Confronted with severe and debilitating conditions such as severe preeclampsia, haemorrhage, etc., critically ill obstetric patients are subjected to heightened levels of anxiety and depression.^1,2. The ICU environment characterized by a tech-savvy approach, high-intensity medical interventions, constant monitoring, and invasive procedures, can exacerbate feelings of helplessness and anxiety. ICU-related psychological distress may be associated with delayed physical and psychological recovery, post-ICU syndrome, and decreased satisfaction with care. Prevalence of psychological distress in ICU patients has been reported to be high (30-35%), andcan lead to adverse psychological outcomes in up to 50% of patients³. It is recognised that the feeling of agony, fear, helplessness, hopelessness, perception of loss of control, spiritual distress, or even decreased self-esteem may be part of the ICU psychological distress experience⁴.Although modifiable factors that contribute to psychological distress have been identified; there are limited practical strategies to address these factors within the usual constraints of time and resources in ICU settings.

Yoga, a practice that originated over 5,000 years ago, has its roots in ancient texts of the Vedas and the Yoga Sutra of Patanjali.It has been shown to enhance psychological wellbeing in diverse cohorts. Meditation, an important constituent of Yoga, helps individuals to attain balance and harmony. It is one of the components of spiritual care aimed at improving the quality of life of patients, satisfaction with medical care and even alleviating negative psychological consequences of hospitalization. However, there is a dearth of studies on the effects of Guided Meditation (GM) on psychological wellbeing in critically ill obstetric patients. We hypothesized that listening to audio recording of GM script can provide a platform for scalable, and effective environmental manipulation in the ICU to alleviate stress and enhance wellbeing of critically ill obstetric patients. As a non-invasive technique, GM allows patients to engage actively in their own care and provides a sense of agency and inner communique, which is especially important in the ICU.Unlike pharmacological treatments, meditation does not carry risks of side effects or drug interactions, making it a particularly safe option for obstetric ICU patients who may already be on multiple medications. The quintessential effects of GM which cover emotional, cognitive, and spiritual aspects of well-beingthrough neuroplasticity,can only be fully understood by including both objectively measurable phenomena andsubjective experiential effects. This present paper reports the results of a qualitative analysis of the effects of GM in critically ill obstetric patients in the ICU in a tertiary care setting. For this phase of the study, we opted to collect experiential and subjective narratives to evaluate the qualitative effects. We followed Equator guidelines for qualitative research, ensuring a rigorous and transparent analytical process of this seldom explored area⁵.Qualitative analysis of experiences of recipients of GM was chosen as one of the methods of inquiry since, it would allow a deeper understanding of the personal and emotional experiences of patients. By focusing on individual narratives, we sought to explore the nuanced effects of meditation on emotional well-being, patient empowerment, and perceived control over their health in this unique subset of critically ill patients.

METHODOLOGY

Setting and design: This qualitative study was carried out as part of a larger RCT in a rural tertiary care teaching hospital. The trial, including this qualitative component, was conducted between January 2023 and March 2024 after obtaining ethical approval from the institutional ethics committee (IEC/BU/133/Faculty/15/73/2022). The trial was registered under the Clinical Trial Registry of India (CTRI/2022/11/047307).Written and informed consent was obtained from all participants and their relatives.Anonymity of all participant information was strictly maintained throughout the study.

Inclusion criteria: Critically ill conscious obstetric patients (antenatal/postnatal) aged more than 18 years who were not on mechanical ventilation at the time of enrolment. Exclusion criteria: (i) development of cardiac arrhythmias/hemodynamic instability, (ii) presence of any psychiatric disorder, (iii) deterioration in condition during course of illness (e.g., requirement of ventilation), (iv) altered mental status, (v) death/transfer to other medical centre/discharge, or the need for emergency surgery during the study.

Study protocol:

Fifty participants in the intervention group received guided meditation sessions with noise-blocking headphones or earphones for 20 minutes daily over three days, in addition to standard care. The guided meditation audio recording was prepared by the principal investigator, who has expertise in the domain. Participants were provided with diaries to record their reflections after three days of intervention. No specific questionnaire was provided; instead, they were given open-ended instructions to describe, in their own words, the experiences they observed during the intervention period, using their vernacular language.

Analysis:

All 50 participants submitted their reflective diaries, which were transcribed by one researcher and subsequently verified by a second researcher. There were no issues with illegibility during this process. The data underwent thematic analysis following Braun and Clarke's six-step approach to thematic analysis⁶. To ensure a thorough understanding of the data, both researchers collaboratively read the transcripts multiple times, noting key concepts at each stage. This iterative process allowed the researchers to familiarize themselves with the data and identify text segments relevant to the research question. The themes were refined through extensive discussions until a consensus was reached, ensuring that the derived themes accurately reflected participants' experiences. The development of the final coding scheme followed a systematic process. Initially, codes and categories were generated, and subsequent meetings were held to address and resolve any differences in interpretation. This iterative approach led to a consensus-driven coding scheme, which was applied to all diary entries. Two overarching themes emerged, particularly emphasizing the effects of guided meditation.

To validate the findings, the diary data was reviewed in collaboration with another investigator to reach a consensus on codes and themes and address any interpretive discrepancies. The process adhered to triangulation methods to enhance the credibility and reliability of the analysis. Efforts to minimize researcher bias included maintaining a clear decision trail and applying triangulation techniques throughout the study. Rigor and integrity were prioritized from the outset to uphold the quality of the analysis.The themes and categories thus deduced are as shown in table 1.

The present paper reports the qualitative effects of guided meditation GM, as captured through the analysis of participants' subjective experiences documented in their reflective notes. The simultaneously conducted quantitative arm measured heart rate variability (HRV) parameters and vital parameters (heart rate, respiratory rate, systolic blood pressure, diastolic blood pressure, and SpO₂), which were recorded before and immediately after the intervention on all three days. The results of the Visual Analog Scale (VAS) scores for anxiety and well-being are also included alongside HRV observations and shall be published separately due to enormity of data and the distinct characteristics and interpretations involved.

RESULTS

All 50 participants submitted their diaries. Handwritingswere legible. A summary of the thematic analysis (Theme 1: 4 categories; Theme 2: 9 categories), along with the frequency of respondents for each category, is presented in Table 2 and 3. Representative quotes for each category, as described verbatim by participants in their vernacular language and English translations, are also included. The findings indicate improvement in physiological and psychological well-being in patients undertaking GMsessions.

Theme 1: Physiological Impact

1. Enhancement in Sleep Quality (Category 1)

Four respondents stated that they slept well. Better quality of sleep could be due to the relaxing and calming effect of meditation which may have helped alleviate anxiety and restlessness, enabling better sleep behaviour patterns.

2. Reduction in Pain (Category 2)

Nine participants said that a reduction in pain with one of whom explained: "My pain has reduced!" Patients reported their pain and discomfort have reduced, which could suggest that meditation may have a role in managing pain, potentially by increasing the body’s relaxation response and easing stress, both known to exacerbate pain.

3. Decreased Restlessness (Category 3)

One patient said she became less agitated, saying, "I feel relaxed, the restlessness in my body has decreased." This indicates that meditation may help patients regain somatic control over their bodies and reduce symptoms such as restlessness, which are commonly linked to higher levels of stress or discomfort.

4. Regulation of Heart Rate and Respiratory Rate (Category 4)

Thirty subjects noted feelings of improvement in their rhythm of breathing and heart rate, with the comments: "I felt my breathing was under control!" and "My heartbeat has come down!" This finding is of particular importance because it mainly reflects the physiological impacts of guiding meditation as stabilizing vital parameters, such as heart rate and respiration, which are crucial within an intensive care unit that is highly stressful.

Theme 2: Psychological Impact

1. Sense of Wellbeing (Category 1)

Twenty-four Participants showed a general feeling of wellbeing regardless of their health and medical condition. Patients described feelings of relief, the absence of discomfort, and a notable sense of health improvement. These responses suggest that GM may have contributed to improving patients' overall perception of their physical and psychological health, fostering positive outlooks even in critical situations.

2. Alleviation of ICU-related Fear (Category 2)

Twenty-four participants reported overcoming their fear of being in the ICU. A patient commented, "I did not feel like I was undergoing treatment in the ICU". This suggests that meditation could help patients dissociate from the anxiety associated with intensive care, reducing psychological distress.

3. Relief from Disease-related Anxiety (Category 3)

Five participants reported relief from anxiety related to their illness. One participant expressed, "I became free from worries about the illness". Patients expressed a sense of freedom from the mental burden of illness. This is very crucial because anxiety can exacerbate physical symptoms and delay recovery. This indicates that meditation may provide a coping mechanism for patients to manage their emotional responses to severe illness.

4. Mental Clarity (Category 4)

Four participants describe an improvement in mental clarity. For example, one stated: "My mind, which had been overthinking, became calm". This is an important finding because the maintenance of mental clarity is key to patients' management in critical care since they can understand their condition and the treatment-recovery process far better.

5. Achieving Peace of Mind (Category 5)

Forty-five reported experiencing peace of mind. One said, "I experienced peace of mind". Mental peace may well be an essential recovery element because it might help reduce psychological stress that exacerbates physical symptomology.

6. Stress Reduction (Category 6)

Thirty-two subjects reported reduced stress, as one notes, "I became free from mental stress." Lowering one's stress can also be important in promoting the healing of the body because stress is known to negatively impair the functioning of the immune system and affect recovery in a healthy manner.

7. Experience of Joyfulness (Category 7)

Seven participants experienced feelings of joy. One patient reported, "I felt a deep sense of satisfaction and joy in my mind!"This shows that, in addition to reducing negative emotions, meditation actively cultivates a positive emotional state, thereby enhancing overall emotional well-being.

8. Gaining Strength (Category 8)

Ten participants reported a sense of being strengthened to fight their illness; one stated, "I gained the strength to fight the illness." This empowering procedure is crucial in medical recovery; as a positive mindset is often associated with better health outcomes.

9. Reassurance (Category 9)

Six participants also reported to have decreased worries about their family. One said, "My worries about my family were decreased!" This, therefore, reflects that meditation leads to a broader impact in reducing not only personal anxiety but also concerns related to family and responsibilities.

Table 1: Themes and categories

Table 2: Thematic analysis- Physiological Impact.

Table 3: Thematic analysis- Psychological Impact.

DISCUSSION

The findings of this study support our hypothesis that GM is an effective non-pharmacological means for enhancing psychological well-being in critically ill obstetric patients admitted to the ICU. To the best of our knowledge, ours is the first study of its kind which has carried out detailed qualitative analysis.

Reported non-pharmacological strategies to reduce anxiety and stress in ICU patients include music therapy, aromatherapy, massage therapy, etc⁷.Sound-based treatments have been shown to reduce somatic and cognitive state anxiety⁸.Anxiety reduction by music therapy has been reported to be greater than that achieved by anti-anxiety drugs such as midazolam⁹.Smruti et al have reported that receptive music therapy reduces perioperative anxiety in patients undergoing hysterectomy and caesarean section¹⁰.Esfandiari et al. have highlighted the distinct psychological impacts of music on human emotions, emphasizing its ability to inspire, relax, motivate, energize, and alleviate anxiety while also influencing hemodynamic parameters¹¹.

Meditationhas been defined, in modern times as “a family of self-regulation practices that focus on training attention and awareness to bring mental processes under greater voluntary control”¹². In the parlance of ancient civilization, it is described as a practice for harmonizing body, mind, and transcend suffering by developing an abiding awareness of one’s spiritual nature. GMis a component of the pratyahara technique in Yoga, which promotes inner awareness and detachment from external distractions through a structured and predominantly scripted process of guided relaxation¹³.

As described in the results, GM resulted in the alleviation of several stressful experiences and the creation of positive experiences during ICU stay. The first impressions, or, the “Aha!” moments were expressed by patients in different wordings. “I experienced peace of mind”, stated a30- years-old patient with eclampsia. “I became free from worries about the illness!”, was the exclamationof a 26-year-oldpatient with eclampsia. Relief from pain was an important observation.  “Whatever discomfort I had, has subsided” narrated a patient; “I experienced relief from my pain.”wrote the other patient. Patients also reported a reduction in restlessness, reflecting meditation's ability to calm the nervous system and reduce hyperarousal symptoms. By reducing uncomfortable awareness about heart rate and respiratory rate, the practice of meditation demonstrated its effectiveness in stabilizing crucial physiological parameters.These physiological improvements support Barnes et al.'s findings, which emphasize that meditation aids in regulating autonomic functions, critical in managing intensive care unit patients¹⁴.Participants also reported improvement in sleep and enhancement of wellbeing. Meditation has been shown to regulate the body's stress response and improve sleep patterns, particularly during high anxiety and discomfort¹⁵.Lee et al have documented that virtual reality-based meditation enhances the quality of sleep in intensive care unit patients¹⁶. In their systematic review of medical applications of meditation in randomised control trials, Kim D et al have reported that improvement insleep quality and fatigue are major benefits of meditation¹⁷.The positive effects of yoga during the peripartum period have been discussed extensively in the literature^18,19.

An improvedsense of well-being reported by many participants shows that meditation can foster emotional resilience even in critical care settings. An important finding in our study was the reporting of the alleviation of ICU-related fear and disease-related anxiety by the participants, both of which are crucial in any patient management. These psychological benefits are likely related to meditation's ability to distance patients from the stressors associated with their medical environment. Evidence supports that mindfulness practices during pregnancy to reduce anxiety, depression, and stress during pregnancy, which may continue to have beneficial effects through the postpartum period²⁰.Vaishnav et al. have reported alleviation of deep-seated anxiety and improvement in kidney disease related quality of life in chronic kidney disease patients on maintenance haemodialysis²¹. Effects of GM on the multi-level and multidimensional construct of well-being in healthy individualsand diabetics by Vaishnav et al and others^22-24.

Meditation's contribution to mental clarityand peace of mind is critical in critical care settings, which was reported benefit by 90% of respondents, followed by stress reduction, reported by 64%. Promotion of peace of mind with meditation has also been reported by Chen et al²⁵.Similarly, the most frequently noted physiological improvement was the regulation of heart rate and respiratory rate, observed by 60% of participants, while pain reduction was reported by 18%. The reduction of negative emotions and promotion of positive feelings observed in our study can be linked to meditation's role in enhancing resilience, which is linked to better health outcomes and faster recovery²⁶. The participants' reported reassurance about family-related worries corroborates their emotional empowerment.

All the above experiences can be summarised as meditation-induced enhancement of psychological well-being in considerably morbid and sick patients of the obstetrics intensive care unit. Elucidation of its complete basis of beneficial effects of meditation can be based only on combining scientific and esoteric basis.

In the parlance of ancient Indian psychology, well-being refers to awareness and manifestation of a transcendental state of consciousness, which human beings are capable of accessing at any age and any stage of health or disease. Yoga is the science, the process, the effort, and action by which man attempts to pass out of the limits of his ordinary mental consciousness into a greater spiritual consciousness, from the phenomenal to the real man²⁷.

This study serves as a pioneering step in documenting the role of GM in the whole person care of critically ill obstetric patients, who need ‘healing care’ which extends beyond treatment. Our study is unique in several ways. It demonstrates the positive effects of GM in critically ill obstetric patients when offered over a relatively shorter period of three days and documented through qualitative assessment of physical and psychological parameters. The first-person account of the experience of meditation in our patient allowed us to capture qualitative effects verbatim.The findings offer an inspiring and promising avenue to explore this intervention in different subsets of ICU patients. If corroborated by larger studies, long-term effects, and diverse cohorts, the proposed intervention can contribute to develop an inclusive care program imbued with empathy in tech savvy ICUs.

Conclusion and recommendations: Given the unique challenges faced by critically ill obstetric patients abreast with fear, insecurity, loneliness, helplessness, and lack of control,GM serves as a powerful adjunct to medical interventions by improving psychological wellbeing. It is a safe, convenient, harmless non-pharmacological intervention. Although research in this specific patient population is scarce, this study underscores the potential of mediating meditation for improving care-tenet.

It is therefore strongly recommended that Guided Meditation be integrated into the standard care protocols for obstetric patients in critical care settings since it demonstrated efficacy in transforming a potentially daunting psychological experience into a more positive and reassuring one. It also leverages the collaborative wisdom of science and spirituality aimed at improving the integral well-being of critically ill obstetric patients.

Acknowledgment: The authors extend their heartfelt gratitude to the Research Advisory Committee of Bhaikaka University for their guidance and support, as well as to the patients whose participation made this study possible.

Conflict of Interest: The authors confirm that there is no conflict of interest.

Authors’ Contributions: Concept and design of the study: RP, BV& JV. Acquisition of data: RP &GD. Analysis and interpretation of data: RP, BV, AP, SS& JG. Drafting the manuscript: RP, BV& ST.Critically reviewing the manuscript to ensure significant intellectual contributions: RP& BV.

REFERENCES

1. Pan WL, Lin LC & Kuo LY, Effects of a prenatal mindfulness program on longitudinal changes in stress, anxiety, depression, and mother–infant bonding of women with a tendency to perinatal mood and anxiety disorder: a randomized controlled trial, BMC Pregnancy Childbirth, 23 (2023) 547.
2. Jimènez-Barragan M, Falguera-Puig G & Curto-Garcia JJ, Prevalence of anxiety and depression and their associated risk factors throughout pregnancy and postpartum: a prospective cross-sectional descriptive multicentred study, BMC Pregnancy Childbirth, 24 (2024) 500.
3. Wade D, Als N, Bell V, Brewin C, D'Antoni D, Harrison DA, Harvey M, Harvey S, Howell D, Mouncey PR, Mythen M, Richards-PBelle A, Smyth D, Weinman J, Welch J, Whitman C, Rowan KM & POPPI investigators, Providing psychological support to people in intensive care: development and feasibility study of a nurse-led intervention to prevent acute stress and long-term morbidity, BMJ Open, 8 (7) (2018) e021083.
4. Gültekin Y, Ozçelik Z, Akıncı SB &Yorgancı HK, Evaluation of stressors in intensive care units, Turk J Surg, 34 (1) (2018) 5-8.
5. O’Brien BC, Harris IB, Beckman TJ, Reed DA & Cook DA, Standards for reporting qualitative research: a synthesis of recommendations, Acad Med, 89 (9) (2014) 1245.
6. Braun V & Clarke V, Using thematic analysis in psychology, Qual Res Psychol, 3 (2) (2006) 77-101.
7. Esfandiari S, Shorofi SA, Shabankhani B, Golshani S, Arbon P & Jafari H, The effect of eye mask and selected music on the level of anxiety and hemodynamic parameters in patients undergoing cardiac angiography, J Nurs Midwifery Sci, 9 (1) (2022) 1-7.
8. Mendes FCO, Santos KVGD, Dantas JKDS, Araújo SCM, Teixeira FC, Leal KCDS, Dantas DV & Dantas RAN, Non-pharmacological strategies to reduce stress and anxiety in endovascular procedures: A scoping review, Nurs Open, 11 (3) (2024) e2105.
9. Bringman H, Giesecke K, Thörne A & Bringman S, Relaxing music as pre‐medication before surgery: a randomised controlled trial, Acta Anaesthesiol Scand, 53 (6) (2009) 759-764.
10. Mallik A & Russo FA, The effects of music and auditory beat stimulation on anxiety: a randomized clinical trial, PLoS One, 17 (3) (2022) e0259312.
11. Vaishnav S, Chowdhury AB, Raithatha N, Panchal N, Prabhakaran A, Kalaskar P, Nimbalkar S & Vaishnav B, Receptive music therapy: An effective means to enhance well-being in patients undergoing cesarean section and hysterectomy and their operating team, Int J Yoga Philos Psychol Parapsychol, 9 (2) (2021) 73-79.
12. Walsh R & Shapiro SL, The meeting of meditative disciplines and Western psychology: a mutually enriching dialogue, Am Psychol, 61 (3) (2006) 227-239.
13. Singh G & Singh J, Yoga Nidra: A deep mental relaxation approach, Br J Sports Med, 44 (Suppl 1) (2010) i71-72.
14. Barnes VA, Treiber FA & Davis H, Impact of transcendental meditation on cardiovascular function at rest and during acute stress in adolescents with high normal blood pressure, J Psychosom Res, 51 (4) (2001) 597-605.
15. Rusch HL, Rosario M, Levison LM, Olivera A, Livingston WS, Wu T & Gill JM, The effect of mindfulness meditation on sleep quality: a systematic review and meta-analysis of randomized controlled trials, Ann N Y Acad Sci, 1445 (1) (2019) 5-16.
16. Lee S & Kang J, Effect of virtual reality meditation on sleep quality of intensive care unit patients: A randomised controlled trial, Intensive Crit Care Nurs, 59 (2020) 102849.
17. Kim DY, Hong SH, Jang SH, Park SH, Noh JH, Seok JM, Jo HJ, Son CG & Lee EJ, Systematic review for the medical applications of meditation in randomized controlled trials, Int J Environ Res Public Health, 19 (2022) 1244.
18. Abera M, Hanlon C, Daniel B, Tesfaye M, Workicho A, Girma T et al., Effects of relaxation interventions during pregnancy on maternal mental health, and pregnancy and newborn outcomes: A systematic review and meta-analysis, PLoS ONE, 19 (1) (2024) e0278432.
19. Yilmaz ET &Rathfisch G, The spiritual effects of yoga during the birth process, Indian J TraditKnowl, 22 (4) (2023) 891-898.
20. Babbar S, Oyarzabal AJ & Oyarzabal EA, Meditation and mindfulness in pregnancy and postpartum: A review of the evidence, Clin ObstetGynecol, 64 (3) (2021) 661-682.
21. Vaishnav, B.S., Hirapara, J.J. & Shah, M.K. Study of effect of guided meditation on quality of life in patients of end stage renal disease (ESRD) on maintenance hemodialysis – a randomised controlled trial. BMC Complement Med Ther22, 238 (2022).
22. Vaishnav BS, Vaishnav SB, Vaishnav VS, Bharucha ND & Varma JR, Transformative effects of yoga nidra on hedonic and eudemonic dimensions of well-being: A qualitative study in trainee teachers, Int J Yoga Philos Psychol Parapsychol, 7 (2019) 17-23.
23. Vaishnav BS, Vaishnav SB, Vaishnav VS & Varma JR, Effect of yoga-nidra on adolescents' well-being: A mixed method study, Int J Yoga, 11 (3) (2018) 245-248.
24. Kumar SS & Priya SP, Beneficial effects of mindfulness-based stress reduction (MBSR) on bio-physiological and psychological parameters among type 2 diabetics, Indian J TraditKnowl, 21 (4) (2022) 766-773.
25. Chen R, Essader T, Jang J &Kaundinya K, Acute impact of mindfulness meditation on cognitive performance, J Sci Med, 3 (Special Issue) (2020) 1-6.
26. Fredrickson BL, Cohn MA, Coffey KA, Pek J & Finkel SM, Open hearts build lives: Positive emotions, induced through loving-kindness meditation, build consequential personal resources, J Pers Soc Psychol, 95 (5) (2008) 1045-1062.
27. Aurobindo G, Essays divine and human, IN: Sri Aurobindo Ashram Trust, Pondicherry: Sri Aurobindo Ashram Press, (1997) 330.