A mindfulness approach to antenatal preparation

Abstract

This article describes a small exploratory workshop undertaken to investigate the feasibility and acceptability of using a mindfulness-based approach to antenatal childbirth education. Good mental health and wellbeing, and not simply the absence of mental illness, have been shown to result in health, social and economic benefits for individuals, communities and populations (Department of Health, 2011). Mindfulness practices are increasingly being used as a way of managing pain, reducing stress and anxiety and have the potential to help parents preparing for childbirth to reduce the risk of postpartum depression and increase ‘availability’ of attention for their baby. As mindfulness practices help participants to see more clearly the patterns of the mind, it helps both to halt the escalation of negative thinking that might compound pain or depressed mood, and deals with the tendency to be on autopilot. This small pilot workshop received a remarkably positive response and showed that the training was acceptable to couples and midwives in the UK context.

Full text

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British Journal of Midwifery • March 2012 • Vol 20, No 3
research
A mindfulness approach
to antenatal preparation
Improved mental health and wellbeing is asso-
ciated with a range of better outcomes for
people of all ages and backgrounds, and in its
strategy paper ‘No health without mental health’
(Department of Health (DH). 2011), the govern-
ment acknowledged that the foundations for life-
long wellbeing are already being laid down before
birth. This echoes the Marmot review (2010) which
recognized that not only the physical but the
mental and emotional health of a woman while
pregnant and in her infant’s early years will have a
lifelong effect (Marmot, 2010: 22):
‘Giving every child the best start in life
is crucial to reducing health inequalities
across the life course. The foundations
for virtually every aspect of human
development—physical, intellectual and
emotional—are laid in early childhood.
What happens during these early years
(starting in the womb) has lifelong
effects on many aspects of health and
well-being— from obesity, heart disease
and mental health, to educational
achievement and economic status’.
This is important, for although mental health
is key at all stages of life, we know that women
are particularly vulnerable during and immedi-
ately after pregnancy, with one in ten women
being affected by postnatal depression (DH, 2007;
Patients Association, 2011). Postnatal depression
is similar to depression at other times, involving
low mood and affecting a mother’s ability to look
after herself or her baby. Infant sleep routines and
a baby’s cries for attention and care may become
difficult to cope with, along with other symptoms
such as loss of appetite, irritability, sleepless-
ness, lack of energy, self blame and terminating
breastfeeding early (Patients Association, 2011).
It is well documented that this unrecognized and
untreated distress can have long-term implications
for bonding, attachment and outcomes for chil-
dren long-term (DH, 2010: 3; DH, 2011: 10):
‘Maternal health during pregnancy
and the child–parent relationship
during the first few years of life have
a very significant influence on brain
architecture, lifelong habits and
patterns for dealing with life and
adversity, and future mental health and
well-being’
‘A mother’s mental health during
pregnancy is an important factor in
determining the child’s mental health.
Better maternal mental health is
associated with better outcomes for the
child, including better relationships,
improved learning and academic
achievement, and improved physical
health’.
In addition, the ‘Birth and Beyond’ reports
(Barlow et al, 2009; McMillan et al, 2009) prepared
for the Department of Health note that ante-
natal education provision is ‘seriously inadequate’
and ‘midwives are inadequately prepared and
supported in this role’. They concluded that UK
antenatal education materials and methods
urgently need updating and researching, encom-
passing the transition to parenthood, support for
fathers and peer support.
In 2007 Oxford maternity services began a
collaborative project with mental health service
Abstract
This article describes a small exploratory workshop undertaken to
investigate the feasibility and acceptability of using a mindfulness-
based approach to antenatal childbirth education. Good mental health
and wellbeing, and not simply the absence of mental illness, have been
shown to result in health, social and economic benefits for individuals,
communities and populations (Department of Health, 2011). Mindfulness
practices are increasingly being used as a way of managing pain,
reducing stress and anxiety and has the potential for parents preparing
for childbirth to reduce the risk of postpartum depression and increase
‘availability’ of attention for their baby. As mindfulness practices help
participants to see more clearly the patterns of the mind, it helps both
to halt the escalation of negative thinking that might compound pain
or depressed mood, and deals with the tendency to be on autopilot.
This small pilot workshop received a remarkably positive response and
showed that the training was acceptable to couples and midwives in the
UK context.
Sian Warriner
Consultant Midwife
John Radcliffe Hospital
Oxford
Mark Williams
Professor of Clinical
Psychology, University
of Oxford, Department
of Psychiatry, Oxford
Nancy Bardacke
Assistant Clinical
Professor, Mindfulness-
Based Childbirth and
Parenting Program,
Osher Center for
Integrative Medicine
University of Califoria,
San Franciso, USA
Maret Dymond
Lead Clinical
Psychologist, Oxford
Mindfulness Centre
University of Oxford

28 British Journal of Midwifery • March 2012 • Vol 20, No 3
research
providers, health visitors, GPs and commissioners
which has resulted in an improved perinatal service
that offers support to pregnant and new mothers,
with not only acute but also ongoing mild-to-
moderate mental health problems. Through this
initial work the possibility of exploring the role of
‘mindfulness’ in improving perinatal services and
supporting women who may have suffered previous
postnatal depression or traumatic birth arose.
Mindfulness
Mindfulness is now widely considered to be an
inherent quality of human consciousness. That is, a
capacity of attention and awareness oriented to the
present moment, that varies in degree within and
between individuals, and can be assessed empiri-
cally and independent of religious, spiritual, or
cultural beliefs (Black, 2011). One of the most well-
recognized Western definitions of mindfulness
comes from Kabat-Zinn (2005) who defined mind-
fulness as ‘the awareness that arises from paying
attention, on purpose, in the present moment, and
non-judgmentally.’
Mindfulness can be cultivated through medi-
tation practice and increases engagement with
the present moment, allowing for a clearer under-
standing of how thoughts and emotions can impact
our health and quality of life. Mindfulness-based
approaches in healthcare began in the USA with
Kabat-Zinn’s pioneering Mindfulness-Based Stress
Reduction (MBSR) programme at the University
of Massachusetts Medical Center. Subsequent
research investigating participants with chronic
pain (Kabat-Zinn, 1990) and participants with
anxiety documented the effectiveness of this
approach (Kabat-Zinn et al, 1992). Mindfulness
meditation in the form of Mindfulness-Based
Cognitive Therapy (MBCT), is now a recognized
way of reducing the risk of recurrence in depres-
sion (National Institute for Health and Clinical
Excellence (NICE), 2009).
Often one of the greatest challenges of child-
birth for a pregnant woman is learning how to
work with pain and the anxiety that fear of pain
can cause. Mindfulness meditation is increasingly
being used as way of managing pain and reducing
stress and anxiety. It also has the potential for
parents preparing for childbirth to reduce the risk
of postpartum depression and increase the ‘avail-
ability’ of attention for their baby (Hughes et al,
2009). As mindfulness practices help participants
see more clearly the patterns of their mind, it helps
them both interrupt the escalation of negative
thinking that might compound pain or depressed
mood, and step out of the tendency to be on auto-
pilot, where painful emotions and reactions often
go unnoticed and unaddressed.
Oxford Mindfulness project
In November 2009 an 8-week introductory course
in mindfulness for midwives and health visitors
was facilitated by Professor Mark Williams of the
University of Oxford. Following on from this, the
possibility of applying a ‘mindfulness’ approach
to antenatal preparation for birth began to be
explored by professionals from Oxford maternity
services, Oxford University’s Mindfulness Centre
and Oxford’s child and adolescent mental health
services.
It was recognized that the Mindfulness-Based
Childbirth and Parenting (MBCP) programme
developed by Nancy Bardacke (nurse-midwife,
mindfulness teacher and Assistant Clinical
Professor, Osher Center for Integrative Medicine
and Department of Family Healthcare Nursing,
University of California, San Francisco) in the
USA, that uses Kabat-Zinn’s work as its founda-
tion, provided the authority on mindfulness-based
antenatal preparation for birth and parenting. Ms.
Bardacke’s work, focusing particularly on how
to use mindfulness skills for the stress, fear and
pain that often surround childbirth and parenting
has shown a great deal of promise (Duncan and
Bardacke, 2009; 2010).
This approach also provides support for the
partner of the pregnant women, treating the preg-
nant woman and her partner as equal participants
in the programme, teaches skills to navigate the
transition to parenthood and fosters supportive
peer groups as called for by the Department of
Health.
Mindfulness can be cultivated through meditation practice and increases engagement
with the present moment, allowing for a clearer understanding of how thoughts and
emotions can impact our health and quality of life.

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British Journal of Midwifery • March 2012 • Vol 20, No 3
research
The Oxford group developed a funding
proposal for the Hospital Innovation Fund and
was successful in its bid to host an exploratory
antenatal mindfulness workshop for midwives and
expectant couples facilitated by Nancy Bardacke to
run over 5 days in April 2011.
The workshop
The weekend workshop was attended by both
expectant parents and professionals. There was
an additional pre-workshop briefing day and a
post-workshop round-up session for professionals
only.The briefing day provided an opportunity for
the professionals to meet Nancy Bardacke and
gain an understanding of the mindfulness prac-
tices and skills taught in the MBCP programme
that they would be participating in during the
weekend workshop. The professionals who
attended included five midwives from Oxford,
a consultant nurse from Child and Adolescent
Mental Health Services (CAMHS) from Oxford,
a midwife from Southampton, a clinical psychol-
ogist from Southampton University, a professor
in midwifery from Germany, an antenatal yoga
teacher from Sweden and a mindfulness teacher
from the Oxford Mindfulness Centre.
The workshop was advertised locally through
the community midwifery service and nine couples
registered for the course. Eight couples attended
the Friday evening introduction with six couples
returning for the Saturday and Sunday full day
workshop. One couple who registered was unable
to attend for medical reasons and two couples did
not return after the Friday introduction because
they felt the course was not for them.
Evaluation
Lay attendees (the couples)
Post-workshop forms were received from 10 of
the 12 lay attendees, with results shown in Table 1.
Attendees were also asked, ‘What was the most
important thing you learned over the weekend?’ All
10 attendees commented covering:
lManaging pain
lActing not reacting
lListening
lNot to over-analyze
lControlling fear
lCommunicating with partner
lTo be in the moment.
They were asked to provide any additional feed-
back and seven comments received:
‘Great weekend, I wasn’t sure at first,
but I’m glad I came. I have learnt a lot
and will be sharing the knowledge I have
gained with my pregnant friends’
‘Totally blown away; skills for life’
‘Just a massively helpful weekend that
will have impact for a long time’
‘Thank you; amazing course and feel
moved to have been part of it’
‘Thank you before I came I was so fearful
of giving birth. I have been given tools I
need to change my thought process and
the group has been supportive’
‘I have struggled to deal with my
emotions in a controlled way … I now
feel I can’
‘Venue, good excellent. Interaction with
other attendees very useful and it was fun’.
Professionals
Post-workshop forms were received from 6 of the
10 professional attendees with the results shown in
Table 2. Attendees were also asked ‘What was your
most important insight about the value of teaching
mindfulness to expectant parents?’:
‘The idea that it is a lifelong skill that
can be adapted in many situations
besides parenting and passed on
throughout the family’
‘The impact it can have on a couple’s
relationship in such a short space of
time and how it can foster and nourish
closeness between people so quickly’
Table 1. Post-workshop feedback received from
the lay attendees (n = 10)
Question Yes No Comments
Was this weekend workshop
useful to you?
10 0
Would you recommend this
workshop to others?
10 0
Was there anything else you
would have liked covered?
2 8 Wanting to be able to take the
course further locally x2
Do you have any suggestions
or comments for improving the
workshop?
5 5 More comfortable chairs
Move around more
Longer course
Local information on
mindfulness x2

30 British Journal of Midwifery • March 2012 • Vol 20, No 3
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‘Parents were given concrete tools to use
and it improved communication’
‘How fear and pain can be broken down
into manageable pieces and learning
skills to cope with them’.
They were asked ‘What insights (if any) did you
gain about yourself during our time together?’ The
responses included:
‘That I sometimes struggle to be
motivated due to negative thoughts,
fear of failure, or not being good
enough!’
‘How much time my mind is not in the
present’
‘Many! I became more aware of some of
the subtle differences between lack of
skill/knowledge and lack of confidence
and how self-compassion is linked to
this. I learnt on a deeper level about
connectedness, energy and the need to
invest my energy wisely. I also gained a
heightened awareness of the importance
of compassion towards the body and
mind and new ways in which I might
continue to work with this’
‘Anxiety is an everyday facet of my
character’
‘How little attention I pay to the here
and now; how thinking about what
might happen leads to increased stress
rather than dealing with things as they
arise; how the mind and body interact
not always for the best.’
Post-birth evaluation from the lay
attendees
Post-birth evaluation forms were received from 5 of
the 12 lay attendees (Table 3). Additional feedback
included the following comments:
Table 3. Post-birth feedback received from lay attendees (n = 5)
Question
1
Not at all
2 3
Moderately
4 5
Extremely
Reflecting back on the weekend workshop how
helpful for labour and birth do you feel it was?
Mother 3
Father 2
How helpful for labour and birth was anything you
learned for managing emotional states, such as
fear, during labour, birth or post-birth?
Mother 3
Father 1 1
How helpful for labour and birth was anything
you learned for managing the physical pain of
childbirth?
Mother 1 2
Father 1 1
How helpful has anything you learned in the
workshop been following the birth of your baby?
Mother 1 1 1
Father 1 1
Would you recommend this workshop to others as
a way of preparing for birth and parenthood?
Yes 5
No 0
Table 2. Post-workshop feedback received from professional attendees (n = 6)
Question
1
Not at all
2 3
Moderately
4 5
Extremely
Was the content interesting? 6
Was the content useful? 6
Was the teaching experience
well-structured?
1 5
Avoid
Recommend
with reservations Recommend
Highly
recommend
Would you recommend this
programme to colleagues?
6

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‘I have found the mindfulness techniques
to be indispensable in my daily life. My
self awareness has increased and I am
able to manage my stress level which is
invaluable with a young baby. During
c section, my husband kept reminding
me to do my breathing and it has
become our cue for identifying when
I need sometime out. Even our baby
responds if I practice mindful breathing
whilst holding him. Quite often it will
be enough to calm him down from a
screaming fit’
‘Due to our previous experience I found
aspects of the course very difficult ...
I found the course quite emotionally
difficult. It wasn’t until I ref lected on
the weekend and used the techniques in
labour that I realised how important it
was. I am sure without the techniques
of mindfulness I learnt I would have
found labour much harder and more
frightening than I actually did. I am now
very glad that I attended and am trying
to use the techniques as a parent’.
Moving forward
As a result of the positive impact of the workshop,
the Oxford Mindfulness Centre has appointed a
part-time psychologist for 18 months to facilitate
the development of a formal 9-week Mindfulness-
Based Childbirth and Parenting programme. The
Maternity Service at the John Radcliffe Hospital
will continue to collaborate with The Oxford
Mindfulness Centre in this innovative work and
plans to train a number of midwives over the next
2 years to deliver mindfulness antenatal prepara-
tion. In this way we hope to meet the aspirations
of Midwifery 2020 which identified three areas as
key to the future role of midwives: reducing the
social gradient through promoting wellbeing and
preventing ill health; enabling children to have the
best start in life through parenting education; and
the opportunity for midwives as coordinators of
care to identify vulnerable groups. BJM
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Key points
lMindfulness practices help participants to see more clearly the
patterns of the mind
lMindfulness practices are increasingly being used as way of managing
pain and reducing stress and anxiety
lMindfulness has the potential for parents preparing for childbirth to
reduce the risk of postpartum depression and increase ‘availability’ of
attention for the infant
lMindfulness practices could contribute to the aspirations of Midwifery
2020 through promoting wellbeing and preventing ill health and
enabling children to have the best start in life through parenting
education