Introduction
Giving birth to a new baby is a transformational process that brings changes in every aspect of a woman’s life. The transition to motherhood comprises many developmental tasks, including taking responsibility over the child day and night, forming a bond with the baby, adapting to changing relationships with the partner, forming a mother identity, finding and accepting support, finding a balance with other activities, and learning mothering (Nelson
2003). Learning mothering encompasses an endless list of abilities, including regulating the baby’s (emotional) states, and the mother’s own emotional reactions to the demands of the baby. When a new mother perceives that the demands she faces exceed available coping resources, she will experience stress (Lazarus and Folkman
1986), and chronic stress can result in mental health problems (Lupien et al.
2009). These difficulties have a higher occurrence in the presence of risk factors, such as a preterm birth (Nelson
2003), attachment insecurity of the mother (Feeney
2003), or lack of social support (Crnic et al.
1986). Also, difficult infant temperament can be a risk factor for mental health problems in mothers, even in the first month of a baby’s life (Britton
2011).
Although immediately after giving birth there is a rise in life satisfaction, over the many months to follow, this seems to decrease (Luhmann et al.
2012). Approximately half of women experience
maternity blues in the first couple of weeks post partum, a temporary mood disturbance with accompanying insomnia, fatigue, irritability, sadness, anxiety, and confusion (Reck et al.
2009). Although maternity blues symptoms are usually transitory, postpartum blues are not insignificant, as they constitute a risk factor for anxiety disorders and depression (Reck et al.
2009) and problems in maternal attachment to the infant (Nagata et al.
2000). As many as 19% of women experience depression in the first 3 months after giving birth to a baby (Gavin et al.
2005). Mood problems are not the only risk after giving birth: 9% of women develop a full-blown posttraumatic stress disorder (Alcorn et al.
2010), and an additional 18% have symptoms of posttraumatic stress. Around a quarter of women have other forms of clinically significant anxieties (Alcorn et al.
2010). Obsessive-compulsive disorder and generalized anxiety disorder, in particular, have a heightened prevalence in the postpartum period (Ross et al.
2006). Maternal stress or mental health problems may interfere with the mother’s ability to attune, regulate, and appropriately respond to their infant, which, in turn, increases the risk for problems in emotional, social, and cognitive development of the child (Crnic et al.
1986; Siegel and Hartzell
2003). High maternal stress (Pesonen et al.
2005) and maternal mental health problems (Henrichs et al.
2009; Titotzky et al.
2010) are predictive of infant temperamental difficulties.
The transition to motherhood is not only a period in which the chances of stress and mental problems are elevated; it is also a time with the potential for emotional growth for the mother (Feeney
2003). The importance of timely intervention in the case of vulnerabilities or the emergence of problems after the birth of a baby is unequivocal (Bennett and Indman
2003). This has the potential to improve maternal sensitivity towards her infant and prevent long-term consequences of maternal stress for the child (Bakermans-Kranenburg et al.
2003). At present, a variety of interventions for mothers with babies who experience stress in motherhood are already available. Depending on the nature of the problem, an intervention is chosen with either a primary focus on the mother, on the baby, or on the interaction between mother and baby.
In the case of mental health problems of the mother, the intervention of choice often focuses on the mother. When a mother has a depression or anxiety disorder, pharmacological treatment is often prescribed (Misri et al.
2004). However, the efficacy of antidepressants in postpartum depression is not unequivocal (Sharma and Sommerdyk
2013), and possible effects of antidepressant drugs in breast milk on the nursing infant cannot be excluded (Gentile et al.
2007). Therefore, effective non-pharmacological treatments may offer a preferable alternative to medication in the postnatal period (Dimidjian and Goodman
2009). Individual psychotherapy for the mother often alleviates the mother’s psychological complaints, but the baby may not be taken along in the process of change. A meta-analysis showed that individual psychotherapy for mothers is not effective in improving mothers’ sensitivity (Kersten-Alvarez et al.
2011). For mothers whose primary worries are focused on infant behavior, for example eating or sleeping, behavioral interventions are available that focus on the problem behavior of the child. However, attention to factors that may prevent improvement (e.g., the mother-child relationship or the inner world of the mother) may not be part of these programs. Another disadvantage of behavioral interventions is that they may not fit with the mother’s ideas about parenting and may undermine the mother’s intuition about what is right for herself and her baby (Douglas and Hill
2013). There are also interventions that focus on the mother-infant relationship or are aimed at improving maternal sensitivity, such as video-home training or parent-child interaction therapy. A disadvantage of these interventions is that mothers may miss concrete tools to deal with stressful situations and accompanying emotions.
An intervention that is designed to cope with stress is the mindfulness-based stress reduction (MBSR) training (Kabat-Zinn
1990). MBSR has shown to have beneficial effects in dozens of randomized controlled trials (De Vibe et al.
2012). Mindfulness can be defined as “paying attention in a particular way: on purpose, in the present moment, and non-judgmentally” (Kabat-Zinn
1994, p. 4). The MBSR training consists of meditations; inquiry, in which participants share about their experiences during meditations; and psychoeducation. This training is applicable and is being used worldwide for many different mental and somatic complaints. Mindfulness-based cognitive therapy (MBCT; Segal et al.
2002,
2012) is an important adaptation of MBSR, developed for people with (recurrent) depression. Dimidjian and Goodman (
2009), that have reviewed the evidence base for non-pharmacologic interventions for depression during pregnancy and the postpartum period, stated that the application of MBCT to at-risk perinatal women may significantly enhance prevention efforts. When MBCT is applied in this group of new mothers, adaptations might be beneficial. Mothers should be offered mindfulness not only as a way to relate differently to their own experience but also to their babies. That is, the mindfulness training should be transformed into a mindful parenting training.
In a training in mindful parenting, a term that was introduced by Kabat-Zinn and Kabat-Zinn (
1997), parents learn to cultivate mindfulness (thus intentionally bring non-judgmental awareness to their experience in the present moment) in parenting and in the relationship with their child. Bögels and Restifo (
2013) adapted the MBSR and MBCT trainings to a mindful parenting training for parents in a mental health care context. This training has been applied to different groups of parents (e.g., Bögels et al.
2014; Meppelink et al.
2016), but no adaptations so far addressed mothers who experience stress in taking care of their babies in particular.
Another adaptation to MBCT and MBSR was made to develop the Mindful Motherhood intervention for pregnant women; in a small randomized controlled trial, this intervention was shown to be effective in reducing anxiety and negative affect during pregnancy (Vieten and Astin
2008). Qualitative research showed that mothers that participated in the Mindful Motherhood intervention during their pregnancy went on to use mindful awareness in their relationships with their babies (Krongold
2011). Participants reported that mindful awareness helped them to reflect upon their experiences, to cope with distress, and to enhance pleasure with their babies.
Yet another mindfulness-based intervention (an adaptation to MBSR) for pregnant women is the Mindfulness-Based Childbirth and Parenting (MBCP) program. Two pilot studies among pregnant women showed that anxiety and depression symptoms decreased and that mindfulness increased after participating in MBCP (Duncan and Bardacke
2010; Dunn et al.
2012). Improvements maintained at follow-up 6 weeks post partum (Dunn et al.
2012). Qualitative reports from participants also showed perceived benefits of mindfulness in early parenting (Duncan and Bardacke
2010; Dunn et al.
2012). Another qualitative study showed that participants reported that they still practiced mindfulness 3 years after the program and that mindfulness practice improved their self-regulation and attunement to their child (Shaddix
2014).
Aforementioned follow-up measurements in the postnatal period of studies evaluating the Mindful Motherhood intervention and MBCP program show that mindfulness practice might be useful for mothers with babies. However, more rigorous changes to the program might be needed when mindfulness is taught to mothers in the postnatal period, as not only the mother’s needs but also the baby’s are at stake. Hassan (
2014) teaches mindfulness to mothers with infants in Mindful Mothers’ Groups; however, to the extent of our knowledge, no research on these groups is yet available. Also, Reynolds (
2003) has been facilitating mindful parenting groups, in which parents learn to quietly observe their babies with curiosity and to reflect on what they notice both in the babies and in themselves during the observation. Reynolds (
2003) offered mindful watching to the participating parents, to facilitate self-regulation of, and co-regulation between parent and baby, and improve parents’ mentalizing capacity. For this intervention, which is rooted in the infant mental health (IMH) and psychoanalytical tradition, only anecdotal evidence is available, which seems to point to a positive impact on the parent-child relationship. Although the groups aim at enhancing mindful awareness in parents, mindfulness theory and meditations are not explicitly taught.
A manualized mindfulness training that is adjusted to the needs of both mothers and babies might be of added value for women who experience stress (whether it is because of their own mental health problems, infant (regulation) problems, or mother-infant interaction problem) in mothering their baby. It may teach them tools that they can use to deal with stressful emotions and be more attentive and responsive to their own needs and the needs of their babies. Furthermore, it may offer mothers a holding environment in which they can safely reflect not only on behavioral aspects of their relationship to their babies but also on the inner world of both themselves and their babies. It may support the mothers’ intuition because parenting behaviors are not prescribed and no standpoint on different parenting methods that mothers may choose to employ is taken.
Although the literature about the effects of mindfulness training on mothers with babies is scarce, there is some scientific support for the benefits that mindfulness might have for mothers and babies. Maternal mindfulness during pregnancy has not only shown to be associated with less maternal prenatal and postnatal emotional distress but also with better social-emotional development of their babies (Braeken et al.
2016; Van den Heuvel et al.
2015a), less difficult infant temperament, and improved infant neurodevelopmental outcomes (Van den Heuvel et al.
2015a,
b). Also, postnatal mindfulness in parenting (not mindfulness in general) has shown to be predictive of infant stress regulation. In families with high life stress, maternal mindful parenting assessed 3 months post partum was associated with lower infant cortisol at 6 months (Laurent et al.
2016).
Siegel and Hartzell (
2003) used insights from the research fields of both attachment and neurobiology to explain how mindfulness might help parents to communicate well, and form secure relationships with their children, and how this impacts different parts of the child’s developing brain. When parents are preoccupied with the past or worried about the future, they are not available for their child to connect with them. Practicing mindfulness means practicing focusing attention on what is happening in the present moment, awareness of the inner experience, being open to the inner experience of the child, and recognizing the separateness of the child’s experience to one’s own experience. Self-attunement, self-care, and self-compassion of the parent form the basis for connecting with, and compassion for others, including a (young) child (Siegel
2007; Siegel and Hartzell
2003). When parents are mindful, they are able to direct their behavior, taking into consideration the (emotional) well-being of the child, and when parents communicate mindfully, they open the space for a child to gain a sense of self, learn to trust others, and build relationships (Siegel and Hartzell
2003).
Cree (
2010) explained how improving compassion in compassion focused therapy, an intervention that is related to mindfulness, can improve mother-infant attachment. Starting points are the three major affect regulation systems that interact with each other: a threat-based system and two positive systems, namely an incentive-seeking system and a soothing system. When the threat-based system is highly activated for a long period, the soothing system is suppressed. Cree (
2010) described how the soothing system can be stimulated, which will stimulate oxytocin production. Oxytocin then inhibits the threat-based system and opens the door to bonding of the mother to the infant and the development of a secure attachment and relationship between them.
The goal of the current study is to evaluate the effects of a mindful parenting group training, Mindful with your baby, for mothers and babies who were referred to a mental health clinic because of elevated stress or mental health problems of the mother, (regulation) problems of the baby, or mother-infant interaction problems. The Mindful with your baby training makes use of the same general meditation exercises and similar attitudinal foundations as the regular mindful parenting, MBCT, and MBSR trainings but is adapted to the presence of the babies and the themes that play a role for most mothers with a baby. We used a longitudinal design, with a pretest, posttest, 8-week follow-up, and 1-year follow-up. We hypothesized that Mindful with your baby would be feasible, acceptable, and effective in improving maternal mindfulness, mindful parenting, self-compassion, well-being, psychopathology, parenting stress, lack of confidence, warm and negative behavior towards the infant, and infant temperamental behavior. We expected that these effects would be maintained up to 8 weeks and 1 year after the training had ended.
Discussion
In this study, we aimed to evaluate Mindful with your baby, a mindful parenting training for mothers with infants aged 0 to 18 months. We hypothesized that Mindful with your baby would be acceptable for the participants and would improve maternal mindfulness, mindful parenting, self-compassion, well-being, psychopathology, parenting stress, lack of confidence, warmth and negativity towards the baby, and infant temperament and that these effects would maintain for 8 weeks and 1 year after the training had ended.
With respect to the first hypothesis, it can be concluded that Mindful with your baby is a feasible and acceptable program for mothers with infants, who experience stress in motherhood. Dropout and attendance rates were acceptable, all mothers who completed the evaluation form felt that they had gotten something of lasting value from the training, and participants rated the importance of the training with an average of 8.1 (scale 1–10).
In line with our second hypothesis, mothers became more mindful, both in general and in their parenting, and more compassionate towards themselves during the training, and this improvement was maintained during the 8-week follow-up period (medium to large effect sizes). Effects on mindfulness and mindful parenting are smaller than those on the regular mindful parenting training (Meppelink et al.
2016). It is important to note that the results were obtained when meditating with the babies present during most sessions, which gives a very different atmosphere than in a group of only parents, as was the case in Meppelink et al.’s study. Also, the meditations that were practiced at home were shorter (about 15 min) than in the regular mindful parenting training (about 30 min). Mindfulness and self-compassion (but not mindful parenting) further improved during the 1-year follow-up period (large effect sizes). Due to the limited number of participants that filled in the 1-year follow-up (about 60% of the research participants that had already been administered a 1-year follow-up measurement), results of the 1-year follow-up should be interpreted carefully.
There was a significant improvement in maternal well-being (small effect size). At pretest, the mean score was below the cutoff score for low mood and thus indicative of reduced well-being. At posttest and follow-up, mean scores were above this cutoff score. Also, there were improvements in maternal psychopathology. At posttest, somatic complaints, anxious/depressed, and aggressive behavior improved (small to medium effect sizes). At 1-year follow-up, all aspects of psychopathology had improved (medium to very large effects). Mean maternal psychopathology scores at pretest were at a clinical level for the internalizing scale and at a subclinical level for the total scale, the anxious/depressed subscale, and attention subscale, whereas at posttest and both follow-ups, all mean (sub)scale scores were in the normal range. It is not possible to rule out the possibility of spontaneous recovery of the mothers, related to the passage of time after giving birth and adjustment to motherhood. However, infant age was not related to any of the psychopathology outcomes, suggesting that passage of time alone was not responsible for recovery. Also, the improvement of maternal mindfulness during the 1-year follow-up period, and earlier research showing that mindfulness is the mechanism of action for psychological outcomes of mindfulness-based interventions (Gu et al.
2015; Meppelink et al.
2016), suggest that the further improvement in psychopathology up to 1 year after the training may be (partly) attributable to Mindful with your baby.
Maternal confidence in parenting improved over time (from a small to medium effect size), but maternal parenting stress took some more time to improve (small and medium effect sizes at 8-week and 1-year follow-up, respectively). Maternal responsivity improved at all three measurement occasions (small to large effects), maternal affection only at 1-year follow-up (small effect), and the last subscale that maternal warmth comprised of, attention, did not improve. Neither did maternal rejection, but the other subscale that maternal negative behavior was comprised of hostility did show improvement at the three time points (small effects). Mothers seem to recognize not only a change in internal experience but also a translation of this change to the way they behave towards their baby. It would be of interest to study whether this increased responsivity and decreased hostility can be observed in mother-child interactions before and after Mindful with your baby.
In this study, infant behavior was measured with a questionnaire measuring temperament. This choice might raise concerns, as most dimensions of temperament are regarded as relatively stable (Rothbart et al.
2000). However, it has been recognized that parental factors may influence infant temperament (Pesonen et al.
2005; Tikotzky et al.
2010). Rothbart (
1991) distinguished two components of temperament, self-regulation, and reactivity. In mindfulness-based interventions, both self-regulation and non-reactivity are trained. Possibly, these qualities in mothers may support the development of the same qualities in infants. Yu and Smith (
2016) showed that the joint attention between mothers and 1-year-old infants that was sustained by the mothers extended the duration of the attention of the infants. This is an example of a self-regulatory ability of the infant that develops in relationship with the mother.
Earlier research found an association between maternal mindfulness in pregnancy and infant temperament (Van den Heuvel et al.
2015a,
b). The current study shows that also after birth, the development of temperament, namely the development of positive affectivity, may be influenced positively when mothers practice mindfulness and mindful parenting. Although infant age was a significant covariate, the effect size of measurement occasion was in the medium range both at posttest and follow-up. A possible explanation is that babies become more positive when their mothers are more attentive towards them. Another explanation of this change is that, because mothers become more able to focus their attention on their infant with openness and curiosity, they might be able to recognize positive affect in the infant better. This might open opportunities for mother and infant synchrony, dyadic interactions that are mutually regulated, harmonious, and reciprocal (Reyna and Pickler
2009).
Infant temperament was reported by the participating mother. The question therefore can be asked, whether infant temperamental behavior really changed or whether mothers’ perception changed. Possibly, perception might be negatively biased before the training, due to psychopathology of the mother (Najman et al.
2000), or positively biased after the training. Where a bias to exist, this would not necessarily make the findings on infant temperament less important, as parental perceptions shape parental behaviors (Pauli-Pott et al.
2003; Tikotzky and Sadeh
2009) and thus the relationship with the child, which may lead to actual changes in infant temperament.
Infant age was not only predictive of infant behavior (positive affectivity/surgency and orienting/regulatory capacity) but was also a significant covariate in several models predicting maternal behavior (attention and affection) and mindful parenting. Mothers with an older infant gave their infants more attention, showed more affection, were more mindful in their parenting, and showed more compassion for the child. They were, however, more emotionally reactive. Possibly, emotional reactivity starts to play a bigger role when babies slowly develop into toddlers and start to show more challenging behavior.
Group was also used as a control variable; the fixed effect was significant in the majority of the models. The group that participants are part of seems to matter in the effect of the training. This difference in effect of the training between groups may depend not only on differences in trainers and IMH specialists but also on the composition of the groups, openness of the participants, and group processes.
Limitations
The findings of the current study should be interpreted, considering the following limitations. First, the lack of a control group or waitlist condition limits our conclusions on the beneficial effects of the training. People who suffer from stress or psychopathology tend to improve in functioning over time, especially when they decide to seek help. Second, the effects that were shown in this paper may be (partly) attributable to other factors, such as adjustment to motherhood with time or developmental stage at which the infant is in. Although infant age was shown to not be a significant covariate in this study, another study design addressing the additional dimensions of overall adjustment to parenthood is needed to rule out this possibility. The fact that the group of women with babies that participated in Mindful with your baby was not a randomly chosen group of mothers with elevated stress or mental health problems, babies with (regulation) problems, or mother-infant interaction problems is also a limitation. The participating mothers were not only from a sample referred for treatment but also actively chose for this training. Therefore, they may have been more motivated to benefit than referred mother who did not choose for this training. Another limitation is that a substantial proportion of participants (61% of the training participants and 65% of the research participants) received other forms of psychological help during the training and/or in the follow-up period. Because the Mindful with your baby program was new, and the effectiveness unclear, we found it unethical to withhold possible additional support from vulnerable participants in this essential time of their life. As a result of this practical decision, it remains unclear how much of the reported change is a result of mindfulness intervention. To reach firm conclusions about the effectiveness of this intervention, future studies should consider including a control group or waitlist condition in to the design. Yet, another limitation is the fact that all measurements were done only by the mothers who participated in the training. Given that they spend time and effort to the training, they may have been biased to attribute positive effects. Also, the use of questionnaires has its limitations. Parent report of child behavior may be more biased for parents of infants than parents of older children, because of lack of knowledge about normal development in infancy, and hesitance to report problem behavior in infants (Carter et al.
2009). Also, to reliably measure parent-child interaction, the use of questionnaires is not sufficient (Miron et al.
2009). Future studies should include observational measures (for example, sensitivity observations) and multiple informants (for example, the father reporting on child functioning and on maternal functioning).
Nevertheless, the current study provides initial evidence supporting the idea that Mindful with your baby is a promising intervention for mothers with infants who experience stress in motherhood or mental health problems. The attendance rates and positive evaluations suggest that Mindful with your baby is a feasible and acceptable intervention. Furthermore, the training seems to be effective, as was shown by improvements in maternal mindfulness, mindful parenting, self-compassion, psychopathology, well-being, parenting stress, lack of confidence, warmth, responsivity, and hostility. Infants also seem to benefit from the intervention, as was shown by improved positive affectivity.