Participants and Procedures
We conducted a mixed-method observational pilot study of MBCP with four cohorts of expectant couples from an urban context who self-selected to participate in MBCP in 2008. All study procedures were approved by an academic medical center Institutional Review Board. The course instructor invited all course enrollees to participate in the research study and informed consent procedures were conducted by study staff at the beginning of the introductory class meeting. Pregnant women (N = 35) in the late second or early third trimester of pregnancy (mean age 34.6; 92.6% first-time parents; 70.4% reported experiencing a major stressful life event during pregnancy; 92.6% with prior yoga or meditation experience) enrolled in MBCP with their partner or support person and all agreed to participate in some portion of the study even though study participation was not a requirement for course enrollment (see Table 1 for more detailed sample demographics). Study participants completed self-report questionnaires pre-intervention (late 2nd trimester/early 3rd trimester) and post-intervention (late 3rd trimester). Participants also provided qualitative descriptions of their experiences of pregnancy, childbirth, and early parenting and their use of course skills. The developer of MBCP (the senior author) was the instructor for all four groups. Two groups were held in a university integrative medicine clinic and two were held in an off-site location that was more geographically proximal to participants.
Description of the MBCP Program
The MBCP course is held for 3 h once a week for 9 weeks. In addition, there is a 7 h silent Retreat Day on the weekend between Class 6 and Class 7 and a Reunion Class four to 12 weeks after all the women have given birth. The recommended class size ranges from eight to 12 expectant couples. Although the course is expressly designed for expectant couples to attend together, pregnant women without a partner or whose partner cannot attend are welcome and are invited to bring a support person, if so desired.
In the MBCP program, formal mindfulness meditation instruction is given and practiced in each class. In addition, participants are asked to commit to practicing meditation at home using guided meditation CDs for 30 min a day, 6 days a week, throughout the course. The teaching of mindfulness is fully integrated with the current knowledge of the psychobiological processes of pregnancy, labor, birth, breastfeeding, postpartum adjustment, and the psychobiological needs of the infant. A wide variety of mind–body pain coping skills for childbirth and awareness skills for coping with stress in daily life are also included. Course materials are Full Catastrophe Living by Jon Kabat-Zinn (1990), two guided meditation CDs and a workbook with selected readings and resource lists. The MBCP method of childbirth preparation is unique in its focus on teaching mindfulness meditation and the necessary commitment that participants must make to practice meditation outside of class.
In addition to teaching mindfulness practice, an essential element of the course is to encourage a sense of community among the expectant parents to reduce the potential negative impact of social isolation on the mental health of the new parents in the postpartum and early parenting period. Toward this end, each class includes a 15 min snack break to allow for relationship building among participants.
MBCP class one The first meeting is devoted to sharing the history of MBCP as an adaptation of MBSR and the beginning of themes that are interwoven throughout the 9 week course: that the capacity to be fully present for labor and delivery can support the normal physiology of childbirth, and that attentive, present-moment parenting can be key to the development of a healthy, empathetic relationship between parent and child. A definition of mindfulness is given—“paying attention in a particular way: on purpose, in the present moment, non-judgmentally” (Kabat-Zinn 1994), and the relationship between the stress appraisal process and change is explored. Group sharing provides couples the opportunity to normalize the stress they may be experiencing, such as changes in the physical body, living space, finances, work life, hormonal and emotional changes, self-identity, and couple and family relationships. The group process allows couples the chance to hear that these stressors are shared by others and to learn that, if they are approached as a challenge, they can provide an opportunity for self-learning and growth. Partner concerns, such as worry about how to support a woman during childbirth, are addressed.
A portion of this first meeting is devoted to an eating meditation in which one raisin is eaten mindfully. Using the senses of sight, smell, touch and taste, this exercise serves to demystify meditation practice through the participant’s direct experience of paying attention to one’s unfolding, moment-to-moment experience. The theme of interconnectedness is introduced through looking at the “bellybutton” (stem end) of the raisin, seeing that the soil, sun, rain, clouds, and workers who picked and trucked the raisins all contributed to the health and well-being of their body and the body of their unborn baby through the nutrients in the raisin. This exercise can heighten awareness of food and nutrition and begins the conversation about how many of life’s moments can be missed, including moments with our children, because the mind is pulled into thoughts about the future or past. Participants are taught that, with the practice of mindfulness, the choice to be more present in our lives becomes available.
MBCP class two Group bonding and community-building deepen in session two. A guided reflection on the question “Why are you here?” provides expectant parents an opportunity to share hopes and fears around pregnancy, childbirth, and parenting.
The first formal meditation practice, the Body Scan, is taught in session two. Not to be confused with progressive relaxation exercises that are often taught in childbirth education classes, the Body Scan is an awareness practice. The instruction is to slowly and systematically move one’s attention through the body from the top of the head down to the feet, becoming aware of physical sensations in various parts of the body. Whenever the mind wanders, the instruction is to bring the attention back to sensations in the body.
During the Body Scan unpleasant or painful sensations may arise. This experience offers an opportunity to begin developing the skill of uncoupling the sensory component of pain from its emotional and cognitive components right in the present moment. This skill enables participants to become aware of habitual, reactive patterns to discomfort or pain that add the mind’s layer of suffering to intense physical sensations. With repeated and regular practice of the Body Scan before childbirth, participants are encouraged to increase their capacity to “be with” and even accept that which is unpleasant, challenging, difficult, painful, or unwanted. Participants are taught that during labor, this skill is invaluable: with mindfulness, pain can be experienced as it is: intense physical sensation arising and passing, moment-by-moment. Moments between painful sensations (e.g., those experienced between contractions) can be experienced with calm and ease rather than with fear or worry about future pain or recalling the memory of past pain. The Body Scan is also intended to increase body awareness, concentration, and is an opportunity to connect with the unborn baby.
MBCP class three Class three is intended to prompt a fundamental shift in perception of the childbirth experience. The physiology of childbirth from a mind–body perspective is described with an emphasis on how present moment awareness can be a critical skill for supporting the normal physiology of labor. With this description, participants are encouraged to consider how fearful appraisals of pain by the mind may trigger the stress reaction during childbirth and negatively affect the labor process through psychophysiological pathways of the neuroendocrine system.
Participants are asked to describe their home experiences practicing the Body Scan during the previous week. Common challenges such as finding time to practice, falling asleep during meditation practice, and questions about what to do when pain or discomfort arises during the Body Scan are addressed.
In addition to the Body Scan, participants are asked to begin a daily sitting practice of 10 min per day and to begin to bring present moment awareness into the ordinary activities of daily living such as washing dishes, brushing teeth, and preparing meals. This sets the foundation for bringing mindfulness into everyday life as a more responsive and less reactive parent.
MBCPclassesfour, five, and six Yoga is introduced as a formal meditation practice in class four. Over the next 2 weeks, mindful movement/yoga practice is alternated with the Body Scan as the at-home formal meditation practice. Practiced mindfully, yoga is a meditative discipline. Noticing and moving into sensations during yoga practice, particularly sensations of stretching and contracting and noticing the times of ease and rest between poses, is mindfulness preparation for noticing the sensations of contractions and the moments of ease between sensations during the labor process. In class six, open awareness sitting meditation is taught. Sitting meditation is alternated with yoga or the Body Scan in the home practice assignment for the week.
Using ice cubes to induce unpleasant sensations, couples are taught a variety of pain practices in classes four, five, and six. They are taught that simple awareness of breathing, moving directly into the sensations, counting the breaths, and vocalizing low-pitched sounds are all ways to focus attention, accept and even welcome intense body sensations. Participants are encouraged to understand how the non-reactive, concentrated, calm, and focused state of mind that is being cultivated in meditation practice can be used to open to and allow unpleasant sensations to arise and pass, moment by moment. Partners are taught the pain practices along with the pregnant women, and in this way are able to bring empathetic understanding to their partners during the pain of childbirth.
In class five, the baby’s journey through the pelvis during childbirth is demonstrated and couples are taught and spend time practicing various positions for labor. Partners receive instruction in a variety of ways to use mindful touch to calm and support their partner. Class six focuses on making wise choices for childbirth, including selection of a care provider, place of delivery (home, hospital, birth center), and additional labor support such as the use of a doula. It is emphasized that the future is unknown, there is no one “right way” to give birth and that with practice, couples will have a variety of tools to work with pain and whatever comes their way during the birth process.
Throughout weeks four, five, and six, couples are asked to bring awareness to stressful experiences in everyday life, noticing how the body and mind “contract” in response to stress. They are asked to practice “being with” (or responding rather than reacting to) these stressful experiences, just as they are learning to do with the ice in the formal pain practices.
MBCP retreat day The day of silent practice is framed as an opportunity to deepen one’s meditation practice, increase awareness of one’s patterns of mind, and practice living in the present moment for an extended period of time, much as they will do during labor and birthing. All the practices are revisited—the Body Scan, mindful movement/yoga, sitting meditation, and mindful eating. Walking meditation is introduced and practiced. In the afternoon, silence is suspended and participants are led through a mindful speaking and listening practice around fears about the future. In this way, participants are encouraged to bring mindful presence into their most intimate relationships.
MBCP class seven In class seven lovingkindness meditation (Salzberg 1995) is introduced. Lovingkindness practice is a practice of open-hearted friendliness and well-wishing for oneself and others. As a variation on the traditional practice of lovingkindness meditation, in the MBCP course lovingkindness practice begins with extending well-wishing to one’s baby, then to oneself, followed by those nearest and dearest, then to all the babies and parents in the room, followed by well-wishing to a neutral person, a difficult person, to one’s neighbors, community, and finally to all beings everywhere.
Also in class seven, participants are invited to share their experiences of the Retreat Day including experiences that were inspiring or challenging, and any insights they had about themselves or mindfulness practice. Participants are reminded that just as they did not know how the day of silence would unfold, so too, they do not know how the day (or night) of labor will unfold. They are instructed that as with the Retreat Day, all that is needed during childbirth is to simply be present as fully as possible as the labor process unfolds, moment-by-moment.
The biological, emotional, and social needs of the newborn and the needs of the postpartum family are covered in this class and the couple’s plans for the postpartum period are reviewed. Sitting meditation is continued as the formal practice for the week.
MBCP class eight Class eight is devoted to reviewing the previous week’s experiences of meditation practice and exploring how mindfulness skills support the normal physiology of breastfeeding. Emphasis is on optimizing conditions for the establishment of the breastfeeding relationship and how mindfulness practice may be used to promote attachment and bonding in the immediate postpartum period. The symptoms of postpartum depression in both women and men are reviewed, including how to seek help if depressive mood is experienced. As practice for maintaining a sustained mindfulness practice after the class ends, participants are invited to practice without the CDs in the coming week.
MBCP class nine In class nine, an MBCP alumni couple and their new infant visit the current MBCP class to share how they used their mindfulness practice during childbirth and how they are continuing to use mindfulness in the often intense and challenging postpartum period. The remainder of the class is devoted to a course review and a closing graduation ceremony. Contact information is exchanged that serves to keep new parents connected between the time the course ends and the class reunion.
Participants are encouraged to continue their practice in the days and weeks before birth—and for the days, weeks, months and years after the birth of their child. Participants are referred to Myla and Jon Kabat-Zinn’s description of how mindfulness practices can be readily applied to parenting (Kabat-Zinn and Kabat-Zinn 1997) and they are also encouraged to continue meeting after the formal course ends to support each other and their continued practice of living and parenting mindfully.
MBCP class reunion The class reunion provides an opportunity for participants to reconnect with each other, meet each others’ babies, and reflect on what they learned from their birth experience. The couples are invited to share how they are learning and growing themselves as new parents, how they are applying mindfulness skills in parenting, and to express appreciation to and about their partner and themselves. MBCP participants are again encouraged to continue gathering, to provide support for each other and their continued use of mindfulness practice as a foundation for a way of parenting mindfully: with present moment attentiveness, nonreactivity, emotional awareness, nonjudgmental acceptance, and compassion for oneself and one’s baby (Duncan et al. 2009).
Three couples who signed up for the course did not attend after the first session due to logistical (work hours, transportation) issues. Because no exclusion criteria were applied, five women enrolled in MBCP too late in their pregnancies to complete the course prior to birth. These women did not provide post-intervention survey data because their babies were born prior to completion of the course (including one woman who delivered twins prematurely), but they did agree to participate in the qualitative post-birth follow-up. One couple declined to participate in the post-birth follow-up data collection. Among all engaged course participants (i.e., women and their partners who attended more than one session), the average attendance during pregnancy was 8.3 sessions out of a possible 10 sessions (class sessions 1–9, and the retreat day). Only data collected from the mothers is reported here.
Perceived stress was measured with the 10-item version of the Perceived Stress Scale (Cohen 1988). This scale was designed for use with community samples and is now the most widely used self-report measure of psychological stress. Participants respond how often (0 = never; 4 = very often) during the past month they experienced thoughts and feelings such as “felt that you were unable to control the important things in your life,” “been unable to control irritations in your life,” (α = .89).
Pregnancy anxiety was assessed with the revised Pregnancy Anxiety Scale (Levin 1991) containing 10 items regarding the degree of anxiety the mother feels during pregnancy about her own health: “I am worried about developing medical problems during my pregnancy,” the health of her developing fetus: “I have a lot of fear regarding the health of my baby,” and healthcare during parturition: “I am afraid that I will be harmed during delivery.” Participants respond about how often they have these thoughts and feelings (1 = never; 5 = always). The Pregnancy Anxiety scale has been shown to have good internal consistency (α = .80).
Positive and Negative Affect
Frequency The Differential Emotions Scale (DES; Izard 1977), modified, was used to assess the frequency of positive and negative affect during the previous week. This version of the DES was modified by Fredrickson (Fredrickson et al. 2008) to include additional positive affect items. The full scale assesses interest, enjoyment, surprise, sadness, anger, disgust, contempt, fear, guilt, shame, shyness, amusement, awe, contentment, gratitude, hope, love, pride, sympathy, and sexual feelings. The scale can be scored for total positive and negative affect. This modified DES has shown acceptable reliability with the positive emotions subscale, α = .79, and the negative emotions subscale with α = .69.
Intensity The Positive and Negative Affect Schedule (PANAS; Watson et al. 1988) was used to assess the intensity of positive and negative affect. The PANAS was designed to assess high activation positive affect (interested, excited, enthusiastic) and high activation negative affect (upset, irritable, ashamed). Moskowitz supplemented the original PANAS with lower activation positive and negative affect items. The final scale consists of 29 items (20 from the original PANAS; 9 additional). Respondents are asked to indicate how strongly they felt each affect during the past week on a scale from 0 = not at all to 4 = extremely. The modified version has been used in two ongoing studies (Moskowitz, 2008, Personal communication), where it showed good reliability (α’s = .88, .92 for positive affect and .92, .93 for negative affect).
Three of the subscales from the Five Factor Mindfulness Questionnaire (FFMQ) (Baer et al. 2006) were used to assess mindfulness: acting with attention and awareness, nonjudging, and nonreactivity. Subjects were asked to indicate agreement (1 = “never or very rarely true” to 5 = “very often or always true”) with a list of 19 statements about their general tendency to be mindful of experiences of daily life. Example items are: “I pay attention to how my emotions affect my thoughts and behavior,” and “I think some of my emotions are bad or inappropriate and I shouldn’t feel them” (reverse-scored). The FFMQ subscales have been shown to have adequate to good internal consistency (subscale α’s = .75 to .91) and convergent and discriminant validity in meditating and non-meditating samples (Baer et al. 2006, 2008). The Observing and Describing subscales of the FFMQ were not as central to study hypotheses as the other three facets, and were thus excluded to reduce participant burden.
An expanded version of the Ways of Coping, (WOC; Folkman and Lazarus 1988) was used. The WOC is among the most widely used coping inventories. Participants were asked to respond in relation to one stressful event or aspect of the pregnancy. One item was added to gauge whether/how often participants used meditation to cope with the pregnancy-related stressful event identified by the participant.
The widely used Center for Epidemiologic Studies Depression Scale (CES-D) (Radloff 1977) was employed to measure depressive mood. The CES-D consists of 20 items which are rated on a 4-point scale according to how frequently they were experienced in the previous week.
Post-birth, participants were asked to respond to a series of open-ended questions designed to elicit descriptions of their experiences of pregnancy, labor and delivery, and the early postpartum period. Questions included the following: “Did you continue to practice mindfulness, formally or informally, during the remainder of your pregnancy?,” “Did you use what you learned in the program to help you during your birth experience?,” “Was anything you learned helpful for managing emotional states, such as fear, during labor, delivery, or postpartum?,” and “How have you used what you learned in the program during your postpartum experience?”
Using a team-based, interpretive phenomenological approach to analysis (Benner 1994; MacQueen et al. 1998), we created a coding protocol that was expanded until both coders were satisfied that saturation had been achieved (i.e., all themes in the participant responses had been assigned a particular code). Both coders independently coded all responses, achieving an inter-rater agreement rate of 91.8% for agreement on 257 of 280 total codes assigned to participant response for these four questions. Disagreements were resolved through discussion. The first author identified key themes present within and across questions, both coders nominated representative quotes for each major theme, with final reporting of quotes determined by consensus.