Mandala Intervention on Mother-Infant Bonding and Parenting Self-Efficacy After Negative Birth Experiences

The Effect of a Mandala-Based Intervention on Mother-Infant Bonding and Parenting Self-Efficacy in Primiparous Women With a Negative Birth Experience: A Randomized Controlled Trial

The purpose of this randomized controlled trial is to evaluate the impact of a mandala-based art intervention on mother-infant bonding and parenting self-efficacy among primiparous women (first-time mothers) who have had a negative birth experience. The study focuses on how structured creative activities can support emotional recovery and maternal confidence in the early postpartum period. A total of 66 participants were randomly assigned to either a Mandala Coloring Group or a Free Coloring Group. The intervention group participated in a structured session involving guided breathing, imagery, and symbolic mandala drawing designed for stress reduction and emotional expression. The control group engaged in a non-guided, free coloring activity. Data were collected using standardized tools, including the Mother-Infant Bonding Scale, the Karitane Parenting Confidence Scale, and the State-Trait Anxiety Inventory. The primary goal is to determine if the mandala-based intervention leads to significant improvements in the bond between mother and infant and increases the mother's confidence in her parenting abilities. Secondary outcomes include changes in anxiety levels following the intervention. All procedures were conducted in a supportive environment under researcher supervision to ensure participant safety and data integrity.

Study Overview

• Status: Completed
• Conditions: Mother-Infant Bonding
• Intervention / Treatment: Other: Free Coloring; Other: Mandala Coloring

Detailed Description

This randomized controlled trial evaluates the effects of a mandala-based intervention on mother-infant bonding and parenting self-efficacy in primiparous women (first-time mothers) who experienced a negative birth experience.

Study Design and Population The study was conducted in the obstetrics clinic of a hospital. Power analysis indicated a minimum sample size of 44 participants to achieve 80% power at a 0.05 significance level. To account for potential attrition, the study aimed for 70 participants and was completed with 66 mothers (34 in the Mandala Group and 32 in the Free Coloring Group).

Inclusion Criteria Eligible participants included women who had a vaginal delivery, were within the first seven days postpartum, were primiparous with a singleton pregnancy, and self-reported a negative birth experience confirmed by a score of 37 or above on the Wijma Delivery Expectancy/Experience Questionnaire Version B. Participants were required to have no diagnosed psychological disorders and no communication difficulties.

Randomization and Procedure Participants were randomly assigned to either the Mandala Coloring Group or the Free Coloring Group using random allocation software. Data collection occurred at two time points: before and after the intervention.

Intervention Protocols The intervention was conducted face-to-face in a quiet, supportive environment under researcher supervision, typically when the infant was asleep. Each session lasted approximately 30 minutes.

Mandala Coloring Group: This structured relaxation process included brief information on mandala philosophy, five minutes of "box breathing" relaxation, and guided imagery of a seaside scene. Participants created and colored a "wish mandala" representing personal intentions, accompanied by shamanic drum rhythm music. The session concluded with the creation of a "stress mandala" using spiral drawings to symbolically release stress.

Free Coloring Group: This activity allowed participants to express emotions spontaneously without guidance. Participants began drawing without prior planning, and the resulting images were evaluated as personal reflections rather than artistic products.

Outcome Assessments The primary outcomes include changes in the Mother-Infant Bonding Scale and the Karitane Parenting Confidence Scale. Secondary outcomes include changes in anxiety levels measured by the State-Trait Anxiety Inventory. Ethical approval was obtained prior to the study, and all participants provided written informed consent in accordance with the Declaration of Helsinki.

• Study Type: Interventional
• Enrollment (Actual): 66
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Turkey (Türkiye)
  • Çanakkale, Turkey (Türkiye)
    • Canakkale Onsekiz Mart University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• Having had a vaginal delivery
• Scoring 37 or above on the Wijma Delivery Expectancy/Experience Questionnaire Version B (W-DEQ-B)
• Being within the first seven days postpartum
• Being primiparous (first-time mother) with a singleton pregnancy
• Self-reporting a negative or adverse birth experience
• The infant being rooming-in with the mother
• Having no diagnosed psychological disorders or problems
• Voluntarily agreeing to participate in the research
• Having no communication difficulties

Exclusion Criteria:

• Having a diagnosed psychiatric disorder or currently receiving psychiatric treatment
• Use of psychotropic medication during the postpartum period
• Experiencing severe obstetric complications (e.g., postpartum hemorrhage, eclampsia, emergency hysterectomy)
• Neonatal complications requiring admission to the neonatal intensive care unit (NICU)
• Having a multiple pregnancy (twins, triplets, etc.) or a cesarean delivery
• Severe communication difficulties or inability to understand study procedures
• Participation in another psychosocial or art-based intervention during the study period
• Withdrawal of consent at any stage of the study

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Supportive Care
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Sham Comparator: Free Cloring; The free painting activity aims to allow the mother to freely express her feelings without any guidance. Initiation: The participant began drawing without any plan. Creative Flow: The drawings reflected the participant's current mood and emotional state. Exploration and Expression: Inner exploration was achieved through the images and themes that emerged during the process. Completion: Upon completion of the work, the participant evaluated the resulting picture as a personal reflection. This activity was evaluated solely for the purpose of emotional expression, not based on artistic skill.	Other: Free Coloring; The free painting activity aims to allow the mother to freely express her feelings without any guidance. Initiation: The participant began drawing without any plan. Creative Flow: The drawings reflected the participant's current mood and emotional state. Exploration and Expression: Inner exploration was achieved through the images and themes that emerged during the process. Completion: Upon completion of the work, the participant evaluated the resulting picture as a personal reflection. This activity was evaluated solely for the purpose of emotional expression, not based on artistic skill.
Experimental: Mandala Coloring; The mandala practice was carried out as a structured relaxation and expression process with the following steps (Sarı Öztürk et al., 2022): Information: The participant was given brief information about the philosophy of mandalas. Breathing Exercise: Relaxation was practiced for approximately 5 minutes using the "square breath" technique. Guided Visualization: The participant was asked to imagine a scene by the sea and clear their mind. Wish Mandala: The participant was asked to draw and color a mandala representing their own feelings and wishes. It was suggested that the mandala be named and hung in their room if desired. Visualization and Music: The guided visualization process was supported by the rhythm of a shamanic drum in the background. Stress Mandala: The participant released their stress with drawings spiraling outwards from the center, and if desired, completed this work symbolically by tearing it or releasing it into water.	Other: Mandala Coloring; The mandala practice was carried out as a structured relaxation and expression process with the following steps (Sarı Öztürk et al., 2022): Information: The participant was given brief information about the philosophy of mandalas. Breathing Exercise: Relaxation was practiced for approximately 5 minutes using the "square breath" technique. Guided Visualization: The participant was asked to imagine a scene by the sea and clear their mind. Wish Mandala: The participant was asked to draw and color a mandala representing their own feelings and wishes. It was suggested that the mandala be named and hung in their room if desired. Visualization and Music: The guided visualization process was supported by the rhythm of a shamanic drum in the background. Stress Mandala: The participant released their stress with drawings spiraling outwards from the center, and if desired, completed this work symbolically by tearing it or releasing it into water.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Mother-Infant Bonding Scale (MIBS)	The Mother-Infant Bonding Scale (MIBS) is an 8-item self-report instrument used to evaluate a mother's feelings toward her infant during the early postpartum period. Each item is scored on a 4-point Likert scale (0 to 3). Total scores range from a minimum of 0 to a maximum of 24. The scale includes five reverse-scored items reflecting negative emotions (e.g., anger, disappointment). A higher total score indicates a higher level of bonding difficulties or problematic attachment, which represents a worse outcome. A score of 13 or higher is used as a threshold to predict problematic bonding.	Immediately after the intervention (Day 1) and post intervention

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Karitane Parenting Confidence Scale (KPSCS)	The Karitane Parenting Confidence Scale is a 14-item self-report instrument used to assess parental self-confidence in mothers and fathers of infants aged 0-12 months. Each item is scored on a 4-point scale. One item is reverse-scored to ensure internal consistency. Total scores on the scale range from a minimum of 0 to a maximum of 42. A higher total score indicates a higher level of parental self-confidence, which represents a better outcome.	Immediately after the intervention (Day 1) and post intervention
State-Trait Anxiety Inventory (STAI)	The State-Trait Anxiety Inventory (STAI) is a self-report instrument used to measure both temporary anxiety (State Anxiety) and long-standing anxiety trends (Trait Anxiety). The scale consists of two parts, each containing 20 items scored on a 4-point Likert scale (1 to 4). The inventory includes both direct statements (expressing negative emotions) and reversed statements (expressing positive emotions). Total scores for each part range from a minimum of 20 to a maximum of 80. A higher total score indicates a higher level of anxiety, which represents a worse outcome.	Immediately after the intervention (Day 1) and post intervention

Collaborators and Investigators

• Sponsor: Çanakkale Onsekiz Mart University

Publications and helpful links

General Publications

• Ucar, E. (2013). Wijma Doğum Beklentisi/Deneyimi Ölçeği B Versiyonu Türkçe uyarlaması ve geçerlilik-güvenilirlik çalışması [Yüksek Lisans Tezi, Hacettepe Üniversitesi].
• Yılmaz, E., & Oskay, Ü. (2021). Karitane Ebeveyn Kendine Güven Ölçeği'nin Türkçe uyarlaması ve psikometrik değerlendirmesi. Psikiyatri Hemşireliği Dergisi, 12(1), 34-42.
• Kırca, Ş., Dağlı, H., et al. (2024). Mandala art intervention as a therapy for anxiety in postpartum women: A randomized controlled trial. Women's Mental Health Journal, 18(2), 79-85.
• Akbulak, F., & Can, R. (2023). Mandala boyamanın ruh sağlığı üzerindeki etkisi: Bir sistematik inceleme. Sanat ve Psikoloji Dergisi, 15(2), 102-117.
• Amelia, S., Jones, T., & Smith, R. (2020). Art therapy through mandalas: Reducing anxiety and enhancing emotional well-being. Journal of Art Therapy, 26(1), 35-42.
• Hopewell, S., Chan, A. W., Collins, G. S., Hróbjartsson, A., Moher, D., Schulz, K. F., ... & Boutron, I. (2025). CONSORT 2025 statement: updated guideline for reporting randomised trials. The Lancet, 405(10489), 1633-1640.

Study record dates

Study Major Dates

• Study Start (Actual): June 26, 2025
• Primary Completion (Actual): November 28, 2025
• Study Completion (Actual): December 29, 2025

Study Registration Dates

• First Submitted: December 29, 2025
• First Submitted That Met QC Criteria: March 9, 2026
• First Posted (Actual): March 10, 2026

Study Record Updates

• Last Update Posted (Actual): March 10, 2026
• Last Update Submitted That Met QC Criteria: March 9, 2026
• Last Verified: June 1, 2025

More Information

Terms related to this study

• Keywords: Mother-Infant Bonding; Mandala Coloring; Art-Based Intervention
• Other Study ID Numbers: 2025-YÖNP-0105

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: Individual participant data will not be shared due to confidentiality concerns and ethical restrictions specified in the ethics committee approval.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No