The work presented in this Module is partly inspired by the Mindfulness Based Childbirth Education Pilot study conducted by Jean Byrne PhD and researchers at Curtin University and The University of Western Australia in Perth Australia. The results of this unique study resulted in these academic publications:
The intervention – Mindfulness-Based Child Birth Education (MBCE) – was a novel combination of mindfulness meditation and antenatal education that aims to integrate a skills-based antenatal education program with Mindfulness Based Stress Reduction (MBSR), a widely validated group intervention. The protocol focused on the skills of evidence-based decision-making and mindfulness. Involvement in decision-making is a key component in maternal satisfaction with birth. Therefore MBCE aimed to assist women and their partners by practicing communication and decision-making skills in order to feel actively involved in pregnancy, birth and early parenting, thereby increasing their self- efficacy. At the same time, practicing mindfulness meditation aimed to improve their mental health, by reducing stress, anxiety, depression and fear of birth.
MBCE was designed to take advantage of the latest research to provide an innovative approach to antenatal education and care where the focus is on mental health, resilience and protective factors rather than clinical treatment. The focus was on: learning to manage labour pain more effectively; limiting the negative effects of unhelpful thoughts; learning ways to communicate with caregivers in order to feel involved in the decision-making process during pregnancy, birth and early parenting; learning how to make informed decisions; identifying fears regarding birth and parenting and identifying effective ways to work with and overcome those fears; identifying values and expectations of birth and working towards a positive birth experience. We believe these specific benefits are likely to result in the more generalized benefits of improving emotional functioning and wellness in pregnancy, which are likely to have beneficial flow-on effects for postnatal and infant health.
The research priorities for this project were twofold: to improve the mental health of women and their birth support person and increase resilience and emotional functioning during pregnancy and early parenting (which will have numerous flow on benefits for parents, infants/children, families and the community in general). Recent research suggests that women and their birth support person are not gaining the necessary skills they need during.
Childbirth education classes to prepare them for birth or early parenting (Renkert & Nutbeam, 2001). In order to improve outcomes for mothers and families mental health promotion and health literacy must be central to ante natal education, so that women and their birth support person leave classes with the skills and confidence to make informed and evidence-based decisions regarding their pregnancy and birth (Nolan, 1997; Renkert & Nutbeam, 2001). Furthermore, a health literacy approach to antenatal education will arguably improve women’s satisfaction with their care during pregnancy and birth.
Antenatal programs do not traditionally offer stress reduction techniques to pregnant women and their birth support person, even though research suggests that stress and anxiety during pregnancy contribute to: lower birth weight, shorter gestation and emotional and behavioural problems in children (O’Connor, Heron, Golding, Beveridge, & Glover, 2002; Rini, Dunkel- Schetter, Wadhwa, & Sandman, 1999; Talge, Neal, & Glover, 2007). Due to the demonstrated long term effects of stress during pregnancy on children, research into programs to reduce maternal stress in pregnancy seems warranted and indeed would contribute to best practice in health promotion during pregnancy (van den Bergh, Mulder, Mennes, & Glover, 2005).
Mental Health initiatives are necessary during pregnancy due to the negative consequences antenatal depression and postnatal depression has for mothers, infants, children and families. However skills-based antenatal programs have not been determined a sufficient protective factor in the development of postnatal depression (Brugha et al., 2000). Since strong evidence links mindfulness to the prevention of depressive relapse and stress reduction
this program unites two disparate fields of evidence-based practice (skills based education & mindfulness) in order to improve emotional functioning and wellbeing in pregnancy. Additionally, given that paternal depression or stress is linked to excessive infant crying, best practice in antenatal education must encourage the participation of fathers / partners.
Further, research shows that Australian women are largely dissatisfied with their care during labour and childbirth (Brown & Lumley, 1994). Maternal dissatisfaction stems from a sense that for these women labour happens to them, rather than with them (Dannenbring, Stevens, & House, 1997; Simkin, 1992; Waldenstrom, 1999). This suggests that many women are not equipped for the experience of pregnancy and birth. Studies show that much of what women hear from friends and family hinders, rather than improves their experience of pregnancy, childbirth and early parenting (Savage, 2006). This is of particular concern given that Australia is currently experiencing a relatively high birth rate compared to the falling birth rates of the last forty years (Drago, Sawyer, Sheffler, Warren, & Wooden, 2009).
Studies have shown that promoting maternal satisfaction is tied to facilitating women in developing a greater ability to access relevant information to make informed choices, rather than simply giving consent to decisions relevant to their pregnancy or birth (Halldorsdottir & Karlsdottir, 1996; Hallgren, Kihlgren, Norberg, & Forslin, 1995; Wilcox, Kobayashi, & Murray, 1997). It has been suggested that rather than gaining access to factual information regarding pregnancy and birth, women need to be equipped with the communication and decision making skills that might enhance their ability to feel part of the experience of labour (Savage,2006). Similarly, it has been recognized that existing childbirth education classes do not adequately equip women with information and skills that are important in early parenting (Fabian, Radestad, & Waldenström, 2005). Therefore, the evolution of a more beneficial form of childbirth education will likely involve a shift towards skills-based approaches (Renkert & Nutbeam, 2001; Savage, 2006).
In addition to neglecting skills acquisition, traditional childbirth education does not actively promote prenatal mental health, both of expectant mothers and their birth support partners. This is of concern due to the relationship between prenatal mental health and both postnatal maternal outcomes and foetal development. For example, maternal mood during pregnancy (27-28 weeks), as observed by ultrasound, has been shown to impact on foetal behaviour (van den Bergh et al., 2005). Similarly, there is a strong correlation between maternal and foetal cortisol levels (Talge et al., 2007). Stress is also associated with shorter gestation periods, low birth weight and is a risk factor for delay in mental and motor development in infants (Huizink, Robles de Medina, Mulder, Visser, & Buitelaar, 2003). Longitudinal studies have also highlighted the negative behavioural impacts on children of maternal stress during pregnancy (Talge et al., 2007). Furthermore, paternal mood during pregnancy has been linked to excessive infant crying (van den Berg et al., 2009). Given these findings, it appears childbirth education should not only emphasise a skills-based approach, but involve mental health promotion for both expectant mothers and their partners.
One approach that holds significant promise in promoting psychological resiliency during pregnancy is the use of mindfulness-based interventions. Mindfulness involves the cultivation of moment- to-moment awareness of experience with a non-judgmental attitude (Bishop et al., 2004). Mindfulness- based interventions have been shown to be beneficial for such conditions as stress (Kabat-Zinn, 1990; Shigaki, Glass, & Schopp, 2006), anxiety disorders (Miller, Fletcher, & Kabat-Zinn, 1995), chronic pain (Kabat-Zinn, Lipworth, & Burney, 1985; Teixeira, 2008), and emotional dysregulation (Samuelson, Carmody, Kabat-Zinn, & Bratt, 2007), amongst others. A meta-analysis of 64 empirical studies found that one such intervention, Mindfulness-Based Stress Reduction (MBSR), has significant health benefits for a broad range of clinical and non-clinical populations, with a significant effect size of d = 0.5 (Grossman, Niemann, Schmidt, & Walach, 2004). The effectiveness of mindfulness therapies in preventing depressive relapse has also been replicated in several controlled trials (Ma & Teasdale, 2004; Segal, Williams, & Teasdale, 2002; Teasdale et al., 2000; Williams, Duggan, Crane, & Fennell, 2006). More pertinently, one recent pilot study of a mindfulness-based prenatal intervention showed significant increases in positive affect, along with decreases in pregnancy anxiety, depression and negative affect (Duncan & Bardacke, 2009). There is therefore a substantial body of literature attesting to the benefits of mindfulness-based interventions in treating and preventing psychological dysfunction in a broad spectrum of people. This suggests that cultivating mindfulness may have significant mental health benefits for prenatal women and their partners, with at least one recent pilot providing evidence for this.