Mindfulness-Based Childbirth and Parenting
for the reduction of perinatal anxiety in
pregnant women
Master thesis Orthopedagogiek
Pedagogische en Onderwijskundige Wetenschappen Universiteit van Amsterdam
S.L. van Berge
First supervisor: Dr. E.I. de Bruin Second supervisor: I. Veringa, Msc. Amsterdam, January, 2015
Index
Acknowledgements...3
Abstract...4
Introduction5 Prevalence and effects of perinatal anxiety...5
Prevalence and effects of perinatal stress...6
Mindfulness...7
Mindfulness-Based Childbirth and Parenting...9
Current study...10
Method...11
Participants...11
Procedure...11
Inclusion- and Exclusion criteria...12
Study design...12
Treatment...12
Measurements ...14
Statistical Analysis...18
Results...19
Direct treatment effects...19
Midterm treatment effects...20
Partial correlations...23 Discussion...26 Limitations...29 Future research...30 Conclusion...30 References...31
Acknowkledgements
First and foremost, I would like to thank my supervisor dr. Esther de Bruin for her support and guidance in the process of writing this theses. I would also like to thank my second supervisor Irena Veringa, Msc. for her support and for letting me participate in a Mindfulness-Based Childbirth and Parenting training. This let me fully experience the effects of the
training and helped me enrich my knowledge about mindfulness.
Third, I thank my parents for their unconditional mental support and finally, I would like to thank all the MBCP participants, without them this could not have happened.
Abstract
This pilot-study evaluated the effectiveness of the 9-week Mindfulness-Based Childbirth and Parenting program as a treatment for perinatal anxious pregnant women (n = 10). Progress was measured through questionnaires in a pre-, post- and follow-up design, which covered the domains of perinatal anxiety, general anxiety and stress, mindful awareness and
self-compassion. Direct treatment effects showed a significant decrease in fear of childbirth, catastrophizing about labor pain and a significant increase in mindful awareness. Mid-term treatment effects showed again a significant decrease in fear of childbirth, general anxiety and a significant increase the mindfulness facets describing and being non-judgmental.
Furthermore, an increase in mindful awareness from pre- to post-test was significantly negatively related to a decrease in perinatal anxiety from pre- to post-test. This relationship was also found from pretest to follow-up. Last, an increase in mindful awareness from pre- to post-test was significantly negatively related to a decrease in catastrophizing about labor pain from pre- to post-test. In conclusion, the findings in this study support the potential
effectiveness of the MBCP program as a clinical intervention for perinatal anxious pregnant women. Further research should contain a larger sample size, a randomized controlled trial and have data of the partners included.
Introduction
Pregnancy is usually the beginning of a joyful period. Whether it is the first or third child, most expectant parents experience pregnancy as an exciting and intense journey. Despite the joy of being expectant parents, pregnancy can also be both emotionally and physically challenging. One can be rushed into different kinds of positive and negative emotions. Negative emotions like anxiety and stress are usually manageable up to a certain extent (Terry, 1991; Saisto & Halmesmäki, 2003). However, when these perinatal emotions, like anxiety and stress, become severe and cause a certain amount of distress, they could be harmful for both mother and child (Hogue & Bremner, 2005). At the same time the expectant mother has to deal with severe bodily changes. Saisto and Halmesmäki (2003) argue that primarily these physical and emotional changes cause anxiety and stress in pregnant women (Austin & Leader, 2000; Nonacs & Cohen, 2003).
Anxiety during pregnancy and childbirth is called perinatal anxiety and is manifested in fear of childbirth, anxiety for the pain during childbirth and fear that something bad will happen to the baby and/or mother (Saisto & Halmesmäki, 2003). Research shows that fear of childbirth is a very common feeling during pregnancy. In the Netherlands, approximately 47% of first time mothers rapport to be fearful of childbirth. Within this fear of childbirth, 38% of all pregnant women, fearlabor pain most (DELIVER, 2011). Experiencing severe perinatal anxiety as well as having general anxiety during pregnancy can have a negative effect on the perinatal period. For example, according to Nilsson, Lundgren, Karlström and Hildingsson (2012) fear of childbirth can be associated with negative birth experiences. In this study, one year after giving birth, women still reported the childbirth as a negative experience. They also found fear of childbirth to be associated with an emergency caesarean section. In addition to these findings, Andersson, Sundström-Poromaa, Wulff, Åström and Bixo (2004) and Nieminen, Stephansson and Ryding (2009) state that women with perinatal anxiety are more likely to have an elective caesarean section and epidural anesthesia. Hofberg & Ward (2004) found that having a negative birth experience plays a crucial role in postnatal depression and developing symptoms of posttraumatic stress disorder (PTSD).
Alongside the negative perinatal effects on mothers and childbirth outcomes, anxiety during pregnancy can also have negative effects after childbirth. For example, children of mothers who experience perinatal anxiety are at higher risk for delayed mental and motor development as well as higher at risk of having ADHD symptoms, externalizing problems and
anxiety (O’Connor, Heron, Golding, Beveridge, & Glover, 2002; Huizink, Mulder, Robles de Medina, Visser & Buitelaar, 2004; Van den Bergh & Marcoen, 2004).
There are different studies on the effects of fear of childbirth and labor pain. For example, Lang, Sorrell, Rodgers and Lebeck (2006) found that anxiety sensitivity in pregnant women can lead to catastrophizing thoughts about childbirth and labor pain. Catastrophizing about pregnancy and labor pain can be seen as a negative cognitive-affective response to pain whereby pregnant women have the tendency to predict the worst case scenario about the perinatal period (Dehghani, Sharpe & Khatibi, 2014; Sharpe and Johnson, 2012). This catastrophizing can lead to labor pain-related fear which causes, among others, avoidance behaviors, physiological reactivity and negative cognitions. These ‘coping patterns’ result in more intense labor pain appraisal and experience. Research shows that catastrophizing is a strong predictor for increased labor pain and has negative effect on postpartum recovery (Flink, Mroczek, Sullivan & Linton, 2009). Furthermore, Bussche, Crombez, Eccleston and Sullivan (2007) found in their study a positive relationship between catastrophizing and the tendency to avoid pain during childbirth. In line with these findings, Veringa, Buitendijk, de Miranda, de Wolf and Spinhoven (2011) show in their study that catastrophizing about labor pain indeed seems to be positively related to the request for pain relief in low-risk pregnant women. Their results also showed that negative cognitions about pain were related to adaption to labor pain but were not related to pain intensity.
Besides these specific effects, studies have also found that anxiety in pregnancy can cause psychological stress, which, in turn, can have negative effects on the mothers as well as the childs mental and physical health (van den Bergh, Mulder, Mennes & Glover, 2005; Huizink et al., 2004; Talge, 2007). Approximately 12% of Dutch pregnant women experience family stress (Guxens et al., 2013). Too much stress during pregnancy can cause extremely elevated blood pressure and heart rate and an increase in obstetrical interventions which in turn can affect the development of the fetus and contribute to early delivery and lower birth weight (Alder, Fink, Bitzer, Hosli & Holzgreve, 2007; van den Bergh et al., 2005; Huizink, Robles de Medina, Mulder, Visser & Buitelaar, 2003). Studies have also shown that
experiencing a severe amount of stress in the third trimester can be associated with a difficult temperament of the baby (O’Connor et al., 2002). In addition, it appears that stress during pregnancy is a determining factor for delay in motor and mental development in infants of eight months of age (Huizink et al., 2003). Perinatal maternal stress can also negatively affect the relationship between mother and child. More specifically, a negative mood can have
found to be a risk factor for the child’s development (Coyl, Roggman & Newland, 2002; Murray, 1992; Vieten & Astin, 2008).
All in all, pregnant women who experience a certain amount of anxiety,
catastrophizing and/or stress are at risk for mental as well as physical problems during the perinatal period (Alder et al., 2007; Hofberg & Ward, 2004; Huizink et al., 2004; O’Connor et al., 2002). In addition, children of mothers who experience anxiety and/or stress are at risk for behavior-, emotional- as well as cognitive problems (van den Bergh et al., 2005; Talge, 2007). But despite these alarming study results, evidence based interventions for anxious and
stressed pregnant woman are rare. Given that in several studies the negative effects of
perinatal maternal anxiety and stress are investigated and proven, it would be of great value to have an evidence-based intervention that reduces anxiety and stress in pregnant women.
An already existing intervention that has been found to reduce anxiety and stress is mindfulness (Carlson, Speca, Patel & Goodey, 2003; Goldin & Gross, 2010; Miller, Fletcher & Kabat-Zinn, 1995). Mindfulness can be seen as the practice of being “in the moment”. More specifically, it has to do with developing a certain attention and awareness in the present moment instead of being focused on the past or future which, in general, one tends to do. Besides the importance of being aware in the present moment, being mindful is also being non-judgmental, non-reactive and accepting to all unfolding experiences, positive as well as negative. Historically, mindfulness has been called “the heart” of Buddhist meditation (Kabat-Zinn, 1990; Teasdale et al., 2000). Another important aspect of mindfulness is
self-compassion. The definition self-compassion as described by Birnie, Speca and Carlson (2010) involves “feelings of caring and kindness towards oneself in the face of personal suffering and involves the recognition that one's suffering, failures and inadequacies are part of the human condition”. This study displays the strong relation between self-compassion and
psychological functioning. More specifically, positive associations have been found between self-compassion and life satisfaction and happiness. Due to developing self-kindness, a sense of common humanity and mindfulness, self-compassion is potentially a protective factor for anxiety, rumination and self-criticism (Neff, 2003; Neff, Rude, & Kirkpatrick, 2007)
Such as creating a healthy and fit body by practicing sports, one can create a healthy mind through the practice of mindfulness. Given that practice is needed to create a fit and healthy body, practice will be needed to achieve a ‘mindful’ state of mind. In practicing mindfulness, this is taught through meditations in which one practices to develop a certain quality of attention to bodily sensations as well as meditations where the focus practice lies on developing a certain quality of attention to the mind and all its thoughts or to breathing. The
purpose of body meditations is to be more aware of the body and its sensations, like tension or excitement, during the day. This can be taught through a body-scan or breathing exercise, for example. Meditation, where the attention lies on mental experiences, has the intention to show and teach how thoughts can be observed as passing mental events instead of serious beliefs, and to release negative feelings by observing thoughts in a more accepting way,
non-judgmentally and non-reactive (Kabat-Zinn, 1990; Teasdale et al., 2000).
Mindfulness is offered as a therapy through, for example, Mindfulness-Based
Cognitive Therapy (MBCT) and Mindfulness-Based Stress Reduction (MBSR) (Kabat-Zinn, 1990; Teasdale et al., 2000). Research shows that MBCT as well as MBSR are helpful to reduce chronic pain, but also as an effective therapy for psychological problems, like anxiety symptoms and stress (Kabat-Zinn, 1990; Miller et al., 1995; Segal & Williams, 2012). In particular, research shows that MBCT and MBSR are significantly effective for improving anxiety and generalized anxiety disorder (Evans et al., 2008; Hofmann, Sawyer, Witt & Oh, 2010). Mindfulness meditation, in the form of MBCT, is therefore increasingly being used as a way of managing pain and reducing anxiety and stress (NICE, 2004).
In response to these effects Hughes et al. (2009) emphasized the possible effects of a mindfulness-based interventionon labor pain and negative cognitions about labor pain. These negative cognitions are often part of catastrophizing. When catastrophizing about labor pain, a pregnant women’s feelings of not being able to cope, and of losing control, are very similar to the reactions on patients who suffer chronic pain (Hughes et al., 2009; Kabat-Zinn, 1990; Kabat-Zinn, Lipworth, Burney & Sellers, 1986). Usually the patient has a tendency to reduce or resist the pain in every possible way. The practice of mindfulness in experiencing pain aims to change a person’s relationship to the pain sensations so that the experience of the pain is less overwhelming and negative emotions that make things worse, are triggered less. As different studies have shown that in chronic pain patients, this way of training the mind reduces anxiety and pain intensity (Reiner, Tibi & Lipsitz, 2013), this approach might also work for catastrophizing about labor pain and experiencing actual labor pain. Through the practice of mindfulness in catastrophizing, or when a women experiences the actual labor pain during childbirth, she could be more able to be in touch with the present moment and to be non-judgmentally aware of het catastrophizing thoughts about labor pain and her bodily sensations. In this way, instead of reacting to these thoughts or sensations with tension and anxiety, she can approach this in a more accepting and non-reactive way.
Although there are no studies about the effects of mindfulness-based interventions on catastrophizing about labor pain and labor pain yet, mindfulness-based interventions show great promise for pregnant women with perinatal distress (Baer, 2003; Astin, Shapiro, Eisenberg & Forys, 2003; Narendran, Nagarathna, Narendran, Gunasheela & Nagendra, 2005). Dunn, Hanieh, Roberts & Powrie (2012) did a pilot study to study the effects of an 8-week MBCT intervention for distressed pregnant woman (n = 10). The participants were stressed, anxious and/or depressed. This study showed that pregnant women who participated experienced a reduction of stress, anxiety and depression in the perinatal period, compared to the control group (n = 9). While this reduction remained stable in the postnatal period, an increase in mindfulness and self-compassion in the postnatal period was reported.Important to mention is that the goal of this mindfulness intervention wasn’t primarily to reduce symptoms like stress, anxiety and depression, but to increase the psychological flexibility of these pregnant women. This primary aim may apply to more mindfulness interventions since an important factor is to accept different kinds of emotions, such as negative ones, instead of trying to oppose to these emotions.
In accordance with previousstudies, Vieten and Astin (2008) explored the effects of an 8-week mindfulness-based intervention on prenatal stress and mood. This ‘Mindful Motherhood’ randomized trial (n = 31), where women who received the intervention during the last half year of their pregnancy were compared to a wait-list control group, included pregnant women in their second and third trimester who were between twelve and thirty weeks gestation at the start of the intervention and were able to speak and read English. Other inclusion criteria were an affirmative response to the question “Have you had a history of mood concerns for which you sought some form of treatment, such as psychotherapy, counseling, or medication?”. In their study a significant decrease in anxiety and negative affect was found. The three main components for the achievement of mindfulness in this intervention were at first to think and feel in a mindful way through conscious breathing, second, to create a mindful body by increasing the consciousness of the body through guided meditations like a body-scan and third, to observe events and thoughts non-judgmentally through the practice of meditation.
Because of the promising results of mindfulness-based interventions on distressed, pregnant women, it makes sense to develop an intervention, which includes al these mindfulness-based facets into one mindfulness-based intervention for distressed, pregnant women. Therefore, in 1998 an intervention for pregnant women and their partners was developed. This intervention is called ‘Mindfulness-Based Childbirth and Parenting’
(MBCP) and is potentially helpful to cope with and reduce anxiety, stress and pain in pregnant women. The MBCP program is offered through a weekly three-hour program and lasts for nine weeks. A mixed-method observational pilot study of the MBCP program was conducted with four cohorts of expectant couples from an urban context (n = 27). No inclusion criteria were applied as the participants self-selected to participate in this intervention. In this pre-post design, the couples were asked to fill in self-report questionnaires pre- and post intervention.
The MBCP program aims to reduce pregnancy-, childbirth- and early parenting related stress, through the practice of meditation and self-regulation (Duncan & Bardacke, 2010). In addition to the meditations during the sessions, participants were asked to practice the meditations at home through different homework assignments. It was intended to practice these meditations with a CD of guided meditations for 30 minutes a day, six days a week, throughout the course. In their pilot study, Duncan and Bardacke (2010) found large effect sizes for the decrease of perinatal anxiety and the increase of mindfulness as an effect of the MBCP program. Furthermore, they found that pregnant women were able to cope
significantly better with stress and noticed their stress much earlier than before.
More specifically, it seems that the MBCP program gave the pregnant women an adaptive strategy to cope with stressful aspects of pregnancy and early parenting, since they reported to use mindfulness more frequently in these situations. For example, the pregnant women and their partners learned to remain calm or go back to a calmer state of mind in a stressful situation, by practicing meditation. They used these meditation skills they had learned during the MBCP program to maintain present moment awareness and
non-judgmental acceptance of their experiences and thoughts. With these skills they were able to cope better with stressful events during the perinatal period and early parenting. The women and their partners reported that being in the present moment was primarily important for their emotional well-being, the quality of the relationship with their baby and partner, and maintain a calm state of mind.
Last, although research on the effects of a mindfulness-based intervention on
catastrophizing about labor pain and actual labor pain has not been done yet, in the study of Duncan and Bardacke (2010) pregnant women reported to be less fearful about childbirth. They reported that through the practice of mindfulness, they learned to relate differently to their negative thoughts about pain and were less overwhelmed by the feeling of being unable to cope with the pain and which made them less fearful of losing control.
This pilot study evaluated the potential effectiveness of the MBCP program for perinatal anxiety in pregnant women. In this line, the purpose of our study is to further investigate the effectiveness of the MBCP program on reducing perinatal anxiety, like fear of childbirth and catastrophizing about labor pain and increasing mindfulness and
compassion. According to Neff (2003), mindfulness can be seen as a precondition of self-compassion. Given that self-compassion, as a single component, is positively associated with the reduction of several psychological problems, including stress, in this study
self-compassion will be analysed separately.
Through the current pilot study, the promising results of the pilot study of Duncan and Bardacke (2010) are possibly being further supported and promoted. Hence, it is expected that the MBCP program will lead to a reduction in fear of childbirth and catastrophizing about labor pain directly after training and that these effects last into the first follow up. Second, it is expected that the MBCP program leads to a reduction in general anxiety en stress directly after training and that these effects last into the first follow up. Third, it is expected that the MBCP program leads to an increase in mindful awareness and self-compassion directly after training and expected is that these effects last into the first follow up. In line with the
hypotheses above, we expect that the results also show a relationship between this increase in mindful awareness from pretest to post-test and the decrease in fear of childbirth from pretest to post-test. We expect a similar relationship in the pretest to follow-up period. Further, a significant relationship between an increase in mindful awareness from pretest to post-test and a decrease in catastrophizing about labor pain from pretest to post-test is expected.
Method
Participants
The study population consisted of 11 pregnant women who were in the 26th-28th week of their pregnancy. Having the partner or a significant other person related to the pregnant woman, that will be present during childbirth, participating in this study was highly
recommended (n = 10 partners participated). The pregnant women were aged between 28 and 42 (Mage= 34, SD = 10.81). The partners were aged between 28 and 38 (Mage= 33, SD = 4.46).
All pregnant women were in a relationship with the partner of their upcoming child. Six of the participants (54.5%) were becoming first-time mothers. For three mothers (27.3%) this was their second pregnancy and two participants (18.2%) expected their third child. Before training, all pregnant women experienced moderate to severe fear of childbirth according to the Wijma Delivery Expectancy/Experience Questionnaire version A (W-DEQ A). One woman (9.1%) reported having moderate levels of fear of childbirth. The other nine women (90.9%) reported severe levels of fear of childbirth. At the first measurement (T1) the women were asked about their preference for the MBCP program (intervention), the
Childbirth Fear Consultation program (reference condition) or if they had no preference at all. 36.4% of the women had no preference and 63.6% of the women preferred to participate in the MBCP program.
Among the pregnant women everyone was highly educated, which meant completion of higher vocational education (HBO) or University. Among the partners 18% was low educated (Elementary School), 18% had an average education (Secondary Education) and 64% was highly educated (HBO or University). 27% of the pregnant women stated to be religious and no one of the partners reported to be religious. 9.1% of the pregnant women had a German background, 9.1% had a Moroccan background, 9.1% had a Turkish background and 72.2% were of Dutch origin.
At post-test one woman (9.1%) did not fill in the questionnaires. At follow-up another woman (9.1%) did not fill in the questionnaires. As a result, at the pretest – post-test analysis, the pretest means differ from pretest means at the pretest – follow up analysis. Therefore, in this study data of 10 participants were analysed.
Procedure
Potential participants for this study were pregnant women in the 20-26th week of their pregnancy and their partners. The pregnant women, who experienced moderate to severe anxiety and/or stress for the pregnancy and giving birth, were recruited via posters and information folders at different midwifery settings situated in practices and hospitals in Amsterdam and surroundings and in The Hague and surroundings. When a pregnant woman signed up for participation she was approached via e-mail or telephone for further
information. After she received the information and was still interested, she received a link to the W-DEQ A questionnaire via e-mail. This questionnaire measures the participants
experienced level of anxiety and stress concerning labor. A higher score on this questionnaire indicates a higher level of fear of childbirth: ≤ 37 indicates low fear, a score of 38 to 65 indicates moderate fear, ≥ 66 represents high levels of fear (Zar, Wijma & Wijma, 2001). Inclusion- and Exclusion criteria
In this study, a cut-off score ≥ 66 on the W-DEQ A is indicated to be included. When a pregnant woman scored above this cut-off and was still willing to participate, an interview followed where the exclusion criteria were checked.
Exclusion criteria were (1) no understanding of the Dutch or English language, (2) women who are at high risk for obstetrical complications during the current pregnancy and therefore possible admission to the obstetrical unit, (3) a current diagnosis of psychosis/psychotic disorder or schizophrenia, present suicidal tendencies, substance abuse and dependency, or borderline personality disorder are also excluded and (4) receiving one of Mindfulness-Based interventions on a regular basis during last year. Based on this protocol, one woman was excluded from the study. When the participant met none of the exclusion criteria she was asked to sign an informed consent after which she and her partner officially entered in the MBCP study.
Study design
The total MBCP study is a randomized controlled trial (RCT) with two study’s arms: MBCP (intervention) and the Childbirth Fear Consultation program (reference condition). After inclusion, participants were randomized to either the MBCP program or the Birth-Anxiety consults. In this larger RCT, data was collected during four times points: pre intervention between 16 and 26 weeks pregnancy (T1), post intervention, within one week after the
9-week intervention (T2), 14 days after giving birth, follow up 1 (T3), and 12-14 9-weeks after giving birth, follow up 2 (T4).
In this thesis only the pretest, post-test and follow-up 1 (T3) data from the first 10 participants, who were randomized to the MBCP program, were included.
Treatment
Each session in the MBCP program lasted three hours. At the beginning of the first session of the course, participants received a CD with mindfulness meditations and were encouraged to practice these meditations six days a week. Depending on the session-theme, each week a different meditation on the CD was practiced. After each session, homework and instructions for the next week were discussed, after which participants received their homework. This consisted of a summary of the session content, weekly diaries and written meditations. When a participant missed a session, homework was send via e-mail. During each session,
homework was being discussed and participants were encouraged to share their experiences and to ask questions.
General mindfulness exercises like the body-scan, sitting with attention for the breath and the sit-meditation were practiced on a regular basis. In addition to these exercises, perinatal meditions were practiced, like a ‘being with your baby’ meditation, the pain medition with ice and an anxiety-meditation. In extension to practicing mindfulness meditation, an important part of the sessions was the education. This psycho-education consisted of different themes about pregnancy and giving birth in relation to mindfulness. Among others, psychobiological processes in pregnancy, childbirth,
expectations about labor pain, the postpartum period and needs of the baby were discussed. The training was given by an experienced MBSR-trainer who is also a midwive. To insure treatment integrity, every session was recorded. In Table 1 a short overview of the session themes is presented.
Table 1. Session theme and content overview of the MBCP program
Session 1: background of mindfulness, the MBCP program, raisin meditation, awareness of senses meditation and ‘being with the baby’ meditation.
Session 2: Body scan meditation. Practicing to ‘be in your body’ and a breathing meditation. Session 3: Psycho-education: physiology of pregnancy and childbirth from neurobiological perspective. Body-scan and breathing meditation.
Session 4: Yoga: mindful movement, balancing between strain and relaxation, breath and body meditation and a pain meditation with ice.
Session 5: Yoga, sitting with attention for the breath, physical sensations and sounds, ‘Being with the baby’ meditation. Psycho-education: The miraculous birth channel. The power of not knowing. Pain meditation with ice.
Session 6: Sitting with attention for the breath, physical sensations, sounds, thoughts and emotions. ‘Being with the baby’ meditation. Psycho-education: Find your way in what is. Childbirth as a meditation practice. Coping with thoughts and emotions.
Session 7: Practicing the taught meditations in silence. Mindful talking and listening to each others fears. Mindful walking meditation.
Session 8: Loving-kindness meditation: self-compassion and compassion for others. Psycho -education: biological, emotional and social needs of the newborn.
Session 9: Continuing the above-mentioned meditations. Psycho-education: breastfeeding and postpartum disbalance from a neurobiological perspective
Measurements
Through the use of self-report questionnaires effects of the MBCP program on three main outcome domains were assessed; 1) perinatal anxiety 2) general anxiety and stress, and 3) mindfulness and self-compassion.
Perinatal anxiety
Wijma Delivery Expectancy/Experience Questionnaire version A and B (DEQ A and W-DEQ-B).
Perinatal anxiety was assessed with the W-DEQ A. In this questionnaire fear of childbirth was measured through 33 questions on a 6-point likert scale, using questions concerning a
childbirth (version B). In both versions, each question can be answered on a 0 to 5 scale with the extremes (0 and 5) representing the contrast between a certain thought or feeling about labour or giving birth. In version A the focus lies on the expectations about childbirth (e.g., ‘How do you think you will feel in general during the labour and delivery’?, 0= I feel
extremely safe, 5= I feel not at all safe’; Cronbach’s α= .87). In version B questions about the experiences of childbirth are asked (e.g., ‘How did you experience your labour and delivery as a whole’?, 0= Extremely frightful, 5= Not at all frightful; Cronbach’s α= .87). A higher score on these questionnaires indicates a higher level of fear of childbirth (Wijma, Wijma & Zar, 1998).
Labour Pain Coping and Cognition List: subscale Catastrophizing Labour Pain (CLP)
Perinatal anxiety was also assessed with the CLP (Catastrophizing Labour Pain), a subscale of the Labour Pain Coping and Cognition List, which measures catastrophizing about labor pain in pregnant woman. This subscale consists of 13 questions on a 6-point likert scale, with questions concerning thoughts about the possible catastrophic consequences of labor pain (e.g., ‘The pain of childbirth will make me feel absolutely terrible’, ‘I feel it will be too much for me.’ and ‘The words ‘pain of childbirth’ make me feel scared.’, 0= Completely disagree, 6= Completely agree;
Cornbach’s α=0.84). A higher score on this subscale indicates a higher amount of
catastrophizing (Veringa et al., 2011). This questionnaire was only filled in at pre- and post-test.
General anxiety and stress
Depression, Anxiety and Stress Scale: subscales Anxiety and Stress (DASS-21).
The subscales that measure common anxiety and common stress both consist of seven items. The subscale anxiety, that measures the level of common anxiety during the past week, contains questions like ‘I felt scared without any good reason’ (Cronbach’s α= .82). The 7-item stress-subscale measures the negative emotional states of stress in the past week. (e.g., ‘I felt I was close to panic’; Cronbach’s α= .90; Lovibond & Lovibond, 1995). The 7 items are scored on a 4-point likert scale (0 = did not apply to me at all, 3 = almost always/applied to me very much or most of the time). A higher score on this subscale indicates higher
experienced stress.
Perceived Stress Scale (PSS)
participants score each of the 10 items (e.g., ‘Talking about the past two weeks, how often have you felt nervous an “stressed”?’; Cronbach’s α=.78) on a 5-point Likert scale (0 = never, 4 = always), in which
a higher score indicates a higher amount of perceived stress.
Mindfulness and self-compassion
Five Facet Mindfulness Questionnaire (FFMQ)
This questionnaire consists of 24 items and measures a participant’s general mindfulness or mindful awareness (Bohlmeijer, Peter, Fledderus, Veehof & Baer, 2011) (e.g., ‘When I have distressing thoughts or images, I just notice them and let them go.’ ; Cronbach’s α=.82; Bohlmeijer et al, 2011). Within the FFMQ there are five mindful awareness subscales: 1. Observing Inner Experience, 2. Describing Experience, 3. Acting with Awareness, 4. Non-judging of Experience, and 5. Non-reactivity to Inner Experience. The 24 items were scored on a 5-point Likert scale (0 = never or very rarely true, 5 = very often or always true). Higher scores on this questionnaire reflecting greater mindful awareness.
Self-Compassion Scale – Short Form (SCS-SF)
In order to measure self-compassion, the Self-Compassion Scale – Short Form was used. Originally this is a 26-item questionnaire which measures 1. Self-Kindness, 2. Self-Judgment, 3. Common Humanity, 4. Isolation, 5. Mindfulness and 6. Overidentification (Neff, 2003). In time, two short-forms were developed for this scale. One 12-item form and one 3-item form. Because of the high correlation of this 3-item form with the original 26-item scale, the 3-item scale was used in this study (Raes, Pommier, Neff & van Gucht, 2011). These items represent the 1. Common humanity – isolation domain 2. Mindfulness – overidentification domain and 3. Self-kindness – selfjudgment domain (e.g., ‘I try to see my failings as part of the human condition.’). Questions were scored on a 7-point Likert scale (0= never or almost never, 7= almost always).
Statistical analysis
By means of paired t-tests results of direct treatment effects, from pretest to post-test and results mid-term treatment effects, from pretest to follow-up, were analysed. Effect sizes of change (Cohen’s d) were calculated by the mean of the difference (post-test minus pretest) divided by the SD of these differences. Effect sizes >.2 are considered small, >.5 medium and >.8 large (Field, 2009). Because significance is partly driven by sample size, it is possible that in this study (n = 10) no statistical significance is found between differences in means of two measurements, but that results do show a medium-sized effect between these differences. This is why an effect size gives important information about the effects of an intervention, especially for studies with a small sample size (Hoyle, Harris & Judd, 2002).
By means of a partialcorrelation analysis, the relations between fear of childbirth, catastrophizing about labor pain and mindfulness were analysed. This analysis was used to explore the relationship between an increase in mindful awareness from pretest to post-test and a decrease in fear of childbirth from pretest to post-test. Next, the relationship between an increase in mindful awareness from post-test to follow-up and a decrease in fear of childbirth from post-test to follow-up was analysed. Last, the relationship between mindful awareness and catastrophizing about labor pain from pretest to post-test was analysed. This relationship could not be analysed in the follow-up period too because the CLP is a prenatal measurement, which makes the questions not applicable in the follow-up period, after giving birth.
In this partial correlation analysis we controlled for age and filial rank of the child as there are different studies and contradicting results about the impact of age and filial rank of the child on psychological distress in pregnant women. There is evidence for increased risk in psychological distress in older women, while other studies highlight the psychological
beneficial effects of a higher maternal age (Stein & Susser, 2000; Zasloff, Schytt &
Waldenström, 2007). We also controlled for filial rank of the child as studies have found that nulliparous women are more fearful of childbirth than parous women (Alehagen, Wijma, & Wijma, 2000; Wijma, Söderquist, & Wijma, 1997), although other studies have also shown reversed results (Rofé, Littner, & Lewin, 1993; Ryding, Wijma, Wijma, & Rydhström, 1998).
Results
Descriptives and data inspection
Before analyzing the results, data were screened for the presence of outliers and missing values. First, the means and standard deviations were calculated. Outliers were inspected with the use of the following criterium: z < -3.29 of z > 3.29. No outliers were found. Inspection of the distributions of outcome variables revealed all data were normally distributed. The descriptive statistics are presented in Table 2.
Direct treatment effects
Paired-samples t-tests were conducted to evaluate the direct effects of the MBCP program. Pregnant women reported a significant decrease in fear of childbirth from pre- to post-test on the W-DEQ A, t (9) = 3.50, p<.01, d=1.26. They further showed a significant decrease in catastrophizing about labor pain on the CLP, t (9) = 3.28, p=.01, d= 0.83. Both effect sizes can be considered large. No significant decrease was found in general anxiety t(9) = 0.39, p>.05, d=0.11 on the DASS-21. Results for general stress showed no significant decrease on the DASS-21 t (9) = -0.79, p>.05, d= 0.24 and no significant decrease on the PSS
t (9) = 0.69, p>.05, d= 0.14.
Further, directly after training significant improvement for mindful awareness (FFMQ) was found in the total scale, t (9) = -4.51, p<.01, d= 0.84. The effect size is large. Within different of the FFMQ significant increases from pretest to post-test were found for
describing t (9) = 3.21, p<.05, d=0.86, acting with awareness t (9) = 2.47, p<0.05, d= 0.60, non-judging of inner experience t (9) = 2.27, p=.05, d=0.57, and non-reactivity to inner experience t (9) = 2.39, p<.05, d=0.76. No significant increase in the subscale observing t (9)
= 0.54, p>.05, d=0.12 was found. After training, results showed no significant increase in self-compassion, on the SCS-SF t (9) = 1.18, p> .05, d=0.31.
Mid-term treatment effects
Paired-samples t-tests were conducted to evaluate the mid-term effects (follow up 1) of the MBCP program. Results are presented in Table 3.
At follow up 1, two weeks after labor, again a significant decrease, t (9) = 5.52, p<.001,
d=2.11 in fear of childbirth was found on the W-DEQ B from pretest to follow-up. Results
showed no significant increase for mindful awareness, on the total FFMQ
scale t (9) = -0.96, p>.05, d=0.38 from pretest to follow up. Within the different subscales of the total FFMQ, significant increases were found for describing t (9) = -2.5, p<.05, d=0.60 and judgement t (9) = -2.59, p<.05, d=0.50. A trend was found for the increase in
non-reacting t (9) = -2.18, p<.1, d=0.87. No significant increases were found on the subscales observing t (9) = 0.71, p>.05, d=0.14, and acting with awareness t (9) = -1.06, p>.05, d=0.42.
Further at follow up, a significant decrease in general anxiety, t (9) = 2.36, p<.05, d=0.63 was reported on the DASS21. No significant decreases in general stress were reported, t (9) = -0.46, p>.05, d=0.12, and t (9) = 1.28, p>.05, d=0.48, on the DASS-21 and the PSS
respectively.
Last, results from pretest to follow up showed no significant improvement in self-compassion on the SCS-SF t (9) = 0.27, p>.05, d=0.06.
Table 2. Descriptives (M’s and SD’s) at pretest and post-test and p-values and effect sizes for
the effects of the MBCP program from pretest to post-test (n = 10).
Note: †p < .1(trend), *p< .05, **p<.01, ***p< .001.ᵅ Effect Sizes d, 0.2, 0.5, and 0.8, indicate respectively small, medium, and large effects.
Pretest Post-test Pretest – Post-test
M SD M SD p ES Fear of childbirth (W-DEQA) 92.00 20.90 63.40 24.22 0.007** 1.26 Catastrophizing Labor Pain (CLP) 41.50 14.12 30.30 13.00 0.01** 0.83 General Anxiety (DASS-21) 6.60 2.98 6.00 2.45 0.70 0.11 General Stress (DASS-21) 12.60 3.34 14.40 4.02 0.41 0.24 General Stress (PSS) 16.70 7.85 15.70 6.93 0.51 0.14 Mindful Awareness (FFMQ) 78.20 10.81 88.80 14.09 0.002** 0.84 FFMQ Facets: Observing 13.80 3.88 14.30 4.60 0.61 0.12 Describing 19.20 2.86 21.50 2.46 0.01* 0.86 Acting with Awareness 15.60 3.66 17.80 3.68 0.04* 0.60 Non-judgement 15.50 3.34 18.10 5.49 0.05* 0.57 Non-reactive 14.10 3.67 17.10 4.25 0.04* 0.76 Self-Compassion (SCS-SF) 11.40 3.53 12.80 5.22 0.27 0.31
Note: †p < .1(trend), *p< .05, **p<.01, ***p< .001.ᵅ Effect Sizes d, 0.2, 0.5, and 0.8, indicate respectively small, medium, and large effects.
Table 3. Descriptives (M’s and SD’s) at pretest and post-test and p-values and effect sizes
for the effects of the MBCP program from pretest to follow-up 1 (n = 10).
Pretest Follow up Pretest – Follow up
M SD M SD p ES Fear of childbirth (W-DEQB) 94.20 17.02 46.70 26.85 0.000*** 2.11 General Anxiety (DASS-21) 7.20 2.88 4.20 1.73 0.04* 0.63 General Stress (DASS-21) 13.80 2.99 14.80 4.90 0.66 0.12 General Stress (PSS) 16.40 8.26 12.70 7.27 0.23 0.48 Mindful Awareness (FFMQ) 73.10 12.81 77.90 12.43 0.36 0.38 FFMQ Facets: Observing 13.80 3.88 13.30 3.20 0.49 0.14 Describing 18.20 2.74 19.80 2.57 0.03* 0.60 Acting with Awareness 15.20 3.19 16.60 3.44 0.32 0.42 Non-judgement 15.40 3.34 17.00 3.09 0.03* 0.50 Non-reactive 13.70 3.13 16.70 3.74 0.06† 0.87 Self-Compassion (SCS-SF) 11.30 3.50 11.00 3.97 0.79 0.06
Relations between fear of childbirth, catastrophizing about labor pain and mindful awareness
Partial correlations between mindful awareness and fear of childbirth and
catastrophizing about labor pain (controlling for the effects of age and filial rank of the child) were conducted to examine whether hypothesized increases in mindful awareness were related to decreases in fear of childbirth and catastrophizing about labor pain. Results are presented in Figure 1 and 2.
A significant and negative correlation was found from pretest to post-test between the increase in mindful awareness (FFMQ) and the decrease from pretest to post-test in fear of childbirth (WDEQ-A) r = -.687, p<.05. Thus, the higher the increase of mindful awareness during the training, the larger the decrease in fear of childbirth during the training. Further, results showed a significantly negative correlation between the increase from pretest to post-test in mindful awareness (FFMQ) and the decrease from prepost-test to post-post-test in
catastrophizing about labor pain (CLP) r = -.763, p<.05. In other words, the higher the increase of mindful awareness during the training, the larger the decrease in catastrophazion about labor pain during the training. Further, no significant relationship was found from pretest to follow-up 1 between an increase in mindful awareness (FFMQ) r = .352, p>.05 and a decrease from pretest to follow-up in fear of childbirth (WDEQ-B).
Figure 1. Partial correlations between fear of childbirth from pretest to post-test and mindful
awareness from pretest to post-test
Note: Correlation is significant at * (alpha 0.05), ** (alpha 0.01) or *** (alpha 0.001). † (alpha 0.1) indicates a trend.
Figure 2. Partial correlations between catastrophizing from pretest to post-test and mindful
awareness from pretest to post-test
Note: Correlation is significant at * (alpha 0.05), ** (alpha 0.01) or *** (alpha 0.001). † (alpha 0.1) indicates a trend.
Discussion
This study evaluated the effects of the MBCP program on moderate to severe anxious and stressed pregnant women. The findings in this study support the potential effectiveness of the Mindfulness-Based Childbirth and Parenting program as a clinical intervention for women who experience perinatal anxiety.
Directly after the training, a significant large decrease in perinatal anxiety in pregnant women was found. The results show that all the pregnant women went from reporting high levels of fear of childbirth (M = 92, SD = 20.90) at pretest, to reporting moderate levels of fear of childbirth (M = 63.4, SD = 24.22) at post-test (Zar et al., 2001). Further, a large effect was observed for the decrease in fear of childbirth. These effects lasted into the follow-up period with again a significant large decrease in fear of childbirth (M = 46.7, SD = 26.85). Hence, assumed can be that MBCP leads to a decrease in fear of childbirth in the perinatal period. In addition, a significant large decrease in catastrophizing about labor pain from pretest to post-test was found, which indicates that the MBCP program was effective in decreasing catastrophizing thoughts about labor pain in the prenatal period. Since
catastrophizing about childbirth was only a measurement in the prenatal period, the CLP was not included in the follow up measurement.
These results support the earlier findings of Duncan and Bardacke (2010) in which they found MBCP to be significantly effective in reducing perinatal anxiety from pretest to post-test. Thus after the MBCP training, women found themselves to be less anxious about giving birth and less catastrophizing about labor pain.
A second main effect of the MBCP program that was found was a significant large increase in mindful awareness in pregnant women from pretest to post-test. After the MBCP program, women showed more improved ability to describe their internal experiences, like feelings and emotions, with words. Women had a heightened awareness about experiences and activities in the moment, found themselves to be less judgmental towards inner
experiences like thoughts and feelings and were less reactive towards these inner experiences, which ment they allowed thoughts and feelings to come and go more, without getting caught up in or carried away by them.
After giving birth significant increases and medium effects were found for the mindfulness facets describing and nonjudgement. Results also showed a trend and a large effect for the increase in nonreacting. The facet acting with awareness showed no significant increase but did show a medium effect. No significant changes in the other facets nor in
self-and stress directly after training. From pretest to follow up a significant decrease in general anxiety was reported with a medium effect. No significant decreases in general stress were found.
The results on perinatal anxiety show large improvement. An explanation for these results is that the MBCP program is especially designed for and potentially effective to help reduce perinatal anxiety and stress in pregnant women (Duncan & Bardacke, 2010). The MBCP program provides different mindfulness exercises as a strategy to approach perinatal fears and stress in a more friendly and accepting way. The extensive psycho-education during each session is also focused on different aspects of pregnancy and childbirth, different studies suggest psychoeducation to be promising in diminishing fear of childbirth and fear of labor pain (Saisto, Salmela-Aro, Nurmi, Könönen & Halmesmäki, 2001;Saisto, Toivanen, Salmela-Aro & Halmesmäki, 2006). This combined with extensive mindfulness practice, which is already a proven approach to reduce stress and anxiety (Duncan & Bardacke, 2010; Segal & Williams, 2012; Vieten & Astin, 2008), is a possible explanation for the decrease in perinatal anxiety.
These results on perinatal anxiety and mindful awareness were also visible in the training during inquiry. In each session women practiced with the seven attitudinal factors of mindfulness: non-judging, patience, beginner’s mind, trust, non-striving, acceptance and letting go (Kabat-Zinn, 2003). During inquiry, women reported to be able to let go of their fears better by accepting that things not always go the way you planned them. Non-striving was also an important area of concern. At the beginning of the training, most women were striving to have an as safe and painless childbirth as possible. During inquiry some of these women reported that they were able to strive less and be trustful and non-judging concerning their upcoming childbirth. Some women even changed their mind about making a birthplan and stated that they would try to let their upcoming childbirth go the way it would go, without planning or striving. One woman, who had a traumatic childbirth experience with her first child, eventually even decided to renounce from her planned C-section and gave birth naturally without complications.
As the results on perinatal anxiety improved significantly, the expectation was the same for general anxiety and stress. A significant decrease of general anxiety was observed from pretest to follow up, however, this may be explained by a floor-effect. There were no significant results found for general stress. A possible explanation for these results is that women who signed up for participation in the MBCP program, were included based on experiencing moderate to high fear of chilbirth. Which could mean that, overall, they did not
suffer much from general anxiety and/or stress to begin with. This assumption is supported by the results on the general anxiety and stress measurements. In Table 2 the scores at pretest for general anxiety and stress were consecutively 6.60 and 12.60. Both these scores are
interpreted as normal (Lovibond & Lovibond, 1995). In addition to the DASS-21 as a measurement for general stress, the PSS was used. Although the PSS is not a diagnostic instrument, which means there are no cut-offs, a score of 16.70 at pretest in a score range from 0 to 40 also indicates low levels of general stress. Because of this ‘floor-effect’ it is harder to find significant results (Cohen et al., 1983).
Although not all facets of mindful awareness showed improvement directly after training, increases were found in describing of internal experiences like feelings and emotions, acting with awareness about experiences and activities in the moment, being less judgmental towards inner experiences, like thoughts and feelings, and being less reactive towards these inner experiences, which ment they allowed thoughts and feelings to come and go more, without getting caught up in or carried away by them. After giving birth significant increases and medium effects were found for the mindfulness facets describing and
nonjudgement. Thus, after giving birth, women showed improvement in describing their internal experiences and being non-judgmental about these experiences. It is possible that in larger samples the other three facets would also reach significance or it could be that the MBCP program, in the longer term, does not affect acting with awareness, being non-reactive to internal experiences and observing, which can be described as the tendency to notice internal and external experience like feelings or sounds.
In contrast to the expectations about the increase in mindful awareness from pretest to follow up 1, no significant increase on the total scale of the FFMQ was found. A possible explanation could be that the beginning of the postnatal period requires a lot of attention, coping and adaption to the situation with a newborn and to early parenting (Terry, 1991; Terry, Mayocchi & Hynes, 1991). Because of these changes and, above all, the physical and psychological recovery from childbirth, mindfulness could be something that is practiced less in this period, due to less time and fatigue for example. Although not analysed in this study, this was confirmed by the responses women gave at the follow up session about the question how often they still meditated. All the women replied having poor sleep and therefore little energy and time to practice meditation.
Besides these main findings, it was further found that from pretest to post-test, mindful awareness correlated significantly and negative with fear of childbirth from pretest to
post-training, fear of childbirth decreased significantly during the training. Further, a significantly negative correlation was found between an increase in mindful awareness from pre- to post-test and a decrease in catastrophizing about labor pain from pre- to post-post-test. Thus, more mindful awareness during the training was significantly related to a decrease in
catastrophizing about labor pain during the training. No significant relation was found between an increase in mindful awareness (FFMQ) from pretest to follow-up and a decrease in fear of childbirth from pretest to follow up. The results van pre- to post-test on
catastrophizing about labor pain support the study of Schütze, Rees, Preece and Schütze (2010) in which mindfulness, measured through the FFMQ, is found to be a strong negative predictor for pain catastrophizing. Although in this sample (n = 104) only chronic pain patients and no pregnant women were included, similarity has been found between the effects and role of catastrophizing about labor pain and catastrophizing about chronic pain (Flink et al., 2009).
There are some limitations in this pilot study that should be mentioned. First, the sample size of the current study was small and thereby the study findings have limited generalizability. Medium to large effect sizes from pretest to follow up were observed on some outcome variables, despite these changes being not statistical significant (p< 0.05), it is possible that with using a bigger sample size, statistical significance could be reached. Second, because of the quasi-experimental design of this study, the treatment, the participants and their results were not compared to a control group, such as with a RCT. Therefore, it is not possible to know whether the effects of the MBCP program can be fully attributed to the program itself. Third, data solely relied on self-reported questionnaires which heightened the possibility of social desirability in the responses. Fourth, all participants in the training were highly educated and most were of Caucasian origins. Because of this small socioeconomic and ethnical representativity, it is unclear if the MBCP program has the same effects on women from different races and with different socioeconomic backgrounds.
Last, daily practice, which was not included in this study, was registered through asking the participants during each session about last weeks homework. As there were no registration diaries or registrations about how many minutes per week women meditated, there was limited overview about the frequency and intensity in which the women practiced their homework at home. Not every participant was able to attend all the nine sessions and although some participants stated to practice their homework everyday, others practiced once or twice a week. Mindful awareness is something that develops and deepens over a longer period of time. This requires frequent practice (Kabat-Zinn, 2003). A recent publication
underlined the importance of the amount of home practice in meditation (Crane et al., 2014). These authors found that people who ingaged in more formal home practice during a 7-week MBCT training (n = 99), were half as less likely to relapse as those who reported fewer days of formal home practice. Considering these limitations, results of this study should be interpreted with caution and conclusions should be drawn carefully.
On the other hand this study has a couple of strengths that are worth mentioning. First, this is one of the first theses that further reasearched, supports and promotes the potential effectiveness of the MBCP program in the Netherlands on reducing perinatal anxiety in pregnant women. In addition, the significant relationship between an increase in mindfulness during training and a decrease in fear of childbirth and catastrophizing about labor pain during training is a very promising outcome for the potential effectiveness of the MBCP program. Last, by further supporting the potential effects of the MBCP program, hopefully through further research the MBCP program can evolve in an evidence-based clinical intervention to help women with perinatal anxiety to decrease their perinatal anxiety and the negative effects this can have on mother and child and, therefore, possibly make their pregnancy a more joyful experience and their childbirth more bearable.
Future research about the effectiveness of the MBCP program should be conducted with a larger sample size and the data of the partners included. After all, the MBCP program was designed to get partners to parcticipate too because of the limited research on the role of partner’s attachment and perceptions and on the support of the partner during the pre- and perinatal period.As for the study design it is recommended to use a RCT with a control group that receives another training parallel to the mindfulness groups for more reliable results, internal validity, to measure efficacy and to control for the effects of known and unknown confounders. Furthermore, because of the small sample size, partial correlations were used for the current study to analyze the relations between fear of childbirth, catastrophizing and mindful awareness. For further research it will be more valuable to take this process a step further and analyze the relationships with a multiple regression analysis. Herewith, one can predict one variable from another and see the direction of the related variables.
In conclusion, the MBCP program appears to be a promising and a potentially effective clinical intervention for pregnant women with perinatal anxiety in the perinatal period. Data indicated a decrease in fear of childbirth in the perinatal period. Furthermore, the MBCP program seems to be potentially effective in reducing catastrophizing about labor pain in the prenatal period. Last, MBCP potentially increases mindful awareness in pregnant
awareness during training and a decrease in fear of childbirth and catastrophizing about labor pain during training
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