Research Review: Mind in Labor Childbirth Education – Does It Improve Birth Outcomes?

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September is National Yoga Month in the United States.  Many pregnant people have long found both physical and emotional benefits from participating in a prenatal yoga class.  Mindfulness is a major component of the practice of yoga and can help pregnant parents feel prepared and confident about their upcoming labor and birth.  A study published in May 2017 on the BMC Pregnancy and Childbirth research site – Benefits of preparing for childbirth with mindfulness training: a randomized controlled trial with active comparison examined the impact of a childbirth education course based on mindfulness principles on the pain experienced during childbirth and the ability to handle that pain on a physiological level as well as adjust to the postpartum period.  Researchers believed that participants in a mindfulness-based childbirth preparation class would have less fear of the pain associated with labor and birth and be better prepared to face the challenges that are normally experienced during the postpartum period.

Introduction

People who are facing their upcoming labor and birth experience with a significant amount of fear are more likely to use pain medications, experience more obstetrical interventions and have more likelihood to suffer from postpartum depression.  Childbirth education classes are the most common source of preparation for families to receive information and practice skills that will be helpful in reducing fear and increasing confidence but not all families (especially first-time expectant people) enroll in a birth preparation class, due to access, cost, scheduling or the thought that the class will not be helpful.  We also know that all childbirth classes are not created equal, based on evidence and best practices and each class varies in the amount of time dedicated to hands-on pain coping practice skills.  Research suggests a benefit of having access during the third trimester to practices that reduce the fear of birth with first-time parents improves perinatal outcomes.

The Prenatal Education About Reducing Labor Stress (PEARLS) study was a small randomized controlled trial that used a 2.5-day weekend workshop to teach mindfulness skills for coping with fear and labor and birth pain.  This course is called "Mind in Labor (MIL): Working with Pain in Childbirth".  The researchers hypothesized that this mindfulness training would perform better than a standard childbirth education program in:

  1. producing an adaptive shift in fear and pain-related appraisals of childbirth, thereby increasing childbirth self-efficacy and reducing pain catastrophizing;
  2. leading to lower labor pain ratings, less use of pain medication in labor, and greater birth satisfaction; and
  3. lower perinatal depression symptoms and protect against postpartum depression. 

How the study was done

Study participants were recruited who were English-speaking, pregnant with their first baby, identified as low-risk and healthy, carrying just one fetus, and were in their third trimester and planning to have a vaginal birth in the hospital were selected.  They had to agree to be randomized into either the Mind in Labor program or a standard childbirth education program. If they had previous extensive experience with mindfulness or yoga, they were excluded from the study pool.

Due to funding limitations, thirty participants were selected.  15 were assigned to the Mind in Labor group and participated in a weekend Mind in Labor workshop open to the public.  Tuition was paid for by the research program.  The other 15 parents were provided $200 in tuition reimbursement for attending a study-approved, standard hospital- or community-based childbirth education course in the San Francisco Bay Area.

Some details about the Mind in Labor (MIL): working with pain in childbirth program

MIL is a brief intervention for pregnant women and their partners specifically designed to target labor-related fear and pain by teaching tailored mindfulness-based coping strategies. It is a childbirth-specific, short form of the nine-week Mindfulness-Based Childbirth and Parenting program (MBCP) adapted starting in 1998 from Mindfulness-Based Stress Reduction (MBSR). The MIL course is delivered by professionally certified MBCP instructors and it is held over one weekend (Friday evening and all day Saturday and Sunday) for a total of 18 h of mindfulness training. Mindfulness strategies for coping with labor-related pain and fear are taught through interactive, experiential activities, with periods of didactic instruction.

In addition to standard childbirth preparation topics (i.e. birth physiology), the MIL program includes the following aims and learning objectives: 1) participants are guided to reframe childbirth pain as unpleasant physical sensations that come and go, moment by moment; 2) participants are taught how to uncouple the sensory component of pain from its cognitive and affective components, with the objective of decreasing fear and suffering related to the physical pain of childbirth; 3) participants learn how to be more aware of their own body and fearful reactivity to pain by practicing mindful coping with pain through a pain induction activity with ice; 4) pregnant women and their birth partners develop personalized strategies to best cope interpersonally and provide support to each other throughout the birth process.

To meet these objectives, instruction in formal mindfulness meditation are given during the workshop, including body scan, mindful movement/yoga, sitting and walking meditation, and mindful eating, as well as activities of daily living and pain coping strategies, such as mindfulness of breath, partner touch, body movement, and “sounding” (using low and/or loud vocal tones during periods of intense physical sensation). Additionally, there is an inquiry practice between partners exploring fear in general and fear of childbirth in particular and specific mindfulness coping strategies for being with pain with an attitude of acceptance. Participants are provided with handouts and guided audio materials for optional practicing of mindfulness meditation and pain coping strategies at home. In the current study, the course developer (NB), a senior mindfulness teacher and certified nurse midwife, provided facilitation for all MIL intervention participants.

Pregnant people were assessed using online survey methods at three points in the process: at a third-trimester baseline (TI), immediately after the completion of the childbirth class, (T2) and at a postbirth (six weeks postpartum) follow-up (T3).  The following was assessed and the frequency indicated:

Childbirth self-efficacy (T1, T2)

Childbirth self-efficacy was assessed with the Childbirth Self-Efficacy Inventory, The self-efficacy expectancy items rate how confident respondents feel in their ability to use the behaviors during labor and birth (1 = Not at all sure to 10 = Completely sure).

Maladaptive pain appraisal (T1, T2)

Maladaptive pain appraisal was assessed with the Pain Catastrophizing Scale. Respondents were asked to reflect on past experiences of physical pain and to rate the degree to which they experience particular thoughts and feelings (e.g., “It’s awful and I feel that it overwhelms me” on a scale of 0 (Not at all) to 4 (All the time).

Perceived pain in labor (T3)

The Visual Analog Scale (VAS) was used to assess perceived labor pain. Participants were asked to retrospectively mark the level of pain they felt for each stage of labor on a 10 cm line representing a continuum of “no pain” to “worst possible pain.” The VAS is one of the most commonly used pain measures and it has been used successfully to assess labor pain. Participants rated their experiences of pain on the VAS during early labor (until 3–4 cm dilation), during active labor (from 4 cm to pushing), during pushing until birth, and from birth of the baby to delivery of the placenta.

Use of pain medication in labor

Use of pain medication in labor was ascertained from medical record review. Epidural/spinal anesthesia and opioid analgesia were coded as dichotomous variables. Use of opioid analgesia was endorsed if any systemic opioid narcotic (e.g., fentanyl, morphine) was administered at any point during labor (before birth), independent of epidural/spinal anesthesia.

Birth satisfaction

A modified 24-item version of the Wijma Delivery Expectancy/Experience Questionnaire was used (T1 - T3) to gauge satisfaction with the birth experience (e.g., : “How happy were you in general during the labor and delivery?”) controlling for W-DEQ expectancies captured prior to labor and delivery. Items were rated on an intensity scale from 1 = Extremely to 6 = Not at all, and response options are customized for each item (e.g., 1 = Extremely happy to 6 = Not at all happy). Minor modifications to the scale were made in consultation with obstetric experts on the study team to enhance interpretability and cultural sensitivity of the terminology (e.g., we removed the item asking whether participants imagined they would feel “funny, natural, self-evident, or dangerous” at the time of delivery).

Additionally, we asked respondents to rate their satisfaction with their overall birth experience (T3), as well as with the care they received from healthcare providers during the labor and delivery (T3), on a scale of 1 – 10, with 1 = Not at all satisfied and 10 = Completely satisfied.

Depression

The 20-item Center for Epidemiologic Studies Depression Scale (CES-D) was used to measure depression symptoms (T1 - T3). The CES-D is widely used and is recognized to be reliable and valid. A score ≥ 16 is the clinical cutoff indicating risk of clinical depression.

Mindfulness and mindful body awareness

The Five Facet Mindfulness Questionnaire (FFMQ) was used to assess levels of dispositional mindfulness (a tendency to avoid mindlessness in everyday life) at each time point (T1 - T3). The FFMQ consists of 39 items, yielding subscale scores that measure five elements of mindfulness (observing, describing, acting with awareness, nonjudging of inner experience, and non-reactivity to inner experience; Cronbach’s α ranging from .75 to .91).

The Multidimensional Assessment of Interoceptive Awareness (MAIA) was used (T1, T2) to assess body awareness, which may be an important dimension of mindfulness and particularly relevant for women preparing for childbirth. The MAIA consists of 32 items and measures eight dimensions of interoceptive awareness (noticing, distracting, worrying, attention regulation, emotional awareness, self-regulation, body listening, and trusting; Cronbach’s α ranging from .66 to .87).

Results

Researchers found that participation in the Mind in Labor weekend program led to an increase in childbirth self-efficacy that was not observed in participants who took a standard childbirth education programs. The MIL program helped people feel better equipped to handle the upcoming pain of labor, to cope more effectively with the labor pain and make choices that were better reasoned about medical options available during the birth.  There was no difference in the number of people who chose an epidural in labor but there was less opioid analgesia used in the MIL group.  Postpartum, there was a reduction in depression symptoms that was maintained at postpartum follow-up in the MIL group. According to the researchers – "this small RCT suggest that by positively impacting labor and birth processes, while also promoting healthy psychological adjustment in the perinatal period, better postpartum outcomes can be expected."

Discussion

While I am not extremely familiar with the Mind in Labor program, it is offered in my community of Seattle.  The continued feedback that I have heard from participants has been positive. I believe that an evidence-based childbirth education course can help a family to reduce fear, improve outcomes, reduce interventions and increase confidence in their ability to have a positive labor and birth experience, and navigate the delicate first weeks and months postpartum.  Lots of coping practice in the class is imperative for families to gain the skills they need.  More research is needed to determine the impact of childbirth education on birth and postpartum outcomes and in particular, the effectiveness of a program taught by a Lamaze Certified Childbirth Educator that adheres to the principles of Lamaze and teaches the Six Healthy Birth Practices.  Rachelle Oseran, BA, LCCE, FACCE, CD(DONA), RYT-200 shared her expert opinion on the connection between Lamaze classes and mindfulness in a recent blog post on Science & Sensibility.  I encourage you to read this post to understand the similarities. Including mindfulness techniques in your perinatal classes may enrich the experiences of the families you work with and help increase confidence and improve outcomes during and after birth.  Do you incorporate any mindfulness practices in your childbirth education classes?  Have you taken a Mind in Labor workshop?  Please share your experiences in our comments section below.

References

Alehagen S, Wijma K, Wijma B. Fear during labor. Acta Obstet Gynecol Scand. 2001;80(4):315–20.

Duncan, L. G., Cohn, M. A., Chao, M. T., Cook, J. G., Riccobono, J., & Bardacke, N. (2017). Benefits of preparing for childbirth with mindfulness training: a randomized controlled trial with active comparison. BMC pregnancy and childbirth17(1), 140

Laursen M, Johansen C, Hedegaard M. Fear of childbirth and risk for birth complications in nulliparous women in the Danish national birth cohort. Br J Obstet Gynaecol. 2009;116(10):1350–5.

Lobel M, DeLuca RS. Psychosocial sequelae of cesarean delivery: review and analysis of their causes and implications. Soc Sci Med. 2007;64(11):2272–84.

Ryding EL, Wijma B, Wijma K, Rydhstrom H. Fear of childbirth during pregnancy may increase the risk of emergency cesarean section. Acta Obstet Gynecol Scand. 1998;77(5):542–7.

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