Learning Objectives:After participating in this continuing professional development activity, the provider should be better able to:
1. Identify pregnant patients who may benefit from mindfulness-based interventions.
2. Develop an evidence-based mindfulness program that can benefit the average prenatal patient.
3. Compare the effectiveness of mindfulness-based programs with other standard therapies for pregnancy-related disorders.
The practice of mindfulness and meditation has origins in multiple Eastern religions. Documentation of these practices extends over more than a thousand years. In recent years, Western medicine has explored the psychologic and physiologic benefits of meditation, specifically mindfulness-based practices. Pregnant women have more recently become the focus of mindfulness-based programs, as they are a unique population that can potentially benefit from nonpharmacologic treatment options. Most of the early mindfulness-based programs focused on psychiatric conditions including stress, anxiety, and depression. All of these conditions are commonly seen in the pregnant population. Furthermore, many circumstances surrounding pregnancy can also be stress-inducing, including preparing for labor, labor pain management, and complications such as preterm premature rupture of membranes. The utility of mindfulness-based programs for the prenatal population has been explored in this article.
Introduction to Mindfulness Principles
Mindfulness is one part of the early Buddhist practice of meditation, a multistage pathway that develops awareness, concentration, and insight to better understand our own desires, suffering, and relationships with other beings.1 Today, mindfulness is considered the practice of being present with one's thoughts, emotions, and physical body in a nonjudgmental manner. The basic terminology important to the general understanding of mindfulness-based practice is outlined in Table 1.
The Development of Mindfulness as an Intervention
Mindfulness-based stress reduction (MBSR), developed using the principles of Buddhist meditation, was first codified and implemented by Jon Kabat-Zinn in 1979.1 Since Kabat-Zinn's implementation of MBSR, there has been a distinct rise in the therapeutic uses of its practice in medicine. As interest in the use of mindfulness-based practice grows, so too does the body of research regarding its therapeutic potential across a variety of diseases and populations.
Currently, one of the most common forms of nonpharmacologic treatment for psychiatric illnesses is cognitive-behavioral therapy (CBT). CBT aims to train the participant to be better aware of their thoughts and actions and to better control their behavioral responses in their day-to-day interactions. Although this has proven to be an effective method of treatment for many people, it is a time-intensive and sometime inaccessible option. MBSR stems from a similar concept but is often more accessible and less time-intensive. Therefore, it may be a viable replacement for those that cannot use CBT. The utility of MBSR has also been studied for conditions in which CBT is not a primary treatment option, furthering its scope as a nonpharmacologic therapeutic option.
Physiologic Effects of Mindfulness-Based Practices
In an effort to demonstrate psychologic and physiologic effects of mindfulness-based practices in an objective manner, several studies have investigated the effects of these practices in the context of neuroplasticity. Studies using functional MRI (fMRI) technology have been conducted using experts in various forms of meditation to monitor changes that occur in blood flow to the brain.2
A study using Theravada Buddhist monks demonstrated that these expert meditators' brains had undergone functional reorganization after years of intensive practice. These researchers argued that meditation-related neuroplasticity was likely to have occurred for these expert meditators, especially in activity patterns of the prefrontal cortex and insular areas.
Another study used fMRI to investigate changes in cortical perfusion patterns of long-term practitioners of transcendental meditation.3 Significantly higher blood flow patterns were observed in executive and attention areas of the brain, namely the anterior cingulate and dorsolateral prefrontal cortices. Furthermore, significantly lower levels of blood flow were seen in the pons and cerebellum, 2 of the arousal areas of the brain.
Recent research into the physiologic effects of yoga may also shed some light on the potential physical changes that may occur with focused practice. Hatha yoga combines movement, meditation, and pranayama-or breathing techniques-to produce physical, emotional, and cognitive benefits.4 In a study of hatha yoga experts, oxygen utilization, carbon dioxide output, and proportions of lipids metabolized were measured during various portions of a hatha yoga session. During meditation, participants experienced a significant reduction in metabolic rate when compared with pranayama and rest. In contrast, pranayama yielded a significant increase in metabolic rate when compared with meditation and rest. Other notable findings were a reduction in heart rate and a significantly lower total caloric expenditure during the meditation portion of hatha yoga. Overall, these findings suggest that the practices of yoga, meditation, and breathing exercises can have profound physiologic effects.
Mindfulness and General Health
Managing a life-changing chronic disease can be difficult and stress-inducing. This increased stress can worsen disease outcomes and lead to compromised immune function, social isolation, and a decreased quality of life.5 Given this association between the mind and physical response, MBSR programs have been used in the management of chronic disease.
Psychiatric diagnoses are the most common focus of mindfulness programs in health care, likely due to the initial goals of mindful meditation such as focusing attention and retraining thought patterns. One randomized controlled trial compared the effectiveness of mindfulness-based group therapy to the standard of care, primarily CBT, for a number of psychiatric conditions.6 After 8 weeks of treatment, both groups showed significant improvements in all 9 subscales on the validated Symptom Checklist-90 (SCL-90), a survey which assesses a large range of psychiatric symptoms. Without a significant difference between the 2 groups, this study provides evidence that mindfulness-based group therapy may be as equally effective as CBT for a number of psychiatric conditions including depression, anxiety, stress, and adjustment disorders.
Patients with chronic illnesses including type 2 diabetes mellitus and hypertension may also benefit from MBSR programs when trying to make significant, and potentially stressful, lifestyle changes to improve their health. Whitebird and colleagues5 implemented an MBSR program for those diagnosed with type 2 diabetes. The interventions included mediation and hatha yoga. After 8 weeks, significant improvements were seen in diabetes self-management, measured by HbA1c levels and the validated Diabetes Empowerment Scale, diabetes-related stress, and other mental health outcomes. Another randomized controlled trial compared 8 weeks of mindful meditation to blood pressure education classes for those with high-normal blood pressures or grade 1 hypertension.7 Those who attended the mindful meditation classes had significantly lower 24-hour ambulatory blood pressures, nighttime systolic blood pressures, and clinically measured blood pressures. Notably, these blood pressure improvements were similar to those seen with other nonpharmacologic techniques used in routine practice, such as regular aerobic exercise. Overall, mindfulness programs may be effective adjuncts or standalone therapies in the management of many common, chronic illnesses.
Mindfulness in Pregnancy
Anxiety
Pregnancy can be a period of increased anxiety for many women, and the common pharmacologic treatments may be considered unappealing due to the potential risks to the developing fetus and concern for neonatal abstinence syndrome. Recent efforts to develop a nonpharmacologic treatment for this population stem from the effectiveness of mindfulness-based therapies as a treatment for psychiatric illnesses in the general population.6
A randomized controlled trial conducted by Zarenejad and colleagues8 in Iran implemented an MBSR program for first-time expectant mothers in their second or third trimester to determine the potential impact on their anxiety levels. Participants in the intervention group completed six 60-minute sessions in groups of 7 along with home mindfulness exercises. The control group received the standard of care (SOC). Anxiety scores were measured by the Pregnancy-Related Anxiety Questionnaire (PRAQ), a validated questionnaire in Iran, and assessed directly after the intervention period and 1 month later.
After completion of the intervention period, significant improvements were seen in the anxiety scores of the intervention group when compared with the SOC group. This significant difference continued to widen when anxiety scores were reassessed 1 month after completion of the study, indicating that the intervention provided continued therapeutic benefit even after its completion.
These results are consistent with another randomized controlled trial completed by Yazdanimehr and colleagues,9 which compared a mindfulness-based CBT (MiCBT) program with routine prenatal care. The intervention group demonstrated significantly lower scores on the validated Beck Anxiety Inventory when compared with the control group. This significant difference in anxiety scores between groups also persisted at the 1-month follow-up. Together, the results of these studies indicate that mindfulness-based programs may be a safe and effective method for lowering levels of anxiety in pregnant women.
Depression
Depressive symptoms are also a common occurrence for women who are pregnant. This is especially true during the postpartum period, as the global prevalence of postpartum depression is estimated at 17.7%.10 The aforementioned study by Yazdanimehr et al9 simultaneously measured depressive symptoms with the previously discussed anxiety symptoms through the use of the Edinburgh Postnatal Depression Scale (EPDS). The MiCBT cohort had significantly lower depressive symptom scores post-intervention when compared with the control group, indicating that a mindfulness-based intervention is effective at reducing both anxiety and depression symptoms in pregnant women.
Duncan and colleagues11 collected data on depressive symptoms directly after their intervention was completed and after birth to look at the direct and lasting effects of mindfulness-based therapies. These researchers used a 2.5-day mindfulness-based childbirth preparation course as their intervention, with the control group of pregnant women attending a standard childbirth preparation course. The intervention was time-intensive and described as a "weekend workshop." Postintervention results revealed that the women who attended the mindfulness-based workshop had significantly fewer depressive symptoms when compared with controls. This difference was maintained at the 6-week postpartum visit.
The benefits of mindfulness programs may extend even further into the postpartum period, as research has demonstrated significantly lower EPDS scores in a group of women who completed a mindfulness program at their 3-month postpartum visit.10 In aggregate, these studies demonstrate that the effects of mindfulness programs may be long lasting. Therefore, mindfulness programs may benefit women not only during their pregnancy, but also during the postpartum period where they may be at their most vulnerable in terms of depressive symptomology.
Another important point of interest is the timing of these mindfulness programs: one study enrolled women in their first and second trimester,9 whereas another enrolled women in their third trimester.11 Despite this difference, both studies yielded positive results in terms of significantly lower depressive symptoms. It may be possible that these mindfulness-based programs are useful to pregnant women at any gestational age. Providers would therefore have a relatively large window of opportunity to introduce mindfulness-based programs to their pregnant patients and still see significant benefit.
Stress
Maternal stress during pregnancy has been strongly correlated with several pregnancy complications, including hypertension, low birth weight, preterm labor, cesarean delivery, and postpartum depression.10,12 In an effort to reduce these complications, stress reduction techniques are being developed for the pregnant population.
A mindfulness-based childbirth and parenting program was created with the goal of lowering maternal stress and depressive symptoms during pregnancy.10 The program included weekly 3-hour sessions for 8 weeks as well as 1 full-day session and was compared with routine childbirth education consisting of a 4-hour presentation by 2 nurse-midwives. Statistically significant decreases were seen in Perceived Stress Scale scores for the intervention group compared with the control group 3 months after birth. These long-lasting and significant reductions in maternal stress levels are the result of an affordable and easily accessible intervention. The authors hypothesized that decreased daily stress levels may lead to a decreased allostatic load, ultimately causing a decrease in adverse health outcomes in pregnant women.
Prenatal stress was also studied by Matveinko-Sikar and Dockray12 through the use of the Prenatal Distress Scale and salivary cortisol levels. The mindfulness intervention in this study consisted of online tasks including completion of a gratitude diary and listening to mindfulness audio clips. Participants in the experimental group were asked to complete these online tasks 4 times a week for 3 weeks, whereas participants in the control group received treatment as usual.
Compared with controls, the participants who completed the mindfulness intervention had significant reductions in perceived prenatal stress scores. Unfortunately, cortisol samples were not provided by enough participants to conduct a comparison between groups. However, in those who provided cortisol samples, reductions were seen in the waking and evening cortisol levels over time as the study progressed. Cortisol levels are expected to rise over time in the pregnant population. Therefore, the reduction observed in these cortisol levels could indicate that the intervention may have an effect on cortisol levels over time. The added benefit of this study is that the intervention was an online, easily accessible mindfulness intervention. Programs like these could make mindfulness interventions available to a greater number of patients in need.
Preparing for Labor
Labor preparations are extremely important, as they are informative for nulliparous women who may not know what to expect with their first birth experience. Fear of childbirth has been related to greater use of pain medication, higher risk of emergency cesarean delivery, and postpartum depression.11 Studies have begun to examine mindfulness techniques in labor preparation classes to enhance their benefits and help lower women's fear about childbirth.
A pilot study conducted in Australia by Byrne and colleagues13 combined techniques used in MBSR with standard skills-based prenatal classes to improve women's labor preparation education. This novel mindfulness-based childbirth education (MBCE) intervention consisted of weekly group sessions over the course of 8 weeks. Participants were also encouraged to extend their mindfulness practice to home by using audio discs and workbooks provided to them. After the completion of the 8-week MBCE program, participants demonstrated significantly higher levels of childbirth self-efficacy and significantly lower levels of childbirth fear via validated surveys.
In the previously described study, Duncan and colleagues11 attempted to build on the results obtained by Byrne and colleagues.13 Not only did Duncan and colleagues11 study the effect of their mindfulness program on maternal depression, but they also evaluated its effect on women's childbirth self-efficacy. Lower levels of childbirth self-efficacy have been associated with greater amounts of childbirth fear.13 The group of women who completed the mindfulness-based weekend workshop had significantly higher levels of childbirth self-efficacy when compared with the women who completed a regular childbirth preparation class. Also there was a significant increase in mindful body awareness that the women in the intervention group experienced. This increased awareness may also reduce some of the fear associated with the sensations of labor and childbirth.
Preterm Premature Rupture of Membranes
Mothers who experience preterm premature rupture of membranes (PPROM) are likely to experience higher levels of stress due to the necessity for hospitalization and the increased risk of complications such as preterm labor and chorioamnionitis. Although many mindfulness-based programs have been created for healthy pregnant women, there are few such programs designed to support pregnant women requiring hospitalization for pregnancy complications.1
To meet this need, a mindfulness-based transition to motherhood (MBTM) program was created by Korukcu and Kukulu1 for patients admitted with PPROM and consisted of 7 daily 90-minute sessions over the course of 1 week. These sessions included a range of activities including silent meditation, body scan meditation, mindful breathing, mindful walking, and mindful eating. An MP3 player was also provided to participants that contained recordings of these mindfulness practices for use outside of the daily sessions.
After the completion of 1 week of the MBTM program, participants displayed a significant increase in their level of readiness to give birth when compared with a control group of PPROM women receiving standard of care. At 1 month postpartum, participants of the MBTM program had statistically significant increases in maternal-baby attachment. From 1 to 4 months postpartum, the women in the MBTM intervention group also had statistically significant increases in measured maternal confidence scores. In contrast, no change was seen in the maternal confidence scores of the control group from 1 to 4 months postpartum. These positive outcomes, obtained by implementing a short and cost-effective mindfulness program, are welcome improvements for a population of women who may have had deleterious effects from increased stress due to unexpected hospitalization, higher risk to their baby's health, and an overall loss of valuable preparation time when transitioning into motherhood.
Labor Pain and Opioid Use
Labor pain is one of the biggest sources of childbirth fear in women, especially those that have not experienced childbirth in the past. Previous research indicates that maternal self-efficacy, or a woman's confidence in her own ability to cope, is related to the ability to manage pain during childbirth.14 Based on this principle, many of the mindfulness programs discussed earlier focused on increasing a woman's self-efficacy, specifically in relation to childbirth.11,13
One of these studies measured the effect of a mindfulness-based weekend workshop on labor pain and the use of pain medication.11 Through review of participants' medical records it was determined that the rate of narcotic use was much higher in the control group when compared with the mindfulness treatment group, although the sample size was too small to find a statistically significant difference. Pain catastrophizing was also measured in this study via retrospective self-reporting with the Pain Catastrophizing Scale (PCS). PCS scores in the mindfulness group dropped 3.6 points after completion of the intervention whereas PCS scores for the control group remained unchanged. This difference did not have statistical significance, but supports the idea that mindfulness-based practice may modify pain perception and help optimize pain management during labor.
Challenges and Future Studies in Pregnancy
The early MBSR program developed by Jon Kabat-Zinn consisted of daily 3-hour sessions over the course of 8 weeks.15 It also included a special review session of all MBSR skills that lasted 8 hours. Although this is an effective method to introduce mindfulness-based practice, it is very time-intensive. Recently, shortened variations of the MBSR program by Kabat-Zinn have been developed for both treatment and research purposes.1,5-13
Some researchers still have difficulty keeping participants engaged with these shortened mindfulness programs.6 The main reasons for their substantial number of dropouts from the mindfulness intervention group were "work constraints" and "lack of time." These issues continue to be barriers to implementing mindfulness-based treatments for all populations. Pregnant women may have increased difficulty keeping up with mindfulness programs that require frequent meetings or large time commitments, as they already have additional demands on their time such as an increased number of prenatal appointments. These women also may be trying to save their time-off from work for appointments or for the birth of their child in the coming months. Future studies should focus on developing a mindfulness program for pregnant women that is less time-intensive, yet still proves to be effective.
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