Mindfulness-Based Childbirth and Parenting (MBCP): A health promotion model of childbirth education?

Nancy Bardacke Founder, Mindfulness-Based Childbirth and Parenting (MBCP); Lead, MBCP Programme, University of California San Francisco (UCSF), Osher Center for Integrative Medicine; Assistant Clinical Professor, UCSF School of Nursing, USA
Maret Dymond Lead Clinical Psychologist, Mindfulness-Based Childbirth and Parenting, Department of Psychiatry, University of Oxford, UK

Can mindfulness practice address some of the complex issues facing this generation of expectant parents, assisting them not only to obtain the healthiest births possible in each of their unique circumstances, but also to learn life skills for healthy parenting and living in the world of today?

Nancy Bardacke
In the beginning, 1989…
As I entered the examination room, I saw the look of fear on the faces of Anna and her husband, Vincent.  Ten weeks pregnant, Anna had called early that morning to report that she was having some bright red bleeding.  I had asked her to come into the clinic to get checked.  After a few questions to update myself on the situation - no, there was still no cramping; no, the bleeding had not gotten heavier - I asked Anna to lie back on the table so I could listen for the baby’s heartbeat.  Tears of joy followed as the welcome sounds ‘tha- thump, tha-thump, tha-thump’ from the baby’s heartbeat filled the room.    
This joyous moment was soon followed by some difficult ones, for I could not reassure Anna and Vincent that all would be well with their pregnancy in the days ahead.  I did not know, nor could I predict that.  All I could tell them was that right now, all was well.  As a midwife for some 18 years and meditation practitioner for almost a decade, how I wished Anna and Vincent had a mindfulness practice to anchor them during this hard period of uncertainty and to help them fully live the joys and challenges that might lie ahead - including the pain, fear and inherent unknowns of the birth process and parenting.   
Fast forward to the moment of conception of the Mindfulness-Based Childbirth and Parenting (MBCP) program.  It was early spring, 1994, and I was sitting in a large meditation hall in Watsonville, California, with 100 other healthcare professionals.  We were attending an introductory training retreat in Mindfulness-Based Stress Reduction (MBSR) with Jon Kabat-Zinn, founder of the MBSR Program and his partner, Saki Santorelli.  In one electric, heart-mind stopping moment, I realized that here might be a way I could share mindfulness meditation practice with the population I knew so well, expectant families living through the transformative process of becoming parents.  I didn’t know then whether it would be possible, but there wasn’t a doubt in my mind that I was going to find out.  

A historical perspective
When antenatal education began in the mid-1960s, it was in reaction to the medicalization and lack of compassion surrounding the birthing experiences of so many women and their partners.  At that time, giving birth in isolation while heavily sedated with amnesiac medications was the norm.  Early in the grassroots childbirth education movement, there was a general bias toward ‘natural’ childbirth’ with the belief that information about the birth process, such as the stages of labor, and training in breathing and relaxation techniques, would go a long way to achieving healthier and more satisfying childbirth experiences.  As childbirth preparation classes became incorporated into hospital settings, information offered in a didactic format became more pronounced, leaving little time for skills building or to address the deeper emotional and psychological aspects of this profound transition to parenthood.
Now almost 50 years later, there is a whole new perspective on and set of questions about the myriad of interrelated factors that support or hinder a healthy physical and emotional pregnancy, childbirth, transition to parenthood and the critical early parenting years.  For example, what is the impact of stress on a pregnant woman and her developing baby, and particularly, its role in preterm birth?  What is the relationship between a laboring woman, her partner and the healthcare provider’s mindset regarding the process of childbirth and the use of technology, medications and surgical deliveries?  What are the short and long-term consequences of anxiety, stress and depression during pregnancy and the postpartum period for the mother, her partner, the infant and the family unit as a whole?  How are patterns of parenting behaviors, both healthy and unhealthy, passed on from one generation to the next?  And is contemporary childbirth education able to address these important issues effectively?  Research is showing that in its traditional form, it may not (Gagnon & Sandall, 2007).
Twenty years have passed since that moment in Watsonville when I set my mind to create a childbirth education course that would offer an opportunity for expectant couples to learn mindfulness meditation. What I have repeatedly witnessed and heard from the several thousand expectant parents whom I have taught through both the Mindfulness-Based Childbirth and Parenting course, and innumerable workshops, has led me to seriously consider whether mindfulness practice might indeed provide a way to address some of the more complex issues facing a new generation of expectant parents. (For a synopsis of the MBCP programme, see Bardacke & Duncan, 2014)
The Mindfulness-Based Childbirth and Parenting program is a formal adaptation of the world-renowned Mindfulness-Based Stress Reduction (MBSR) program.  A substantial body of empirical evidence shows the MBSR program to be effective in reducing stress, anxiety, depression and chronic pain in the general population (see Duncan, 2015).  By combining the awareness practices and ways of teaching used in the MBSR program with the knowledge of the physiology of pregnancy, birth and the early postpartum period garnered from my many years of midwifery practice, the MBCP program offers expectant parents a way to not only prepare for childbirth and parenting but a way to cultivate greater physical and mental health and well-being through increased self-understanding, wisdom and compassion. (Duncan and Bardacke, 2010).

Case Study
Gillian attended a 9-week Mindfulness-Based Childbirth and Parenting course.  During the second week, when the home assignment was to eat one meal mindfully, she sent this email: ‘I am practicing mindful eating all day today and it is wonderful. I have always had a problem with binge eating (a family pattern) and I feel like mindfulness practice may be the solution I’ve been looking for!’  
A week after giving birth, Gillian sent another email. ‘Mark and I applied everything we learned to my labor and had an amazing birth experience. It was a 46 hour labor with four hours of pushing. And although at the time, I was in much discomfort, I found that as long as I stayed in the present moment, taking it one contraction and one push at a time, I could do it!  
And a third email came seven weeks later: ‘Our little Adrienne is now two months old and being a good mother, a nurturing mother, is way more difficult than labor. I continue to apply my mindfulness learning to my parenting, especially the Loving-kindness practice because I am so very hard on myself.  Mark is still using the practice, too, and I think we are becoming a pretty good parenting team.  I am so grateful that we took the course!’

Maret Dymond
And another beginning…
It was 2007 and I was searching for a mindfulness-based antenatal programme to help my husband and I prepare for the birth of our first child.  As a Clinical Psychologist with an established mindfulness practice, a PhD in perinatal psychology, and a teacher of Mindfulness-Based Cognitive Therapy (MBCT), I was looking for a way to apply what I already knew to this momentous new stage of my life.
On my internet searches, I found nothing in the UK that was fundamentally a mindfulness-based antenatal programme. However, I did come across Nancy Bardacke’s work in California and knew instinctively that this was what we needed. Unfortunately, a nine week stay in the US was not possible and so we made it up as best we could.  I attended the three to four hours of antenatal education offered by the National Health Service (NHS), and noticed that afterwards, many of us remained fearful about what might lie ahead.  And I continued to use my mindfulness practice to work with my fears and the unknowable future.
Giving birth to our daughter was a huge challenge and afterward, I marveled that women managed to give birth without having practised how to ‘be with’ intense physical sensations, difficult emotions and uncertainty beforehand.  As parenthood unfolded, I wondered how in the world we might have coped without having the qualities of mindfulness to guide us. Patience, trust, acceptance, curiosity and compassion for the baby, and ourselves, kept us grounded, especially when exhaustion, anxiety and frustration were so abundant.
When our daughter was a few months old, I decided something had to be done to better prepare expectant families. In my research, I once again came across Mindfulness-Based Childbirth and Parenting (MBCP), this time via a secondhand book seller in New York. I immediately ordered what I thought was a book by Nancy Bardacke. However, when ‘the book’ arrived, I was surprised to discover that it was in fact two slightly crumpled, annotated, copies of an A4 notebook that must have been given to an expectant couple during one of Nancy’s classes!
And so began an exciting journey of connection to MBCP. I trained with Nancy to teach, attending the workshop in 2011 organized by Sian Warriner, Consultant Midwife at Oxford University Hospital’s NHS Trust, where Nancy first taught an MBCP workshop to UK expectant couples and midwives (Warriner et al., 2012).  I travelled to California with Sian in 2012 to participate in one of Nancy’s training retreats for perinatal healthcare professionals.  And when I birthed my second baby, my husband and I used everything we learned from MBCP for the labour and a particularly difficult postpartum experience.  Today, I lead the Mindfulness-Based Childbirth and Parenting project at the University of Oxford Mindfulness Centre (OMC) and continue to collaborate closely with the Oxford midwives.
We are learning, as Nancy did, that expectant parents benefit greatly from this approach to childbirth education. They appreciate the opportunity to explore the territory of pain and fear and are often surprised by their own ability to skillfully work with these. In addition, they speak about the renewed connection they feel with their partner and their gratitude for the support of the group. Learning to approach the body and mind in this way for life’s challenges is not easy. It takes time and commitment to practise and those who are able to do so discover the joys are plentiful.  
It is inspiring to witness a mother with extreme fear of childbirth cancel an elective caesarian because she now feels confident enough in her own strength to go through the birthing process.  It is energizing to see an expectant father understanding that his attitude towards the world is one of fear and discovering joy, kindness and self-compassion for himself and his baby.  It is humbling to hear how the couple whose first baby died during labour were able to stay present during the birth of their second, observing their fear without getting lost in it.  And it is deeply moving to see how both parents can leave with something extraordinarily valuable if they stay open to the practices and experiences offered within the programme.  As one initially skeptical father put it at the end of the course: ‘I came for my partner; I stayed for the baby and now I’m practising for me’.

Birthing the future
Since the publication of Bardacke’s book, ‘Mindful Birthing: Training the Mind, Body and Heart for Childbirth and Beyond’ in 2012 and its subsequent translations into Dutch, German and French, the requests for trained MBCP teachers has grown substantially. Training sufficient numbers of Mindfulness-Based Childbirth and Parenting instructors without compromising the essential nature and integrity of what is taught is a very real challenge.  Becoming a mindfulness teacher takes time, patience, commitment and above all, one’s own personal mindfulness practice. With the explosion of interest in mindfulness over the past decade, it is critical that those teaching all mindfulness programmes do so with authenticity, competence and safety so as not to unintentionally dilute the huge potential and power of this approach.   
At present, the Mindful Birthing and Parenting Foundation and the Oxford Mindfulness Centre (OMC) are collaborating to develop high-quality training in this ground-breaking approach to antenatal education, including an online training component. In the US, the Mindful Birthing and Parenting Foundation has trained instructors in nine different countries. In the UK the original Oxford midwives have completed their teacher training and more professionals are in the process of being trained through the Oxford Mindfulness Centre’s Foundations Course in Teaching Mindfulness.   We are also exploring ways to adapt the MBCP programme to meet the needs of more vulnerable populations in our respective countries, such as the partnership with the Centering Healthcare Institute (CHI, 2014) in the USA bringing group prenatal care to low income families, and the work of Sian Warriner and Janine Beck in Oxfordshire, UK, with at-risk populations. And we continue to work in collaboration with our research colleagues around the world exploring the many new and exciting questions that this work invites us to ask (see accompanying article by Larissa Duncan).

What we call the beginning is often the end.
And to make an end is to make a beginning.  
The end is where
we start from.  
T.S. Eliot

And for those of us who serve expectant families, might it be time for us to begin again too? With a new application of a very old way to train the mind, might we have an opportunity to expand the existing paradigm of childbirth education?  Could childbirth education become a profoundly transformational learning experience, an experience where expectant parents cultivate the healthy mind-body life skill of present moment awareness, an awareness that has the potential to benefit themselves and their children as they grow and parent the next generation?

Bardacke, N. (2012) Mindful Birthing: Training the Mind, Body and Heart for Childbirth and Beyond. New York: HarperOne.
Bardacke, N., Duncan, L. (2014) Mindfulness-Based Childbirth and Parenting: Cultivating Inner Resources for the Transition to Parenthood and Beyond. In Baer, R. (Ed) Mindfulness-Based Treatment Approaches: Clinician’s Guide to Evidence Base and Applications. London: Academic Press.
Centering Healthcare Institute (CHI) (2014) <Available at> http://www.centeringhealthcare.org [Accessed: 08 December 2014]
Duncan, L.G., Bardacke, N. (2010) Mindfulness-Based childbirth and parenting education: Promoting family mindfulness during the perinatal period. Journal of Child and Family Studies, 19 (2):190-202.
Gagnon, A.J., Sandall, J. (2007) Individual or group antenatal education for childbirth or parenthood, or both: Cochrane Database Systems Reviews, CD002869.
Warriner, S., Williams, J.M.G., Bardacke N., Dymond M. (2012) A mindfulness approach to antenatal preparation. British Journal of Midwifery, 20(3):194-198.



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