The 8-week Educational Program will be matched in duration, frequency, delivery method, and data collection to the MAAP intervention. Like MAAP, it will be delivered using a hybrid format (virtual Zoom and in person visits).

Sessions will be given in groups by an expert perinatal clinician/educator for all cohorts. Content will be "set" and delivered consistently across cohorts. Sessions will be audiotaped and rated for achievement of objectives and consistency of delivery. Deviations will be promptly addressed. Subject receipt will be monitored by attendance. Sessions will not include content on stress reduction (yoga, meditation, etc.). Classes will be given in the same setting as the MAAP intervention, at the same time but on a different evening, to avoid crossover (diffusion) of effects.

Depressive symptoms include feelings of sadness and loss of interest and can affect sleep, eating, anxiety, trouble concentrating, self-blame, and unexplained physical discomfort. These symptoms can cause difficulty with day to day activities including difficulty with maternal interactions with her infant and daily infant care. Postpartum depressive symptoms are depressive symptoms occurring during the postpartum time which has been defined as up to 4 weeks postpartum ranging to up to one year postpartum. Depressive symptoms will be measured with the Center for Epidemiologic Studies Depression Scale (CESD). The CESD is a self-report measure consisting of 20 depressive symptoms items and rated on a 4-point Likert Scale. Scores range from 0-60. Higher scores indicate more depressive symptoms. Scores >15 indicate elevated depressive symptoms. Cronbach's alpha = .87-91 in minority mothers of preterm infants.

Depressive symptoms include feelings of sadness and loss of interest and can affect sleep, eating, anxiety, trouble concentrating, self-blame, and unexplained physical discomfort. These symptoms can cause difficulty with day to day activities including difficulty with maternal interactions with her infant and daily infant care. Postpartum depressive symptoms are depressive symptoms occurring during the postpartum time which has been defined as up to 4 weeks postpartum ranging to up to one year postpartum. Depressive symptoms will be measured with the Center for Epidemiologic Studies Depression Scale (CESD). The CESD is a self-report measure consisting of 20 depressive symptoms items and rated on a 4-point Likert Scale. Scores range from 0-60. Higher scores indicate more depressive symptoms. Scores >15 indicate elevated depressive symptoms. Cronbach's alpha = .87-91 in minority mothers of preterm infants.

Depressive symptoms include feelings of sadness and loss of interest and can affect sleep, eating, anxiety, trouble concentrating, self-blame, and unexplained physical discomfort. These symptoms can cause difficulty with day to day activities including difficulty with maternal interactions with her infant and daily infant care. Postpartum depressive symptoms are depressive symptoms occurring during the postpartum time which has been defined as up to 4 weeks postpartum ranging to up to one year postpartum. Depressive symptoms will be measured with the Center for Epidemiologic Studies Depression Scale (CESD). The CESD is a self-report measure consisting of 20 depressive symptoms items and rated on a 4-point Likert Scale. Scores range from 0-60. Higher scores indicate more depressive symptoms. Scores >15 indicate elevated depressive symptoms. Cronbach's alpha = .87-91 in minority mothers of preterm infants.

Anxiety includes feelings of worry, nervousness, fear, unease, or excess uncertainty. State anxiety is a transient reaction directly related to an adverse situation and will be measured in this proposal. Maternal state anxiety will be measured with the state anxiety sub-scale of the State-Trait Anxiety Inventory (STAI). The state sub-scale consists of 20 items rated on a 4-point Likert scale and includes topics such as the degree to which the mother currently feels happy, calm, comfortable, jittery, upset, and confused. A higher score is associated with higher levels of anxiety. Cronbach's alphas .85-.95. Numerous reliability and validity studies of the STAI have been conducted with coefficients ranging from .16-.53, as would be expected, as the STAI is designed to be influenced by situational factors.

Anxiety includes feelings of worry, nervousness, fear, unease, or excess uncertainty. State anxiety is a transient reaction directly related to an adverse situation and will be measured in this proposal. Maternal state anxiety will be measured with the state anxiety sub-scale of the State-Trait Anxiety Inventory (STAI). The state sub-scale consists of 20 items rated on a 4-point Likert scale and includes topics such as the degree to which the mother currently feels happy, calm, comfortable, jittery, upset, and confused. A higher score is associated with higher levels of anxiety. Cronbach's alphas .85-.95. Numerous reliability and validity studies of the STAI have been conducted with coefficients ranging from .16-.53, as would be expected, as the STAI is designed to be influenced by situational factors.

Anxiety includes feelings of worry, nervousness, fear, unease, or excess uncertainty. State anxiety is a transient reaction directly related to an adverse situation and will be measured in this proposal. Maternal state anxiety will be measured with the state anxiety sub-scale of the State-Trait Anxiety Inventory (STAI). The state sub-scale consists of 20 items rated on a 4-point Likert scale and includes topics such as the degree to which the mother currently feels happy, calm, comfortable, jittery, upset, and confused. A higher score is associated with higher levels of anxiety. Cronbach's alphas .85-.95. Numerous reliability and validity studies of the STAI have been conducted with coefficients ranging from .16-.53, as would be expected, as the STAI is designed to be influenced by situational factors.

Postpartum post-traumatic stress is a type of stress affecting persons exposed to traumatic events. Elevated post-traumatic stress symptoms include 1) re-experiencing the event through thoughts, 2) avoidance of stimuli related to the event, and 3) increased arousal since the event. Post-traumatic stress symptoms after childbirth may be related to a traumatic childbirth experience or to a previous traumatic event in the mother's life. The Perinatal PTSD Questionnaire (PPQ) will measure the extent to which mothers experience post-traumatic stress symptoms in response to their birth experience. PPQ has 14 yes-no items that measure intrusive thoughts (e.g., bad dreams of giving birth), avoidance or numbing (e.g., inability to remember parts of the hospitalization), and increased arousal (e.g., increased irritability or anger). The "yes" answers are summed. Cronbach's alpha was .83 and test-retest reliability from 2 to 4 weeks was .92

Postpartum post-traumatic stress is a type of stress affecting persons exposed to traumatic events. Elevated post-traumatic stress symptoms include 1) re-experiencing the event through thoughts, 2) avoidance of stimuli related to the event, and 3) increased arousal since the event. Post-traumatic stress symptoms after childbirth may be related to a traumatic childbirth experience or to a previous traumatic event in the mother's life. The Perinatal PTSD Questionnaire (PPQ) will measure the extent to which mothers experience post-traumatic stress symptoms in response to their birth experience. PPQ has 14 yes-no items that measure intrusive thoughts (e.g., bad dreams of giving birth), avoidance or numbing (e.g., inability to remember parts of the hospitalization), and increased arousal (e.g., increased irritability or anger). The "yes" answers are summed. Cronbach's alpha was .83 and test-retest reliability from 2 to 4 weeks was .92

Postpartum post-traumatic stress is a type of stress affecting persons exposed to traumatic events. Elevated post-traumatic stress symptoms include 1) re-experiencing the event through thoughts, 2) avoidance of stimuli related to the event, and 3) increased arousal since the event. Post-traumatic stress symptoms after childbirth may be related to a traumatic childbirth experience or to a previous traumatic event in the mother's life. The Perinatal PTSD Questionnaire (PPQ) will measure the extent to which mothers experience post-traumatic stress symptoms in response to their birth experience. PPQ has 14 yes-no items that measure intrusive thoughts (e.g., bad dreams of giving birth), avoidance or numbing (e.g., inability to remember parts of the hospitalization), and increased arousal (e.g., increased irritability or anger). The "yes" answers are summed. Cronbach's alpha was .83 and test-retest reliability from 2 to 4 weeks was .92

Sleep disturbance includes difficulties falling asleep, staying asleep, and contributes to disease, impaired cognition, and poor quality of life. Sleep disturbances have been reported by many postpartum women and are associate with psycho-behavioral disturbances such as depressive symptoms. Maternal sleep quality will be measured by the Pittsburgh Sleep Quality Inventory (PSQI). The PSQI is a 19 question self-rated questionnaire which assesses sleep quality, has a global score of 0-21, and has 7 sub-scales. Higher scores indicate worse sleep quality. A PSQI score >5 yielded a sensitivity of 89.6% and a specificity of 86.5% in distinguishing good and poor sleepers. Internal consistency is .76-.83 and in perinatal women Cronbach's alpha ranges are .72-.78.

Sleep disturbance includes difficulties falling asleep, staying asleep, and contributes to disease, impaired cognition, and poor quality of life. Sleep disturbances have been reported by many postpartum women and are associate with psycho-behavioral disturbances such as depressive symptoms. Maternal sleep quality will be measured by the Pittsburgh Sleep Quality Inventory (PSQI). The PSQI is a 19 question self-rated questionnaire which assesses sleep quality, has a global score of 0-21, and has 7 sub-scales. Higher scores indicate worse sleep quality. A PSQI score >5 yielded a sensitivity of 89.6% and a specificity of 86.5% in distinguishing good and poor sleepers. Internal consistency is .76-.83 and in perinatal women Cronbach's alpha ranges are .72-.78.

Sleep disturbance includes difficulties falling asleep, staying asleep, and contributes to disease, impaired cognition, and poor quality of life. Sleep disturbances have been reported by many postpartum women and are associate with psycho-behavioral disturbances such as depressive symptoms. Maternal sleep quality will be measured by the Pittsburgh Sleep Quality Inventory (PSQI). The PSQI is a 19 question self-rated questionnaire which assesses sleep quality, has a global score of 0-21, and has 7 sub-scales. Higher scores indicate worse sleep quality. A PSQI score >5 yielded a sensitivity of 89.6% and a specificity of 86.5% in distinguishing good and poor sleepers. Internal consistency is .76-.83 and in perinatal women Cronbach's alpha ranges are .72-.78.

Fatigue is extreme tiredness resulting from mental or physical exertion. Symptoms of fatigue include tiredness, headache, aching/sore muscles, impaired decision-making and judgement, moodiness, and irritability. Fatigue has been reported in many postpartum women and is associate with psycho-behavioral disturbances. Maternal fatigue will be measured by the Multidimensional Fatigue Symptom Inventory Short Form (MFSI-SF). MFSI-SF is a 14 item self-report instrument that measure severity, frequency, and patterns of fatigue. The MFSI provides a score for overall fatigue in 5 domains (general, emotional, physical, mental, vigor). Factor analysis shows good fit and internal consistency ranges from .87-.96

Fatigue is extreme tiredness resulting from mental or physical exertion. Symptoms of fatigue include tiredness, headache, aching/sore muscles, impaired decision-making and judgement, moodiness, and irritability. Fatigue has been reported in many postpartum women and is associate with psycho-behavioral disturbances. Maternal fatigue will be measured by the Multidimensional Fatigue Symptom Inventory Short Form (MFSI-SF). MFSI-SF is a 14 item self-report instrument that measure severity, frequency, and patterns of fatigue. The MFSI provides a score for overall fatigue in 5 domains (general, emotional, physical, mental, vigor). Factor analysis shows good fit and internal consistency ranges from .87-.96

Fatigue is extreme tiredness resulting from mental or physical exertion. Symptoms of fatigue include tiredness, headache, aching/sore muscles, impaired decision-making and judgement, moodiness, and irritability. Fatigue has been reported in many postpartum women and is associate with psycho-behavioral disturbances. Maternal fatigue will be measured by the Multidimensional Fatigue Symptom Inventory Short Form (MFSI-SF). MFSI-SF is a 14 item self-report instrument that measure severity, frequency, and patterns of fatigue. The MFSI provides a score for overall fatigue in 5 domains (general, emotional, physical, mental, vigor). Factor analysis shows good fit and internal consistency ranges from .87-.96

Mindfulness is a mental state of focusing one's awareness on the present moment, acknowledging/accepting one's mental feelings, physical feelings, and thoughts. The Five Facets of Mindfulness Questionnaire (FFMQ) will be used to assess mindfulness. These facets include: observing,describing, acting with awareness, non-judging of inner experience, non-reactivity to inner experience. The FFMQ utility with African American samples is established with an internal consistency range of .60-.86

Mindfulness is a mental state of focusing one's awareness on the present moment, acknowledging/accepting one's mental feelings, physical feelings, and thoughts. The Five Facets of Mindfulness Questionnaire (FFMQ) will be used to assess mindfulness. These facets include: observing,describing, acting with awareness, non-judging of inner experience, non-reactivity to inner experience. The FFMQ utility with African American samples is established with an internal consistency range of .60-.86

Mindfulness is a mental state of focusing one's awareness on the present moment, acknowledging/accepting one's mental feelings, physical feelings, and thoughts. The Five Facets of Mindfulness Questionnaire (FFMQ) will be used to assess mindfulness. These facets include: observing,describing, acting with awareness, non-judging of inner experience, non-reactivity to inner experience. The FFMQ utility with African American samples is established with an internal consistency range of .60-.86

Inflammatory theories posit that stressful experiences stimulate the release of pro-inflammatory cytokines, which signal the brain to engender depressive behaviors. Saliva cytokine changes occur during pregnancy to ensure fetal development and maternal health. Pro-inflammatory cytokines will be assessed through saliva levels. IL-6 and TNF-alpha will be measured via ELISA assay. Samples will be run in duplicate. Sensitivity is < 0.7 pg/ml for IL-6, and <3.9 pg/ml for TNF-alpha. Intra assay variability is <7%.

Inflammatory theories posit that stressful experiences stimulate the release of pro-inflammatory cytokines, which signal the brain to engender depressive behaviors. Saliva cytokine changes occur during pregnancy to ensure fetal development and maternal health. Pro-inflammatory cytokines will be assessed through saliva levels. IL-6 and TNF-alpha will be measured via ELISA assay. Samples will be run in duplicate. Sensitivity is < 0.7 pg/ml for IL-6, and <3.9 pg/ml for TNF-alpha. Intra assay variability is <7%.

Oxytocin is essential to the initiation of nurturing maternal behaviors and bonding between mother and child. Oxytocin release promotes actions relating to the development of social attachments. Low levels of oxytocin are linked to less touch between mothers and infants; whereas high levels of oxytocin are associated with increased gaze, vocalization, positive affect, and touch. Saliva oxytocin will be analyzed using an ELISA. Oxytocin detection levels are 15.6 pg/ml to 1000 pg/ml with sensitivity as low as 11.7 pg/ml. Intra-assay coefficient of variability range from 5-10% with an inter-assay coefficient of variability of 4.6% to 8.6%.

Oxytocin is essential to the initiation of nurturing maternal behaviors and bonding between mother and child. Oxytocin release promotes actions relating to the development of social attachments. Low levels of oxytocin are linked to less touch between mothers and infants; whereas high levels of oxytocin are associated with increased gaze, vocalization, positive affect, and touch. Saliva oxytocin will be analyzed using an ELISA. Oxytocin detection levels are 15.6 pg/ml to 1000 pg/ml with sensitivity as low as 11.7 pg/ml. Intra-assay coefficient of variability range from 5-10% with an inter-assay coefficient of variability of 4.6% to 8.6%.

Oxytocin is essential to the initiation of nurturing maternal behaviors and bonding between mother and child. Oxytocin release promotes actions relating to the development of social attachments. Low levels of oxytocin are linked to less touch between mothers and infants; whereas high levels of oxytocin are associated with increased gaze, vocalization, positive affect, and touch. Saliva oxytocin will be analyzed using an ELISA. Oxytocin detection levels are 15.6 pg/ml to 1000 pg/ml with sensitivity as low as 11.7 pg/ml. Intra-assay coefficient of variability range from 5-10% with an inter-assay coefficient of variability of 4.6% to 8.6%.