An evaluation of mindfulness-based childbirth and parenting courses for pregnant women and prospective fathers/partners within the UK NHS (MBCP-4-NHS)☆
Introduction
It is well documented that perinatal depression and stress represent significant health issues, with approximately 1 in 5 women experiencing depression, anxiety, or other emotional difficulties during pregnancy, birth and the postnatal period (Department of Health 2007, Department of Health 2011, Davé, Petersen, Sherr and Nazareth, 2010, Independent Mental Health Taskforce Report to the NHS in England, 2016). Studies suggest the prevalence of prenatal anxiety and depression ranges from 13% to 21% and the postpartum prevalence ranging from 11% to 17% (Fairbrother et al., 2015). These issues have serious detrimental effects with perinatal psychiatric disorder being a leading cause of maternal mortality for the last two decades, contributing to 15% of all maternal deaths in pregnancy, and the first six months postpartum (Lewis, 2011), largely as a result of deaths by suicide. Furthermore, parental mental health problems during the perinatal period have the potential to interfere with mother-child interactions (Stein et al., 2012) and child emotional, behavioural and cognitive outcomes (Luoma et al., 2001, O'Connor et al., 2002, Ramchandani et al., 2008). For example, research suggests that if a mother is in the top 15% for symptoms of anxiety or depression while pregnant, her child has double the risk of a probable mental disorder by the age of thirteen (Talge et al., 2007). Why is unclear, it could be due to environmental, genetic, factors, or both, or may be mediated by many other factors. However, questions around which type of parental intervention might improve child and parent outcomes, whether an intervention should be delivered as a treatment or prevention, and through which mechanisms of action these interventions might work has formed the basis for many studies over the last three decades. For postpartum depression alone interventions investigated have included those based upon Interpersonal and Cognitive-Behavioural models (Werner et al., 2015).
Importantly, it is not only diagnosable mental illness in mothers which is associated with poorer outcomes for children, but also a range of objective stressors and subjective stresses (including symptoms at sub-clinical levels Glover, 2014). Reducing perinatal distress is a vital public health goal and recent Department of Health reports have continued to call for evidence-based interventions, targeting families at risk of mental health difficulties as well as offering improvements in antenatal education (McMillan et al., 2009, Marmot, 2010, Department of Health 2010, Department of Health 2011). Improving life chances for children and families through robust mental health is also crucial to addressing health and social inequalities in the UK (Marmot, 2010). The question remains, however, of how best to do this without increasing stigmatisation and whilst also promoting social inclusion. A universal, population-based, antenatal education programme addressing the needs of all, whilst teaching skills that decrease vulnerability to stress, anxiety and depression would seem optimal. If such an intervention was also able to offer these skills to both expectant mothers and prospective fathers/partners this would also provide the whole family with the best possible chance of optimal mental health. A systemic inclusive community/public health approach also seems potentially more powerful and synergistic than an intervention targeting only one individual or dyad. Indeed, an evaluation of mindfulness classes for staff in maternity services in the UK NHS services in Oxford recently indicated a positive impact not only on personal factors but also in the organisational domain (Warriner et al., 2016).
Research continues to evolve demonstrating that the practice of mindfulness can generate improvements in a wide range of psychological and physiological health conditions (Woolhouse et al., 2014, Surawy et al., 2015, Liu et al., 2013, Dunn et al., 2012, Duncan and Bardacke, 2010, Dimidjian and Goodman, 2009, Grossman et al., 2004, Khoury et al., 2013). Although it is important to note that many of the studies in the field remain exploratory, have methodological weaknesses and/or do not include active control conditions (Dimidjian and Segal., 2015), a recent systematic review and meta-analysis of mindfulness-based interventions concluded that mindfulness meditation improves pain, depression symptoms and quality of life (Hilton et al., 2017). Indeed Mindfulness-Based Cognitive Therapy (MBCT) has been shown through high-quality Randomised Controlled Trials (RCT's) to significantly reduce the recurrence of depression (Hofman et al., 2010, Kuyken et al., 2016) and now forms part of the UK National Institute of Clinical Excellence (NICE) guidelines for the prevention of depression (NICE, 2009). In addition, an RCT exploring the Mindfulness-Based Stress Reduction Programme (MBSR) for patients with chronic pain, chronic illness and stress concluded that the programme was not only associated with improvements in several patient-centred outcomes, including pain and psychological symptoms over a 1-year period, it also led to reductions in health service utilisation (primary care and emergency department services) up to 18-months later (McCubbin et al., 2014). Similarly MBCT was also shown to reduce Canadian non-mental health care service utilisation 1-year post-therapy compared controls (Kurdyak et al., 2014).
Since mindfulness based programmes have been shown to be helpful for pain and depression at other points in the life-cycle and have the potential to reduce use of health services the potential for these interventions during the perinatal period has begun to be explored (Dimidjian et al., 2015, Woolhouse et al., 2014, Guardino et al., 2013, Dunn et al., 2012, Duncan and Bardacke, 2010). Duncan and Bardacke (2010) observed a decrease in pregnancy anxiety and an increase in mindfulness and positive affect following a nine-week Mindfulness-Based Childbirth & Parenting (MBCP) course but this was not a controlled study. Nor was a study by Dunn et al. (2012) which found that 75% of participants in a mindfulness treatment group experienced a decrease in stress symptoms, and 67% showed positive change in levels of stress and self-compassion at three-month follow-up. Similarly, in a non-randomised study Dimidjian et al. (2015) found that their perinatal mindfulness intervention showed promise as an acceptable, feasible, and clinically beneficial brief psychosocial prevention option for pregnant women with histories of depression.
Woolhouse et al. (2014) designed and conducted a study of in two parts (1) a non-randomised trial targeting women at risk of mental health problems (a selected population; n = 20) and (2) a randomised controlled trial (RCT) of a universal population (n = 32) receiving either a 6-week mindfulness-based programme or care as usual. Significant improvements were noted for depression, anxiety and mindfulness scores for the selected population in the non-randomised study, and significant improvements were noted in anxiety and mindfulness scores in the randomised trial with a non-clinical population. In one of the first randomised controlled pilot trials of a mindfulness meditation intervention during pregnancy Guardino and colleagues (2013) found some evidence that mindfulness training during pregnancy may effectively reduce pregnancy related anxiety and worry.
More recently a systematic review and meta-analysis of mindfulness-based interventions in pregnancy found that mindfulness-based interventions may be beneficial for outcomes such as anxiety, depression, perceived stress and levels of mindfulness (Dhillon et al., 2017). Similarly a systematic review of the effectiveness of mindfulness-based interventions (MBIs) on maternal perinatal mental health outcomes offered preliminary evidence for the effectiveness of MBIs in reducing perinatal anxiety. The review suggested that as MBIs are a non-pharmacological approach to maternal distress likely to be acceptable to women in pregnancy they could therefore be integrated into existing programs of pregnancy care (Shi and Macbeth, 2017).
Of these interventions, MBCP teaches both the skill of mindfulness meditation as well as traditional antenatal education regarding the process and physiology of childbirth, positions for labour etc. and moves beyond the birth into parenting (Duncan and Bardacke, 2010). Furthermore, it includes all of the original components of the traditional MBSR programme and involves fathers/birth partners as equal participants, although the impact on paternal mental health was not explored in this paper (Duncan and Bardacke, 2010). The Mindfulness Based Childbirth and Parenting (MBCP) approach is informed by revised Stress and Coping Theory (Folkman, 1997) and mindfulness theory (Brown et al., 2007, Wallace and Shapiro, 2006, Kabat-Zinn, 2003). Mindfulness allows for an appraisal process involving greater flexibility and accuracy of perception in the moment, as well as greater acceptance of and less mental reactivity to whatever is taking place on a somatic, cognitive, affective or behavioural level (Duncan and Shaddix 2015). This capacity for being fully present when applied during childbirth supports the process of labour, both psychologically and physiologically (Bardacke, 2012). Mindfulness practice also increases positive affect (Bränström and Duncan, 2014) which serves as a restorative resource to support adaptive coping with stress (Folkman and Moskowitz, 2000). Mindfulness applied in the moment-to-moment process of parenting could also support interpersonal, present-centred, non-judgmental awareness and compassion (Duncan et al., 2009), thereby promoting healthy parent-child attachment (Duncan and Shaddix, 2015).
Crucially, MBCP has also been investigated in a brief 18-h form known as Mind-in-Labor (MIL) (Duncan et al., 2014) with a RCT (n = 30) comparing MIL program participants with those who had attended a standard childbirth preparation class without a mind-body focus (Duncan et al., 2017). Compared to the controls, “MIL participants showed greater childbirth self-efficacy and mindful body awareness (but no changes in dispositional mindfulness), lower post-course depression symptoms that were maintained through postpartum follow-up, and a trend toward a lower rate of opioid analgesia use in labor” (Duncan et al., 2017). For the reasons outlined above and with the financial constraints of the UK NHS in mind, including the fact that many traditional NHS antenatal education programmes are only a few hours long, (Barlow et al., 2009, McMillan et al., 2009) it was decided that a brief MBCP based-programme was the most suitable mindfulness-based programme for investigation within the NHS services.
In summary, several studies have suggested that the acquisition of mindfulness skills appears to have a positive impact on the mental health and well-being of pregnant women and perhaps also their families. In addition, although these skills are applicable to pregnancy, childbirth and parenting, perhaps more importantly they are transferrable skills for life, that can be applied at a systemic level for communities and public health which may reduce health service utilisation and promote social inclusion. This pilot study explores whether a brief mindfulness-based childbirth and parenting programme can be feasibly implemented within NHS maternity services as well as some potential maternal and paternal outcomes which, if shown to be promising in this pilot, could later be more fully evaluated in terms of effectiveness and efficacy through a larger controlled trial study.
Section snippets
Participants
Study participants were self-referrals to face-to-face Mindfulness-Based Childbirth and Parenting (MBCP) courses from Oxfordshire maternity services. 155 individuals (86 women and 69 men) took part in the MBCP courses between October 2014 and January 2015. Of these, 100 participants (64 women and 36 men) completed the pre-course questionnaires and 55 participants (36 women and 19 men) completed both pre and post course questionnaires.
Procedure
Posters advertising the MBCP course were displayed in the
Data checks
The data was checked for outliers and issues with score distribution. Shapiro Wilk's tests indicated significantly non-normal scores for the sample of mothers for the frequency of pre-course uplifts, W(34 )= 0.255, p = .000, and hassles, W(34 )= 0.220, p = .000. Interpreting these results in conjunction with histograms, the analyses using the PES was conducted using bootstrapped testing. Missing data was marked as missing in SPSS and not included in analysis. Where questionnaires were missing
Discussion
The aim of this pilot study was to explore the feasibility of implementing a brief Mindfulness-Based Childbirth and Parenting (MBCP) course into UK NHS services (MBCP-4-NHS) and to explore the potential of a few outcome measures for a larger RCT. Previous research has started to evaluate MBCP courses for mood improvements during and after pregnancy, but thus far this research has been limited to the USA, sample sizes are small, general and pregnancy related measures have not always both been
Implications for future work
More research of this brief 4-week MBCP course using a larger sample with a control group is needed. In addition, research to investigate whether similar benefits are seen with different populations would be beneficial especially with individuals who may be more susceptible to low mood, have less access to mindfulness-based courses and represent a more diverse population. However, the results provide justification for a larger scaled controlled trial of MBCP-4-NHS within the UK NHS.
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Prepared for submission to ‘Midwifery’.
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CC is a researcher at the Oxford Mindfulness Centre supported by the Wellcome Trust [104908/Z/14/Z] but does not receive additional remuneration for training workshops or presentations related to mindfulness based interventions