The SMART Moms Program: A Randomized Trial of the Impact of Stress Management on Perceived Stress and Cortisol in Low-Income Pregnant Women

Psychoneuroendocrinology. 2019 Jun;104:174-184. doi: 10.1016/j.psyneuen.2019.02.022. Epub 2019 Feb 22.


Background: Dysregulations in maternal hypothalamus-pituitary-adrenal function and the end product, cortisol, have been associated with a heightened risk for stress-related health complications during pregnancy and post partum. Given the adverse health impact that maternal cortisol may have on expectant mothers and their infants, empirically-based prenatal interventions are needed to target optimal management of stress and its biological effects in at-risk pregnant women, a primary example of which is cognitive behavioral stress management (CBSM). This randomized-controlled trial examined the effects of a prenatal CBSM intervention on reduction in perceived stress and regulation of salivary cortisol patterns [i.e., overall cortisol output (area under the curve), cortisol awakening response (CAR), diurnal slope] during pregnancy and the early postpartum period, as compared to a control group.

Methods: One hundred low-income pregnant women (71% Latina; 76% annual income < $20 K) with low or high anxiety during pregnancy were randomized (stratified by anxiety) to either an eight-week CBSM group intervention (n = 55) or a control group (n = 45). They provided seven salivary cortisol samples (four am samples, 12 pm, 4 pm, and 8 pm samples on one collection day) at baseline (1st trimester; < 17 weeks of gestation), after their prenatal program (2nd trimester), and also in the third trimester and at three months post partum.

Results: Women receiving CBSM had lower perceived stress levels throughout pregnancy and early post partum compared to women in the control group (p = .020). Among women with high prenatal anxiety, those in CBSM showed a steeper decline in their diurnal cortisol at three months post partum compared to those in the control group (p = .015). Further, non-Latina women in CBSM had a lower CAR at three months post partum compared to non-Latina women in the control group (p = .025); these randomization group differences on the CAR were not observed among Latina women.

Conclusions: These findings provide preliminary support for the efficacy of prenatal CBSM interventions in improving stress outcomes among low-income pregnant women and suggest the need to test the effects of these interventions on a larger scale for improving maternal and infant health outcomes long-term.

Keywords: Cognitive behavioral; Cortisol; Mothers; Pregnancy; Stress; Stress management.

Publication types

  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Anxiety / complications
  • Circadian Rhythm
  • Cognitive Behavioral Therapy / methods
  • Female
  • Humans
  • Hydrocortisone / analysis
  • Poverty
  • Pregnancy
  • Pregnant Women / psychology*
  • Psychotherapy / methods
  • Saliva / chemistry
  • Socioeconomic Factors
  • Stress, Psychological / metabolism*
  • Stress, Psychological / therapy*


  • Hydrocortisone