
about panic attacks and stress were collected via the focus
group booklets and evaluated using paired samples t-tests.
Qualitative. Qualitative data analysis procedures were
rooted in Grounded Theory60,61 and were led by the first
author on this manuscript, a Black female doctoral student. Audio transcripts of the BBB SOS focus groups
were reviewed by all authors on the paper. Then, they
conducted an organizational meeting to discuss and create coding guidelines.
The data was open-coded by four undergraduate
research assistants (two Black females, one Black male,
and one White female) for general themes. Coders were
instructed to read the transcripts and identify any general
themes they felt represented many participants’ responses.
In addition, coders were asked to highlight and note any
specific examples on the transcript indicative of such
Somerville et al.
themes on a coding form. They were not given any specific
themes to identify in the transcripts.
Once coders completed and submitted their initial open
coding, they met with the lead author, who provided them
with selective coding procedures. Coders were asked to
re-read the transcripts and identify quotes that represented
or related to learning and feasibility. These themes were
selected by authors on this article during the organizational
meeting as they related to our research question: will Black
pregnant and postpartum women perceive the BBB SOS
sister circle anxiety intervention to be helpful? More specifically, the theme “Learning/Valuable” was defined as
experiences that represented, but were not limited to, successful or useful skills, beneficial takeaways, or additive
value. Coders were given the following examples to guide
their selective coding further: “Because of SOS, I take
deep breaths when I am stressed,” “Gained friendships,”
and “I enjoyed talking about my issues.” The theme
“Feasibility” was defined as comments that represented
sister circles being practical, achievable, reasonable, or
workable (e.g. “the sessions occurred regularly,” “doulas
handed out materials,” “the members worked together as a
team”). Coders were also asked to identify noteworthy
themes. They were instructed to note such themes as
“Other” and provide a descriptor that appropriately categorized the statement and/or theme.
Coders documented their selective codings on a separate coding form and submitted it to the lead author. She
combined all coding forms into a single composite summarizing all coders’ responses on an Excel spreadsheet.
Afterward, a consensus meeting was held with the coders
and the first author to discuss the composite. The first
author shared identified discrepancies among the coders in
open and selective codings. Then, she led the coders to
discuss among themselves to reach resolutions. At the
beginning of the meeting, the coders were in 86% agreement. At the end of the meeting, the coders were in 100%
agreement. The first author prepared a summary of the
coders’ themes, which was shared with the four coders for
final confirmation. Our results in this manuscript will
include both the open and selective coding findings. Some
open coding findings were also identified during the selective coding process. These findings will be summarized
once in our “Results” section under the subsection selective coding for brevity. Finally, we believe that saturation
was achieved in our study. After multiple focus group discussions were coded, the codes derived in later focus group
sessions were redundant with earlier sessions. No new
themes appeared to emerge from coders in the last five
focus groups. Therefore, after coding eleven focus groups,
the authors on this article and coders collectively decided
that (1) we received sufficient data to address our research
questions and (2) further data collection would likely not
yield additional insights.
7
Descriptive analyses
Demographic. Data were normally distributed. Participants reported having an average of 1.83 (SD = 1.31)
children. The average household size was 3.31 (SD = 1.86)
and the majority of participants (52%) had a household
income of below US$10,000 annually. Seven (8.75%) of
participants reported being privately insured; 63 (78.75%)
were publicly insured; 1 (1.25%) was not insured; and
9 (11.25%) data were unavailable. Table 1 displays the
number of children, household size, income levels, and
health insurance data.
Additional demographic data on the sample was
obtained via city records. Data highlight that the neighborhoods from which the sample was drawn are racially
homogeneous. Ninety-five percent of residents in these
neighborhoods identify as Black and 11% identify as
Hispanic or Latino.62 Twenty-five percent of residents are
college-educated.63 The sampled neighborhoods are also
considered high-crime areas by national standards, as one
out of 14 neighborhood resident reports being a victim of
a crime annually.64
Results
Anxiety symptomology
Data indicate that participants were experiencing mode
rate levels of worry (M = 25.32, SD = 11.38) and distress
(M = 21.86, SD = 7.14) and low levels of pregnancy-related
anxiety (M = 1.90, SD = .60) prior to the start of the BBB
SOS intervention (Table 2). Participants also reported
experiencing race-related worries, ranging from low (0) to
high frequencies (5). Eleven participants (13.75%) indicated that it was “very typical of [them],” a 5, to worry
they may be treated or viewed unfairly to because of their
race; 8(10%) reported a 4 rating; 12 (15%) reported 3, 9
(11.25%) reported 2, 11(13.75%) reported 1; 26 (32.50)
reported it was “not at all typical of [them]” 0. Data of 3
participants were unavailable.
BBB SOS intervention completion
Eleven cohorts (N = 80) of BBB SOS were conducted
between 2017 and 2019. Of the 80 participants in this
study, 24 participated in the 11-week intervention, and
56 participated in the 7-week intervention. On average,
participants attended four sessions. Thirty-six participants completed the focus group session. Forty participants (50%) were considered treatment completers, as
they attended 50% or more BBB SOS sessions, which
was pre-determined by our grant project objectives.
Table 3 displays a summary of participants that completed approximately 25%, 50%, and 75% of the BBB
SOS Intervention.
8
Women’s Health
Table 2. Summary of descriptive analyses.
Measure
N
Minimum
Maximum
Mean
SD
PSWQ-A
K10
Pregnancy-Related Anxiety
77
59
66
0
10
1
45
40
3.3
25.32
21.86
1.896
11.380
7.143
.603
PSWQ-A, Penn State Worry Questionnaire–Abbreviated; K-10, Kessler Psychological Distress Scale.
Table 3. Summary of participant BBB SOS intervention completion.
Intervention Completion (N = 80)
N (%)
<25%–49% Completion
50%–74% Completion
⩾75% Completion
40 (50)
13 (16.25)
27 (33.75)
BBB SOS Intervention Completion Cuttoffs by Group. Participants who were in the 7-week BBB SOS group: <25%–49% completion is approximately one to two sessions completed; 50%–74% completion is approximately three to four sessions completed; ⩾75% completion is approximately at least five sessions completed. Participants who were in the 11-week BBB SOS group: 25%–49% completion is approximately two to four
sessions completed; 50%–74% completion is approximately five to seven sessions completed; ⩾75% completion is approximately at least eight
sessions completed.
Table 4. Comparisons of pre- and post-knowledge about panic attacks and stress.
M
SD
Pre Knowledge about Panic Attacks
Post Knowledge about Panic Attacks
Pre Knowledge about Stress
Post Knowledge about Stress
4.63
8.49
6.29
8.97
3.011
2.536
3.006
2.189
Focus group booklet responses
A paired sample t-test revealed an increase in knowledge
about panic attacks (t(34) = 9.09, p < .001, d = 1.54) and
stress (t(1, 34) = 6.12, p < .001, d = 1.03) after completing
the sister circle (Table 4). In addition, participants’
responses suggested that they found all activities completed and skills learned in the sessions to be quite effective. Specifically, they reported high ratings for the
development of a personal mission statement (M = 8.24,
SD = 2.57), visualization exercise (M = 8.80, SD = 1.53),
progressive muscle relaxation (M = 9.12, SD = 1.24), pregnancy yoga (M = 9.03, SD = 2.04), nutrition instruction
(M = 8.70, SD = 2.14), cognitive restructuring (M = 8.19,
SD = 1.81), and action planning (M = 9.12, SD = 1.41).
The mean rating for participants’ overall experience
was 9.60 (SD = 1.09), and the mean rating for comfortability with sharing was 9.69 (SD = .80). Finally, most participants (94.30%) indicated that they would be interested in
participating in a sister circle in the future.
Open coding themes
Supportive environment. Open coding analysis of focus
group responses indicated that the BBB SOS provided a
Paired Samples Test
p
d
1.538
1.034
t
df
9.090
34
<.001
6.115
34
<.001
supportive and non-judgmental environment. For example, one participant stated, “I can speak freely now. You
know what I mean. Without fear of being judged.”
Another woman expressed similar sentiments, “It brought
a lot out of me . . . So it’s like I was comfortable in this
setting to speak how I feel without being judged to get
what I needed to get out.” Many participants attributed
their comfortability in the group setting to the efforts
of the facilitators. For example, participants commented,
“I think the doulas made it very comfortable . . . to come
and talk” and “In there, you’re not being judged. Like
they don’t want nothing from you. Like they trying help
you as much as you can and your situation that you’re
about to go through.”
Openness. Another woman compared this group to ones
that she participated in the past stating, “They went over
and beyonder [sic] . . . this group made us feel, or made
me feel more comfortable.” Others highlighted how the
openness of the facilitators impacted their experience and
encouraged them to be vulnerable and transparent. For
example, one woman discussed a facilitator’s approach,
In this field they want to hear your story, but they’ll never tell
you theirs and that’s where a connection is lost. But the minute
Somerville et al.
she started talking, she shared her whole life story and that
instantly got a connection.
Another woman shared a similar viewpoint and added
that the facilitators normalized her experience: “I’m not
the only one who goes through A, B, and C. Hearing different ways that they handle these situations . . . it gives
me a whole new insight on things.”
Building a sisterhood. Focus group participants viewed the
BBB SOS as a sisterhood. They reported, “We got our
little bond together” and “You gain additional family . . .
you create a definite bond with them. Everybody here that
works here really been helpful and understanding.” Some
expressed their appreciation for the support and their lack
of that in prior experiences. For example, “It’s nice. It’s
kind of building that community . . . I have a lot of strong
Black women friends, but all of us live very far apart now,
so I don’t have that.” Others discussed their admiration for
being connected to women with similar experiences and
challenges: “I’m the only one of my friends who has a
child or who’s pregnant, so it was nice to be able to talk to
other people who are pregnant like on a regular basis” and
“I don’t have a whole bunch of moms. So I be in here trying to soak it up okay.”
Sharing experiences with others. Many focus group participants reported that they enjoyed their experience and
would recommend BBB SOS to others in need. For
example, “I would tell people about the sister circles and
stuff because it’s like a support . . . we come here, and we
know that we gonna be able to express ourselves . . .
Gonna get to learn something. We gonna be getting some
feedback.”
Other participants agreed and added, “Whether you’re a
single mother or not, I mean everybody can get something
from it,” and “Yeah, same here. I just be like ‘Girl you better get over there. Get those problems out. Girl they talk to
you. You just get in the class, get with the program honey
like. Just let them know.’” In addition to discussing the
benefits of the group with close friends and family, one
woman recommended it to her young pregnant clientele: “I
think that they could use the information and use the support since they are so young. If they could get the skills
now or at least get introduced to different components.”
Additional findings related to positive experiences not
only appeared in the open coding analysis but also reappeared in the selective coding analysis. These results will
be outlined in the section below for brevity.
Selective coding
Learning/valuable
Psychoeducational. Sixty-six statements were related to
identified benefits and valuable takeaways. Specifically,
focus group participants reported enhanced knowledge
9
about various psychoeducational topics after their participation in the BBB SOS. For example, they reported,
“I could identify a panic attack from a mile away” and
“I think I learned a lot more about stress and anxiety.”
Another expressed that she valued the information she
received about nutrition during pregnancy and postpartum:
“When you’re pregnant, a lot of things change and what
you can and cannot eat is one of them. So getting that professional opinion on what is good for us.”
Applying coping skills. In addition, focus group participants reported that BBB SOS sessions facilitated their
identification of emotions and triggers and implementation
of adaptive coping skills. For example,
I was able to let go in the beginning when we talked about
stress, family, and things like that. I was able to let go of some
of the stresses and let go of a couple more stresses so now I
feel like I’m carefree and I have a lot more freedom.
Similarly, one woman explained that she was able to
manage her emotions in an effective manner and “stop [the
anger] before it gets too bad.” In regard to identifying triggers, one woman stated, “It was an eye opener because it’s
one thing to feel stressed. It’s another thing to be able to
express why you feel stressed . . . When you’re able to kind
of pinpoint what’s triggering your stress, you’re able to
then find coping skills to match your stressors.” Finally,
another woman stated that visualization exercises “recentered” her and assisted her ability to manage parental stress.
Instructional materials and activities
Text. Many focus group participants commented on
specific activities and the related impact on their learning or skill development. One woman explained that the
Soothe Your Nerves text aided in her understanding of
stress and offered normalization. She stated, “It defines
[stress] in a way that is unique, and it doesn’t make it seem
to be like this outcasted feeling.”
Build Your Own Theme Song. The focus group participants
also reported favorable opinions about the BYOTS activity improving their ability to reframe their negative beliefs.
Specifically, some participants alluded that their theme song
helped them remain hopeful during times of adversity. For
example, “I think everyone having an individual theme
song . . . is very helpful because it gives you assurance and
it gives you that boost of self-confidence that everybody
needs.” Another woman added, “The theme song, I personally had one gospel song . . . I think it is very helpful.”
Yoga. Multiple participants reported that the pregnancy
yoga activity alleviated stress. One woman stated, “I think
that yoga is a really good stress reliever for me personally.
I like to stretch, and I’ve always found it to kind of be
really relaxing.”
10
Action planning. Focus group participants found the
action plan activity to be a simple and effective tool for
setting goals and increasing adaptive and decreasing maladaptive behaviors. One woman explained that the activity helped her “break things down” to the point that it
made tasks “seem less severe.” Another woman added,
“[Action planning] would help somebody who never set
a goal before . . . so they could just go back and make a
plan.” Some focus group participants attributed the action
plan to increasing their motivation and commitment to
goal directed behavior. For example, “It gave me a vision.
It helped me see something to look forward to ‘cause I
didn’t. It gave me another goal to see that.” Others commented in agreement:
That’s like my biggest thing is, like I could set a goal, but I’ll
never stick to it so being in this class kinda taught me how to
stick to my goals and make a game plan and plan of management.
Improved mood. Findings showcased that the focus
group participants reported participation in BBB SOS
increased behavioral activation, mood, and functioning
and facilitated personal growth and self-empowerment.
For example, one woman stated, “Having a sister circle
that you like dedicated to every week, it make you feel
better leaving the house every week, especially being a
stay-at-home mom and everything.” In addition, one
woman verbalized her increased ability to effectively process her anger: “Just like knowing what triggers is and how
to refrain from just cussing people out . . . I think that’s
just pretty much where I came from.” Another woman
stated that she can now manage her internalizing symptoms: “I’m in a better place . . . becoming a better person,” and “Us talking about depression and things we’ve
been through. It definitely helped out in those areas.”
Empowerment. The focus group participants underscored that their participation helped change their perspectives on their circumstances, others, and the environment.
For example, one woman stated,
I have more knowledge of my situation and I have more
information as far as what I’m going through that can take
me in my day-to-day life with my child. I’m fully aware of
things that I wasn’t. I have a little bit more confidence . . .
this situation helped me a lot me ‘cause I stay by myself. It
helped a lot with that and to better open up myself up a
little bit more so I wouldn’t be so closed minded to things
that I was before.
Another woman shared a similar realization about how
the sister circle influenced interactions with her mother.
For example,
[My mom] has panic attacks and anxiety so . . . I told her
about the book. It helped with our relationship and our
Women’s Health
bonding because . . . this is what we needed our whole life. It
made a difference in my life because it was something I didn’t
see that needed more focus.
In addition to changing perspectives, some participants
specifically noted an increase in positive thinking:
I just really like the feeling. It was just really nice, and it gave
us a different view of ourselves and everything. How to make
ourselves more positive and not think of the negative in every
situation. It made us more confident.
Family and community impact. One woman concluded
that her participation in BBB SOS helped her and others
in her family: “I actually helped a lot of people now. Like
my sisters and them. They know how to open up and how
to talk about things.” Another woman shared her beliefs
about the impact BBB SOS could have on the Black community and family unit:
I think that they could use the information and use the support
since they are so young. If they could get the skills now, or at
least get introduced to different components, read the book,
come to class, or see an environment where black women
aren’t just fighting each other . . . they would set a good tone
for their family that they’re making.
Feasibility. Forty-two statements were related to feasibility
aspects, specifically the structure and flow intervention
and format of sessions. Participants varied in their opinions about the length and timing of the sessions. Many
reported enjoying the incorporation of various materials
and activities to increase their skill building and understanding of anxiety or panic. Some participants wanted a
wider range of discussion topics:
We always talked about how we done broke up, and that we
may be mad at each other. So how are we going to coparent?
See I came in and I was like, ‘That’s not my life. That’s not
my reality.
In addition, some commented on the varying levels of
participation from participants: “I guess the participation
kinda dwindled as we progressed in the program,” and
“See some people kind of get bored. And them younger
girls, y’all have to try to find a way to draw those younger
girls in and keep them here.”
Discussion
The present study utilized a mixed-methods framework
to evaluate the feasibility and acceptability of BBB SOS,
a manualized culturally relevant stress and anxiety inter
vention, for pregnant and postpartum Black women. To
the best of our knowledge, we are the first to utilize a
sister-circle intervention with a Black perinatal sample.
Somerville et al.
Quantitative and qualitative study findings supported our
hypotheses. Data showcased that participants reported
increased perceived knowledge about stress, anxiety, panic
attacks, and emotional triggers and their ability to identify
such feelings and events and manage them effectively
using CBT coping strategies.
Focus group participants described their overall BBB
SOS experience as positive, empowering, and enriching.
They found the environment and group dynamic supportive and enjoyed connecting with individuals experiencing similar milestones and adversities. This finding is
consistent with other studies that employed sister circle
frameworks.20,26–28,65
Focus groups reported that session activities increased
their motivation for behavior change, encouraged planning
and goal setting, and increased support and behavioral
activation, ultimately contributing to their reported
improved mood. This aligns closely with well-documented
evidence of the effectiveness of CBT approaches in treating anxiety and depression.33,66 Participants also reported
mixed feelings about session length and group-member
participation, which have been common critiques made by
individuals participating in group-based interventions.67
The present study revealed several noteworthy findings.
First, our study had a 39.4% enrollment rate. Evidence
shows that community participatory-based research studies that utilize samples of low-income individuals, racial
minorities, or perinatal women traditionally face significant recruitment and enrollment barriers.68,69 There were
limited data on the enrollment rates of low-income Black
perinatal samples. However, multiple marginalized samplespecific factors would likely contribute to lower enrollment rates.
We attribute our enrollment success to participants’
established relationships with doulas prior to study enrollment. Participants were familiar with receiving resources
from their doulas and valued their referrals and recommendations. In addition, cumulatively, our doula facilitators
have over 35 years of experience working with this population. This likely was beneficial to our study as they were
the first point of contact for participants and could communicate project objectives in a culturally-receptive manner. Also, we believe our study compensation was viewed
favorably by prospective participants. Our study compensations included Walmart gift cards, yoga mats, and food
storage containers. These were not miscellaneous incentives but were linked to population-specific needs and/or
topics and activities discussed in BBB SOS. They showcased that our team cares about participants’ experiences
during pregnancy and motherhood and wants to aid in
reducing their financial and health burdens.
Second, multiple participants reported that they held
the research team and facilitators in high regard, which is
uncommon among Black research participants. Despite
previous study findings of cultural mistrust of healthcare
11
workers and researchers due to historical injustices70
even when staff included racial minorities or Black
women,71 our focus groups commented that the BBB
SOS facilitators’ transparency and authenticity created a
safe space and atmosphere of trust. This development
may be due to our facilitators’ willingness to use selfdisclosure. Some clinicians strongly discourage the use
of self-discourse of personal details in attempts to uphold
concrete professional boundaries between the therapist
and the client.72,73 However, this can have an adverse
effect. By continually prompting clients to be vulnerable,
without sharing on the therapist’s part, clients may
become disconnected and frustrated by the overt power
differential. We believe our facilitators’ use of self-disclosure followed by modeling techniques of identifying
and labeling emotions, quickly set the therapeutic framework for our participants. Our data suggest that self-disclosure may be particularly helpful when working with
Black women, as they report feeling alienated, dismissed,
and ignored in their health encounters.
In addition, Black women are aware of their marginalized and often powerless disposition, which is only amplified in a therapeutic setting. Self-disclosure may help create
authentic conversations, resulting in careful attentiveness
from staff and active participation from Black women.
In addition, we believe our facilitator-led discussions that
utilized storytelling to self-disclose, a common cultural
practice among Black individuals,74,75 promoted group connectedness and shaped a sister-like dynamic. Collectively,
these factors helped increase participants’ confidence in the
facilitators and their instruction.
Third, the group dynamic of Black female facilitators
and peer support sharply contrasts with participants’ frequent experiences of marginalization and rejection linked
to racism and sexism in modern-day society.76 BBB SOS
likely fosters feelings of belonging, security, and safety, as
all staff members and group participants identify as Black
and female. These racial and social components embedded
in the structure of BBB SOS potentially decrease participant anxiety and stress intuitively. Research indicates that
Black individuals in predominately White spaces experience increased stress and anxiety.77,78 Some of these
responses may be linked to anticipating and experiencing
frequent microaggressions in these spaces.79 However,
others may be related to the fear of being a victim of a hate
crime, such as physical or sexual violence that could be
potentially life-threatening or fatal.80–82 Experiences of
stress and anxiety are also likely to present among groups
of other races or ethnicities, given the pervasiveness of
anti-Black racism.83 Similarly, studies of Black women
report within racial group conflict and tensions due to gender-based stereotypes, suggesting that all-female support
groups may be preferred.84,85
Fourth, participants perceived the culturally-tailored
and traditional CBT-based activities to be effective in
12
managing stress and anxiety. Multiple participants reported
enjoying the BYOTS Song musical cognitive restructuring
activity. Some explained that they chose familiar gospel
songs with uplifting and encouraging lyrics, prompting
them to decrease their overall negative thinking. Prior
research supports this finding, as music and spirituality
often promote resiliency and serve as protective factors
for Black individuals against poor mental health outcomes.20,75,86,87 Participants also expressed appreciation
for a traditional CBT action plan worksheet activity that
utilized a step-by-step outline approach. They noted that it
reduced their hopelessness and helped them identify a path
to change. Previous studies highlight mixed findings
regarding individuals’ receptiveness to using worksheetbased activities in therapy.88,89
Finally, participants reported that they believed the
assigned psychoeducational text, Soothe Your Nerves,
enhanced their understanding of topics and the development of CBT skills. In contrast to our findings, previous
studies revealed that participants often do not complete
their assigned homework or complain about having additional work outside of the group.90,91 An explanation for
our finding is that the utilized text readings were recommended, not mandatory. In discussion, facilitators asked
people if they read the text, provided chapter summaries,
and led discussions related to skill development and application. It’s possible that BBB SOS participants enjoyed
group discussions and completed assigned readings to
contribute actively and have enriching group discussions.
Limitations
The present study is not without limitations. We could not
collect data from participants who stopped attending BBB
SOS sessions, which may have highlighted additional
treatment barriers and provided valuable recommendations for future interventions. A second limitation is that
our BBB SOS doula facilitators served dual roles for participants. As part of their job with our community partners,
they provided perinatal support. Methodologically, this
limits the generalizability of our data to situations where
this dual role is not present. Clinically, however, this decision likely increased participant trust and the development
of positive rapport. This dual role likely has a similar clinical strength as when individual therapists encourage their
clients to participate in group therapies that the therapist
facilitates.92,93
Implications
Despite these limitations, the clinical implications of this
study’s findings are promising. For example, the BBB
SOS culturally relevant framework may aid Black women
in understanding and mastering CBT concepts and skills.
Previous research outlines that Black individuals are likely
to struggle to apply CBT skills despite being the leading
Women’s Health
modality in mental health treatment.94 Studies suggest that
most intervention approaches fail to teach in a culturally
sensitive manner.95 However, the BBB SOS intervention
created a sense of sisterhood akin to those already present
in the Black community, which likely made learning new
CBT approaches and techniques less daunting for group
members, given participants’ perceived helpfulness.
Moreover, research shows that individuals are more likely
to try new behaviors and take risks with family or friends
in a supportive and nurturing environment.96
Future directions
Future studies should document various maternal mental
health outcomes of Black women before, during, and
after the sister circle to thoroughly and comprehensively
investigate the mental health impact of BBB SOS or other
CBT interventions that utilize sister circles. Studies incorporating sister circles may also want facilitators to cover
specific session topics that complicate pregnancy and
postpartum, including domestic violence, custody issues,
grief, and COVID-19-related stressors.97–99 Role-playing
activities could help increase interpersonal effectiveness
among participants, friends, and family and navigate racial
mistreatment at doctor offices and hospital settings.100–102
Finally, incorporating journaling activities may help quieter and shyer participants engage in group activities and
be motivated to share their experiences.103
Sustainability plan. As we continue to implement BBB
SOS, we regularly invest in efforts that promote sustainability and meet the multitude of needs of our target population. Our project staff reviews data from each focus group
discussion, paying particular attention to concrete critiques
or suggestions noted by participants. We also request feedback from our facilitators. Then, we actively incorporate
their feedback in our following BBB SOS groups as applicable. We polled participants for our most recent group
to identify a convenient meeting time before finalizing a
schedule. In addition, we prompted our independent
reviewers to assess our facilitators’ efforts to be lively and
maintain the group’s interest. This component was recently
added to enhance our fidelity checks.
We implement weekly group supervision throughout
the intervention and provide training reviews upon request
from doula facilitators or if our clinical psychologist identifies a need. We also conduct biannual meetings to review
the cohesiveness and practicability of the BBB SOS curriculum, intervention materials, and staff resources.
Finally, we regularly disseminate our BBB SOS development, experience, and findings. Our team presents at
community events and regional, national, and international
conferences featuring our community-based participatory
research, which includes Black female lay individuals
(e.g. perinatal doulas, cosmetologists) and researchers
and clinicians (e.g. doctoral students and licensed
Somerville et al.
clinical psychologists). These efforts allow us to (1) educate audiences about the mental health and physical health
risks and needs of Black pregnant women, (2) present our
innovative efforts to address our population-specific needs
using cultural-infused strategies and components, (3)
showcase our participants’ experiences, and (4) exchange
information from other researchers. We have effectively
utilized these exchanges to foster new collaborations and
partnerships and obtain additional funding for our work.
Conclusion
Too often, Black women and their children suffer due to
systemic racism, and their needs are not prioritized in
mental health care settings. The present study aimed to
address these problems by developing a culturally relevant stress and anxiety intervention for Black pregnant
and postpartum women, prioritizing their needs and perceptions in our study design and objectives. Our findings
highlight that doula-led peer-supported interventions are
practical, feasible, and acceptable to Black perinatal
women. We believe our existing community partnerships,
use of lay Black female doula facilitators and peer supports, and interactive curriculum with comprehensive
psychoeducation and concrete strategies to address general pregnancy-related anxieties and race-related worries
contributed significantly to our enrollment success and
overwhelmingly positive feedback from BBB SOS participants. We hope to see others invest in similar cultural
considerations when developing public policy, designing
research, and treating clients. More specifically, we challenge others to employ an iterative process of asking and
listening to Black women. This validates their experience,
gives them a voice and power, and creates a safe space to
receive helpful mental health information and resources.
Collectively, these actions work to combat the mental and
physical health effects and realities of systemic racism for
Black women.
Declarations
Ethics approval and consent to participate
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964
Helsinki Declaration and its later amendments or comparable
ethical standards. Written informed consent was obtained from
all individual participants included in the study. All study procedures were approved by the Kent State University Institutional
Review Board (IRB) (IRB LOG#: 17-517).
Consent for publication
We received written informed consent to publish from all individual participants included in the study in accordance with our
institutional consent procedures.
13
Author contribution(s)
Keaton Somerville: Conceptualization; Data curation; Formal
analysis; Methodology; Writing—original draft; Writing—
review & editing.
Tiffany Rowell: Conceptualization; Data curation; Formal analysis; Methodology; Writing—original draft.
Robert Stadulis: Conceptualization; Methodology; Writing—
review & editing.
Debra Bell: Methodology; Project administration; Resources;
Writing—review & editing.
Angela Neal-Barnett: Conceptualization; Funding acquisition;
Project administration; Supervision; Writing—review & editing.
Acknowledgements
We acknowledge the perinatal women who participated in the
sister circles.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
This study was funded by Ohio Commission on Minority Health
and First Year Cleveland (OCMH) (Grant/Award Number:
413356), Sisters of Charity (Grant/Award Number: 413364),
Akron Community Foundation (Grant/Award Number: N/A),
and Mount Sinai Health Care Foundation (Grant/Award Number:
N/A). These funding sources had no other involvement other
than financial support.
Competing interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of
this article: K.S., T.R., R.S., and D.B. declare that they have no
conflict of interest. A.N.-B. is the Vice President for Healthy
Corporations, Companies, and Communities of A3B, LLC.
Availability of data and materials
This is not applicable as we do not wish to upload our study data
file to protect the confidentiality and anonymity of participants.
ORCID iD
Keaton Somerville
https://orcid.org/0000-0003-3844-9172
Supplemental material
Supplemental material for this article is available online.
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