research
A mindfulness approach
to antenatal preparation
Abstract
This article describes a small exploratory workshop undertaken to
investigate the feasibility and acceptability of using a mindfulnessbased 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.
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, MindfulnessBased Childbirth and
Parenting Program,
Osher Center for
Integrative Medicine
University of California,
San Francisco, USA
Maret Dymond
Lead Clinical
Psychologist, Oxford
Mindfulness Centre
University of Oxford
194
I
mproved mental health and wellbeing is associated 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 government acknowledged that the foundations for lifelong 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 immediately 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, sleeplessness, 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
children (DH, 2010: 30; 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 noted that antenatal 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, encompassing the transition to parenthood, support for
fathers and peer support.
In 2007 Oxford maternity services began a
collaborative project with mental health service
British Journal of Midwifery • March 2012 • Vol 20, No 3
ISTOCKPHOTO
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-tomoderate 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
empirically 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 mindfulness as ‘the awareness that arises
from paying attention, on purpose, in the present
moment, and non-judgmentally.’
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. 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 depression (National Institute
for Health and Clinical Excellence (NICE), 2009).
Often one of the greatest challenges of childbirth 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 a 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
‘availability’ 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 to interrupt the escalation of
negative thinking that might compound pain or
depressed mood, and step out of the tendency to
be on autopilot, where painful emotions and reactions often go unnoticed and unaddressed.
British Journal of Midwifery • March 2012 • Vol 20, No 3
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.
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 foundation, 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, 2009a; 2009b; 2010). This approach also
provides support for the partner of the pregnant
women, treating the pregnant 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.
The Oxford group developed a funding
proposal for the Hospital Innovation Fund and
was successful in its bid to host an exploratory
195
research
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 postworkshop 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 practices 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
from Oxford, a midwife from Southampton, a clinical psychologist 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?’
Table 1. Post-workshop feedback received from
the lay attendees (n = 10)
Question
Yes
No
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
5
or comments for improving the
workshop?
5
More comfortable chairs
Move around more
Longer course
Local information on
mindfulness x2
196
Comments
All 10 attendees commented covering:
ll Managing pain
ll Acting not reacting
ll Listening
ll Not to over-analyze
ll Controlling fear
ll Communicating with partner
ll To be in the moment.
They were asked to provide any additional feedback 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 responses
included:
‘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’
‘Parents were given concrete tools to use
and it improved communication’
British Journal of Midwifery • March 2012 • Vol 20, No 3
research
‘How fear and pain can be broken down
into manageable pieces and learning
skills to cope with them’.
heightened awareness of the importance
of compassion towards the body and
mind and new ways in which I might
continue to work with this’
They were asked ‘What insights (if any) did you
gain about yourself during our time together?’ The
responses included:
‘Anxiety is an everyday facet of my
character’
‘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
‘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:
‘I have found the mindfulness techniques
to be indispensable in my daily life. My
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
Avoid
Recommend
with reservations
5
Highly
recommend
Recommend
Would you recommend this
programme to colleagues?
6
Table 3. Post-birth feedback received from lay attendees (n = 5)
1
Not at all
Question
2
3
Moderately
4
Reflecting back on the weekend workshop, how
helpful for labour and birth do you feel it was?
Mother
How helpful for labour and birth was anything you
learned for managing emotional states, such as
fear, during labour, birth or post-birth?
Mother
Father
1
How helpful for labour and birth was anything
you learned for managing the physical pain of
childbirth?
Mother
1
Father
1
1
How helpful has anything you learned in the
workshop been following the birth of your baby?
Mother
1
1
Would you recommend this workshop to others as
a way of preparing for birth and parenthood?
Yes
5
No
0
British Journal of Midwifery • March 2012 • Vol 20, No 3
5
Extremely
3
Father
2
3
Father
1
1
2
1
1
197
research
Key points
ll Mindfulness practices help participants to see more clearly the
patterns of the mind
ll Mindfulness practices are increasingly being used as way of managing
pain and reducing stress and anxiety
ll Mindfulness has the potential for parents preparing for childbirth to
reduce the risk of postpartum depression and increase ‘availability’ of
attention for the infant
ll Mindfulness 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
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 some
time-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 reflected 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 MindfulnessBased 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 preparation. In this way we hope to meet the aspirations
of the Midwifery 2020 Programme (2010) 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
198
through parenting education; and the opportunity
for midwives as coordinators of care to identify
BJM
vulnerable groups. Barlow J, Coe C, Redshaw M et al (2009) Birth and beyond:
Stakeholder perceptions of current antenatal education
provision in England. The Stationery Office, London
Black DS (2011) A brief definition of mindfulness.
Mindfulness Research Guide. www.mindfulexperience.
org (accessed 6 February 2012)
Department of Health (2007) National Service Framework
for Children Young People and Maternity Services.
Standard 11: Maternity Services. The Stationery Office,
London
Department of Health (2010) New Horizons – Confident
Communities, Brighter Futures: A Framework for
Developing Well-being. The Stationery Office, London
Department of Health (2011) No Health Without Mental
Health: Delivering Better Mental Health Outcomes for
People of All Ages. The Stationery Office, London
Duncan LG, Bardacke N (2009a) A pilot study of the
Mindfulness-Based Childbirth and Parenting education program: Preliminary evidence. Research forum
presented at the 7th Annual International Scientific
Conference for Clinicians, Researchers and Educators.
Worcester, MA
Duncan LG, Bardacke N (2009b) Improving pregnant
women’s well-being during the perinatal period:
Mixed-method results from a pilot study of an integrative stress reduction intervention. Poster presented
at the 2009 North American Research Conference on
Complementary and Integrative Medicine, Minneapolis,
MN
Duncan LG, Bardacke N (2010) Mindfulness-based childbirth and parenting education: Promoting mindfulness
to reduce stress during the perinatal period. J Child Fam
Stud 19(2): 190–202
Hughes A, Williams M, Bardacke N, Duncan LG, Dimidjian
S, Goodman SH (2009) Mindfulness approaches to
childbirth and parenting. BJM 17(10): 630–5
Kabat-Zinn J (1990) Full Catastrophe Living. Using the
Wisdom of Your Body and Mind to Face Stress, Pain and
Illness. Piatkus, London
Kabat-Zinn J (2005) Coming to Our Senses: Healing
Ourselves and the World Through Mindfulness.
Hyperion, New York NY
Kabat-Zinn J, Massion AO, Kristeller J et al (1992)
Effectiveness of a meditation-based stress reduction
program in the treatment of anxiety disorders. Am J
Psychiatry 149(7): 936–43
Marmot M (2010) Fair Society, Healthy Lives: Strategic
Review of Health Inequalities in England Post-2010
(The Marmot Review). http://www.marmotreview.org
(accessed 6 February 2012)
McMillan AS, Barlow J, Redshaw M (2009) Birth and
Beyond: A Review of the Evidence about Antenatal
Education. The Stationery Office, London
Midwifery 2020 Programme (2010) Midwifery 2020:
Delivering expectations. The Stationery Office, London
National Institute for Health and Clinical Excellence (2009)
Depression: the treatment and management of depression in adults. CG90. NICE, London
Patients Association (2011) Postnatal Depression Services:
An Investigation into NHS Service Provision. http://
tinyurl.com/cx928dk (accessed 6 February 2012)
British Journal of Midwifery • March 2012 • Vol 20, No 3