A recent study, 'Benefits of preparing for childbirth with mindfulness training: a randomized controlled trial with active comparison,' was published in the journal BMC Pregnancy and Childbirth and made headlines when it suggested that a new approach to preparing for childbirth that addresses fear and pain may improve self-efficacy in birth, may reduce the use of opiates in labor, and may prevent symptoms of postpartum depression. While the number of participants was small, (n=30), this randomized controlled study yielded interesting results.

The researchers compared first-time mothers in their third trimesters who attended a 2.5-day Mind In Labor course focusing on mindfulness training for pregnancy and birth with women who attended standard childbirth education courses. In the Mind In Labor course, participants learn mindfulness tools to observe that labor pain is unpleasant physical sensations that come and go and they learn coping tools to work with pain and fear during the birthing process. As mindfulness is so prevalent in the media nowadays, several major newspapers, including The New York Times and The Guardian, reported the research.

So what IS the big deal? Mindfulness is a buzzword that's all over the place nowadays.

Based on ancient Buddhist practices, Jon Kabat-Zinn, Ph.D., a molecular biologist, developed a universalist program in the '70s called Mindfulness-Based Stress Reduction (MBSR) as a complementary approach to standard medical care to help deal with fear and pain. Nancy Bardacke, a Certified Nurse-Midwife and mindfulness teacher, realized how relevant mindfulness and Jon's research were to childbirth. She developed a nine-week course: Mindfulness-Based Childbirth and Parenting (MBCP) and a shortened, weekend course of 2.5 days, The Mind In Labor: Working with Pain in Childbirth (MIL). The latter program was the intervention group in the recently-published study. Nancy wrote the award-winning book, 'Mindful Birthing: Training the Mind, Body and Heart for Childbirth and Beyond', and produced a CD and App of mindfulness meditation practices for pregnancy.

In one of the comments to The NY Times article on mindfulness in birthing, a woman asked about Lamaze classes:

'Hmmm. 45 years ago I took an amazing, successful six-week Lamaze class that appears to have included virtually every point in mindfulness preparation. Focus on the breath, focus on conscious relaxation, visual focus on a point, simulated contractions using partner's hand squeezing on upper thigh, staying alert but busy with activities related to relaxation and breathing and focus...Whatever happened to Lamaze?' (Johanna).

The intention of this post is to understand what mindfulness is and how to improve the connection between Lamaze and mindfulness.

Mindfulness means getting off 'auto-pilot' and becoming aware of one's physical, mental and emotional condition in the present moment without judgment. In addition, it's an invitation to notice the stories we tell ourselves about our experiences which can often exacerbate our reactions, particularly fear.

Many people are scared of birth and worry about their ability to cope. During labor, these fears trigger the release of the stress hormones which inhibit the release of oxytocin, making labor longer and more painful. In labor, people often think about how intense the previous contraction was (thoughts about the past) or their thoughts may take them to the future, e.g. 'It took me x hours to get to this point, how much longer will this take?' Or 'Maybe I should get the epidural now as it's only going to get more intense.' Fear of the unknown (thoughts about the future) affects everyone.

Lamaze has traditionally taught expectant mothers and their partners to stay with 'just this contraction' as a means of keeping the laboring person in the present. Lamaze and mindfulness are similar in this regard and the MIL program goes one step further. Mindfulness, or moment-to-moment awareness, invites people to stay with 'just this breath'. Let's look at why that's important.

Mindfulness is often taught through meditation, when we can practice observing a variety of experiences, such as body sensations, thoughts and feelings, and accepting them without being influenced by them. Our natural, human, tendency is to resist what is painful or unpleasant. Resisting contractions increases the release of stress hormones, and can also lead to suffering because we want things to be different from how they are now.

The Body Scan, one of the practices taught in the MIL seminar, (it is not a relaxation exercise), teaches awareness of physical sensations in the body, rather than what a person thinks about the sensation or how they feel about it. Developing the ability to focus only on the physical experience of the sensation has the potential to change our relationship to our experience - meeting this moment and interacting with it rather than trying to control it or trying to resist it. This is a skill that is practiced in the MIL seminar so that we are able to use it under situations of pressure, such as labor.

In the Mind In Labor course, participants practice holding ice cubes to develop coping tools with a simulated pain stimulus. The coping tools vary from attention focusing or distraction techniques (also taught in Lamaze classes), e.g. focusing directly on the breath, counting breaths, visualizing the baby, focusing on all the parts of the body that are NOT experiencing intensity, etc., to mindfulness techniques, e.g. bringing a gentle curiosity to the sensation to really BE with the sensation, observing the changing nature of the sensation, or asking oneself, 'Is the awareness that observes pain/intensity in pain/intense?'

Lamaze childbirth educators used to simulate pain by having the partner squeeze the top of the pregnant person's thigh, as Johanna mentioned above in her comment to The New York Times article. Lamaze educators stopped using this technique decades ago as the partner is seen as a loving support person, rather than someone who inflicts pain on the pregnant person.

Many Lamaze classes use similar coping tools to those used in the MIL course, including holding ice cubes to simulate pain. In addition to many of the attention-focusing tools mentioned above, Lamaze educators often encourage people to be curious about finding their own coping mechanism during a simulated pain experience.

Many people confuse the attention-focusing, or concentration, techniques of Lamaze with mindfulness. What exactly is the difference between mindfulness and concentration? While they are both important in cultivating mindfulness practice, they are very different functions. Concentration is attention-focusing, on purpose, on a particular object, e.g. the breath, an image, a mantra, etc. Mindfulness is watching whatever comes into awareness, e.g. watching thoughts arise and pass without getting drawn into them, and it is mindfulness that notices when the mind has wandered into the past, the future, or into a story.

Mindfulness accepts whatever is here in the present. It doesn't mean that you have to like it, but it means getting off auto-pilot, or our usual reactivity of wanting to fix or resist an unpleasant experience. Acceptance doesn't mean, in the birth context, that we have to passively accept any intervention that is being offered when it may not be necessary or desirable. Rather, it means that if a situation is beyond our control, then accepting it rather than resisting it will allow us to see it in a clearer light, as a starting point to see what our possibilities are.

In a stress situation, which can be an objective situation, or even a negative thought or fantasy, the brain goes into survival mode and releases stress hormones that tell the body to fight, flee or freeze. When this happens, it is difficult to think clearly and to make rational decisions. Learning how to come back to the present moment and to ground oneself by focusing on the breath or on the contact of the body with whatever is beneath it, lowers the sympathetic nervous system (responsible for flight or fight responses) and activates the parasympathetic nervous system (responsible for rest and digest responses). When this happens, the mind comes back online and is able to think clearly. The attention-focusing techniques of Lamaze help in this way too.

A particular emphasis of the Mind In Labor program is practicing staying in the present moment not only during a contraction but also during the rest periods between contractions. As mentioned above, this is often a time when people focus on the past or the future. Many people go into 'what if' stories, which can greatly increase fear. Through mindfulness practice of watching my thoughts, and watching my emotions that are expressed in the body as tension, tightness, etc., I can catch these stories my mind is making up and bring myself back to the present, which is not so scary. Right now I am in the rest period and I'm ok. I can focus on the breath or the contact points of my body with what I'm standing on or sitting on to feel anchored and grounded in this moment.

Let's go back to the research study in question, referred to as the Prenatal Education About Reducing Labor Stress (PEARLS) study. It states: 'Childbirth education courses are the primary mechanism by which pregnant women learn strategies for coping with labor pain, yet childbirth education has limited efficacy for reducing childbirth fear and in some cases may even cause women to doubt their ability to cope with childbirth, increasing fear.'

Do Lamaze classes increase fear? What 'brand' of childbirth courses were included in the control group of the study? While the researchers excluded any CBE courses that had a mind-body or stress reduction component (specifically naming, as examples, Hypnobirthing and the Bradley Method), the control group CBE courses consisted of 'study-approved, standard hospital or community-based childbirth education' in the San Francisco Bay Area. After contacting the researchers, it is unclear at the time of this writing if any classes taught by LCCEs were included in the control group.

Participants in this randomized controlled test completed self-report assessments before the course, after the course, and post birth, and medical record data were collected. The factors measured were: childbirth self-efficacy, maladaptive pain appraisal, perceived pain in labor, the use of pain medication in labor, birth satisfaction, depression, and mindfulness and mindful body awareness. While both groups had a high incidence of epidural use, the MIL group felt more prepared for the birth, was less likely to use opioid pain medication during labor and had lower scores of prenatal and postpartum depression symptoms than the control group.

The contention is that childbirth education courses that are only information based increase fear, and CBE classes that are information and skills based and include a mind-body component were not included in the study control groups. In my opinion, Lamaze education fits into the latter category, but it's still unclear if it was part of the study.

The overall goal of Lamaze childbirth education is to increase women's confidence in their innate ability to give birth. A pivotal research study that all new Lamaze educators learn is by Ellen D. Hodnett, RN, PhD: 'Pain and women's satisfaction with the experience of childbirth: A systematic review'. This study showed that one of the main factors contributing to satisfaction of the birth experience is the person feeling involved in the decision-making process, regardless of whether or not they had an epidural or even a cesarean. The Lamaze Healthy Birth Practices enable people to advocate for themselves and to be a part of the decision-making process, which ultimately contributes to satisfaction of childbirth. Our role is to help families get evidence-based information and remain grounded with coping skills.

Fear of birth and negative birth experiences may lead to postpartum depression (PPD) and the research study found a reduction in PPD symptoms in the MIL group, while the control group experienced a rise in symptoms. This topic is of great importance in Lamaze childbirth education and the Lamaze educator includes resources in the community for anyone who might be experiencing symptoms of PPD. The recommended postpartum Lamaze reunion class is another opportunity for the Lamaze educator to connect with the new parents to help identify any PPD symptoms that may be present.

The conclusion of the study states: 'A large-scale RCT that captures real-time pain perceptions during labor and length of labor is warranted to provide a more definitive test of these effects' (Duncan, 2017).

Both forms of childbirth education, the Mind In Labor seminar and Lamaze childbirth education, have great value for expectant parents to develop confidence in their ability to have a safe and satisfying birth experience. While Lamaze Certified Childbirth Educators don't need to become mindfulness teachers, incorporating some of the mindfulness skills mentioned here may serve to attract childbearing families who are looking for new ways to prepare for the birth of their baby.

References:

Bardacke, Nancy: 'Mindful Birthing: Training the Mind, Body and Heart for Childbirth and Beyond' (Harper One, 2012)

Duncan, L. G., Cohn, M.A., Chao, M. T., Cook, J. G., Riccobono, J. and Bardacke, N.: 'Benefits of preparing for childbirth with mindfulness training: a randomized controlled trial with active comparison'. BMC Pregnancy and Childbirth (2017) 17:140

Hodnett, E.D.: 'Pain and women's satisfaction with the experience of childbirth: A systematic review' Am J Obstet Gynecol 2002;186:S160-72

Kabat-Zinn, Jon: 'Full Catastrophe Living: Using the Wisdom of your Body and Mind to Face Stress, Pain and Illness' (Bantam; Rev. Upd. Edition 2013

About Rachelle Oseran

Rachelle Oseran is a Lamaze Certified Childbirth Educator and FACCE with 33 years of teaching experience and has prepared more than 3000 couples for birth. She is a qualified instructor of MBCP (Mindfulness-Based Childbirth and Parenting) and the Mind In Labor seminar, having studied mindfulness for the past 9 years, training with Nancy Bardacke, CNM (author of Mindful Birthing - Training the Mind, Body, and Heart for Childbirth and Beyond) and mindfulness instructor-trainers accredited through the Center For Mindfulness of U. Mass. Medical School. She is a DONA certified birth doula and a certified yoga instructor. Rachelle lives in Jerusalem, Israel, with her husband, 3 sons and 2 daughters-in-law. She currently teaches Lamaze classes, a Lamaze-accredited childbirth educator training course, Mindfulness-Based Childbirth and Parenting courses, the Mind In Labor seminar, and yoga classes. She co-leads annual mindfulness trips to India and presents workshops in Israel and around the world.

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