Editor’s note: This article first appeared in Midwifery Today, Issue 120, Winter 2016.
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When eminent psychiatrist and psychoanalyst Daniel Siegel asked over 65,000 mental health professionals face-to-face in lecture halls around the world if they had ever had a course on the mind or on mental health, 95% replied no. We can imagine what the scenario is for midwives and other birth-related professionals.
My several years of research/observational study of the “dance of attunement” between mother and infant have led me to astounding discoveries in relation to mother-infant communication. My own experience of pregnancy and motherhood provided me with a vivid sense of the sacred link between maternal life-enhancing emotions and reflective function, prenatal attachment and child well-being. I came to the ground-breaking discovery that attuned bonding can be nurtured during pregnancy and parents can prepare for birth and the postnatal mother-infant relationship, thus preventing both maternal and infant mental health issues. Therefore, it is essential that prospective parents, as well as the whole community at large, become aware of the preborn as a conscious sentient being, who needs emotional care as much as he does healthy nutrients. He is sensitive and responsive to maternal emotions, thoughts, consciousness, stress and the surrounding physical and social environment, including the birth scenario.
It is now known that fear and anxiety enhance levels of adrenaline, which inhibits the release of oxytocin, making labor and birth longer and more difficult.
At a time in history when statistics of perinatal mental illness and infant developmental problems are soaring, we must all work together, with synergistic compassion and empathy, to ensure every mother and father gets appropriate and timely care to optimize their health and mammalian competence and to prevent the adverse effects of perinatal psychological distress. We need to look at the protective function of prenatal attachment and the importance of supporting this early relationship prior to birth, since it has an impact on the welfare of our society and economy. It is time for a new awareness that the prenatal and perinatal stages are the most crucial in human life, that the preborn child is already a psychological and social partner to his/her parents, and through them, to society.
Through a communal mindfulness-based approach to pre- and perinatal care, we can protect the human mother-baby co-adaptive system—that embodied creative dialogue unfolding during pregnancy and determining the term of labor and outcome of birth. A mindfulness-based integrated program tackling the deep-rooted ignorance of the mind-body processes of the pre- and perinatal period and mothers’ psychological and emotional needs could be the route to cultural change and optimal maternity care. Our primary objective as a society should be to create the conditions for birth and for mother and baby’s interactions and bonding to unfold undisturbed. This paradigm shift also implies that we need to introduce mindfulness training for midwifery, obstetrics and all disciplines involved in pre- and perinatal care, in addition to prospective and new parents. Self-development, personal experience of life, attachment style and protosocial skills such as empathy, communication and attunement should be the main focus.
In a randomized controlled trial about doulas in Texas, the prerequisite to participate in the study was personal experience of a normal labor and vaginal delivery with a good outcome (Kennel et al. 1991). It appears obvious that laboring women are more likely to feel secure when protected by a midwife who has had a positive experience of giving birth and can, thus, better understand their needs and connect with them. Those midwives who have not had a positive birth experience would benefit from mindfulness-based training enabling them to work through any birth trauma and overcome fear. Body language and words from birth-related professionals, often reflecting their own trauma, emotional issues and attachment style, are powerful. Awareness of the effects on a mother’s emotions and mind state, pregnancy and birth outcome should be promoted through appropriate training.
It is now known that fear and anxiety enhance levels of adrenaline, which inhibits the release of oxytocin, making labor and birth longer and more difficult. Very often this modern knowledge is embedded in the midwife or other birth partner. The level of adrenaline released by a midwife in a birthing place, however, is also an important issue, since adrenaline is contagious and easily transmitted to the laboring woman. I recall the studies of brain-to-brain nonverbal communication (Schore 2001) or those on the role of the “mirror neuron system” (Rizzolatti and Craighero 2004). This means that when we are in an emotional state, we can activate the same part of our brain as another person. Therefore, emotional states are contagious, including those associated with high levels of adrenaline.
Michel Odent represents the situation associated with an easy birth with only one person around a laboring woman: an experienced and silent midwife, perceived as a mother figure, sitting in the corner of a small, warm, dimly lit room, and knitting (Odent 2015). Odent suggests that the knitting midwife is helping the laboring woman to maintain her own level of adrenaline as low as possible and to let the oxytocin, the key hormone in the birthing and bonding process, flow. Interestingly, what we now call midwife used to be called mammana or empirica in some regions of southern Italy, which was a maternal figure who accompanied the woman throughout pregnancy, birth and the first postnatal months, just as still happens in many indigenous and aboriginal cultures. Empirica means “woman with experience.” It is this consistency or familiarity, which sadly most Western modern birthing women are deprived of, that is an essential element in a natural uncomplicated birth. Women nowadays may deliver with an on-call doctor or midwife they have never seen before.
We should acknowledge that personality traits of self-development training—such as empathy, listening, engagement, nonverbal language and experienced knowledge—may be more important than a scientific background for birth professionals. The woman-centered side of midwifery (its true essence) needs to be protected and nurtured. The number of women who rely on their natural hormones and inner wisdom to give birth to babies and placentas is significantly decreasing. The domination of nature, of our mammalian competence and most human virtues is evident in every aspect of our lives and is seriously threatening humanity.
Furthermore, we need to acknowledge our mammalian nature of giving birth and establishing a mother-baby bond benefitting from the psychobiological hormonal fit. Our society and obstetric practices often violate our evolved need for empathy and cooperation, which has been misinterpreted by our cultural conditioning that a woman does not have the power to give birth by herself. We need to acknowledge that enabling a mother to rely on her own mind-body resources, providing responsive and attuned care beginning in her own in utero life, leads to healthy socioemotional development, which leads to moral development and a cohesive peaceful society (Narvaez 2014). One of the greatest revelations of my experience with Himba mothers and children, indigenous people of northern Namibia, was that we need to appreciate values from our indigenous cultures and create the conditions for them to be transmitted.
Sadly, many children in our society are raised with little or no empathy for others, and so the cycle of problems continues generationally. Indigenous cultures teach us that our species evolved to be strikingly empathic, compassionate and cooperative and with the ability of “self-authorship.” This evolved need is particularly important during pregnancy and childcare, and its fulfillment appears to have an impact on birth and child development outcomes. Studies found that having another woman offer consistent social support and mentoring throughout pregnancy was correlated with a cascade of beneficial outcomes detectable for as long as 15 years after the birth. When matched with similar mothers not visited by a familiar figure, the children of visited mothers grew up emotionally more responsive, more resilient, learned language sooner and were less likely to be abused by their mothers (Olds, Sadler and Kitzman 2007). Modern pregnancy, birth and parenting are missing the benefits of this most distinctive human need for consistent support, which is still paramount among the Himba and other hunter-gathers I visited. If we want to escape the modern threats to humanity and to blossom as a species, we must reconnect with our evolved needs and acknowledge our symbiotic (attuned) relationship with other humans as well as with the natural world, including our mammalian nature.
When I told Badri, a Himba mother, that many children in our civilized world are born far before 9 months, even at 6, and many women decide to have a caesarean section (while mimicking the performance on my belly), she showed a quick visceral reaction and facial expression of puzzlement followed by the question, “Why would a woman decide to have her belly cut when there is a straightforward way?” as if I were talking about a different species.
“Some women fear labor pain,” I remarked. She must have had no idea of the kind of psychic pain I meant, a product of our modern way of life. How would she? At the final stage of labor, a Himba woman will sit on a rock and give birth, on her own or accompanied by one or two other women, who will be with her just to protect the birthing area and accompany mother and baby to the village, where they are accommodated in a shelter of mopane branches erected against the side-wall of the main hut.
Intuition is the ability to know something immediately, without verbal explanation or conscious reasoning (Orlinsky and Howard 1986). Badri intuitively grasped the implications of my information. Looking at ill health statistics, we risk becoming a different kind of human, as a consequence of environmental abuse, technological dominance, processed food, excessive stress generating anxiety, depression and other mental/physical conditions.
Another discovery I made during my experience with the Himba was to realize that Himba women are masters in immediately connecting, despite language and cultural barriers. This could likely be linked to the context of their lives and society. They also probably sensed my profound interest in learning from them. Despite the translator’s help, it was the desire to psychologically connect that helped us understand each other, beyond verbal language. There was a universal nonverbal language—gesture, facial expression, posture, rhythm of speech, laughing—which put our deepest human nature in touch and facilitated mindreading. Later I found out that my insight was supported by Sarah Hrdy’s intuition that what makes us human is not our ability to speak and ask questions, but the eagerness to “tell” someone else what is in our minds and to learn what is in theirs (Hrdy 2009). The desire to psychologically connect with others, to read and share feelings and concerns of others, had to evolve before language and provides the foundation for the evolution of cooperative behavior. This is what is lacking in our midwifery today and what midwifery services fail to provide.
Hyper-stimulation of the neocortex, that part of the brain involved in verbal language and intellect, is not a good ally in birth, as it appears to have an inhibitory effect on the physiological process of giving birth and bonding (Odent 2015). Because we have become so hyper-intellectual, so dependent on spoken and written language, we have neglected our energy-sensing communication system. I believe that excessive stimulation of the neocortex also interferes with our evolved capacity to attune with our own needs and those of others, for instance, by hindering a midwife’s intuitive capacity to understand and respect a laboring or nursing mother’s need for a quiet non-interfering environment.
Indigenous people have a vivid sense of the influence of the environment and their mind on conception, pregnancy and birth, which is what epigenetics acknowledges today. Our Western culture has emphasized the role of the left-brain hemisphere—rational, linguistic, explicit reflection processes—as dominant. But a new paradigm shift acknowledges the right brain’s implicit affective processes, expressing themselves through body language, operating at levels beneath conscious awareness as dominant in relationships and ill health (Schore 2012). This is how a midwife or any other pre- and perinatal practitioner can influence the experience of pregnancy, birth and bonding, and why it is important they become aware of these dynamics.
A mindfulness-based integrative program could aid birth professionals as well as parents in understanding more in relation to pre-verbal communication (body movements, posture, gesture, facial expression, voice inflection and the sequence, rhythm and pitch of the spoken words) and its impact on maternal emotions and mind, and the value of connecting and communicating. This communication is supported by an infant/parent-centered care approach based on compassion, empathy and listening, all capacities fostered by the practice of mindful awareness. Without the nonverbal, it would be hard to achieve the empathic, participatory and resonating relationship necessary to understand the other’s experience (Stern 2005). A clinician or any other practitioner should be perceived by the parent (like any client/patient) as engaging in a natural conversational dialogue growing out of their concerns; he/she should not be perceived as applying a stilted, formal technique (Valentine and Gabbard 2014).
Most health care training courses focus on technique, but the focus should be on relationship and connection. The nonverbal channel of communication, not rational thinking and verbal communication, is much more important in human affairs than most people like to think (Buchanan 2009). It is incredibly naïve to take conscious verbal communication as the primary way that people respond to each other.
I recognize the value of preverbal responsiveness and attunement as paramount to the well-being of infants but also to parents’ mental health. A mother’s feeling of being seen, felt, and valued by a health caregiver through an empathic relationship reflects upon her capacity to connect with and value her baby’s needs and experience. Just as babies see themselves through the nonverbal and verbal exchanges of their caregivers (mirroring), so parents need to perceive themselves as compassionate caregivers through the communication exchanges with their health care providers. Therefore, the care providers need to be sensitively tuned to receive prospective and new parents’ communications. Their right brain, involved in primary process communication (intuition and emotion), should be receptive to the music behind the words. In a world becoming increasingly multicultural and inhabited by refugee pregnant mothers and families struggling with linguistic barriers and isolation, practitioners’ nonverbal skills and compassion are vital. These high quality exchanges require mindfulness awareness training. Mindful presence is a relational stance that is fundamental to evoking an experience and neurophysiological sense of safety in the client, which may have an impact on prenatal attachment, birth and parenting. How can parents value their birthing and parenting experience if pre- and perinatal health care practitioners don’t empathically value it in the first instance? This may have to do with a caregiver’s attachment style or experience of early trauma.
An article in The Guardian (Cooke and Watts 2016) highlights that half NHS (National Health Service in UK) psychologists are depressed, feeling the strain of time limits and targets, with many suffering from the very problems for which they treat patients. Mental health is becoming a major issue among practitioners, threatened by the stress of long working hours and poor understanding of human needs. How can a distressed health care practitioner support a pregnant or birthing woman, or mother-infant bonding, if they need support themselves? The rate of burnout among doctors, midwives and other health care professionals is sobering and every training school program needs to include stress-management, self-development training and mental health in their curriculum.
Mindfulness-based training for both professionals and parents may cooperatively help babies thrive. While supervision would be costly, mindfulness training could mitigate the impact of stress as well as value parenting experience by understanding pre- and perinatal dynamics. It is about empathy, listening, connection and compassion, which caregivers may be unable to apply in their interactions with parents because of their own lived early experiences and trauma, or particular training or lack of analysis.
Therefore, introducing students to self-regulation skills along with other self-care and communication approaches during their training may improve their personal and relational health. The practice of mindfulness has helped practitioners take different perspectives, have self-regulation and be more open to cooperation, listening and attunement (Siegel 2007). It changes the belief system and thus perception and behavioral patterns (Lipton 2008). It transforms the way we perceive ourselves and the way we treat patients/clients. This is not a one-off skill. It is important that we experience mindfulness personally—from the inside—before we learn to pass the skills onto our expectant, birthing clients.
The work of Shapiro, Schwartz and Bonner (1998) also demonstrates that mindfulness education can improve empathy. Empathy is necessary for understanding and meeting human needs. A study with medical students found that those receiving a mindfulness-based stress reduction program showed an increase in empathy over time. These findings suggest the possibility, to be tested in future research, that mindfulness may enhance professional as well as interpersonal connections, which in turn supports interpersonal well-being.
In conclusion, if empowering women is the best way to a new maternity care, we must bear in mind that next to a woman’s supportive husband/partner, a sensitive, understanding, present birth-related professional is the most critical figure in her pregnancy. Most of the unhappy stories I have heard from moms-to-be and new moms during my research and clinical work reflect failure of compassion on the part of the medical and other health care personnel. The changing culture of medicine is becoming increasingly hyper-specialized, responsive to the imperative of business and technology, and less sensitive to the subjective reality of mother and baby. Lack of compassion may have medical consequences on pregnancy and birth outcomes, simply because mothers have evolved to receive empathic support (Hrdy 2009). Receiving caring empathic interactions directly affects one’s psychobiology and predisposes them to be empathic to themselves and others (Adler 2002). This occurs by conveying emotional-physiological experiences to each other.
Mothers (and fathers), and not just those affected by mental conditions, need to receive a non-judgmental approach to both education and therapeutic work and great compassionate dedication from others. Recall that our behavior can promote bracing or yielding in the other. There is a reciprocal influence, a back-and-forth flow of energy and openness between the “self” and “other.” The way we behave toward others “creates states of mind in others” (Gilbert 2005, 19). We can promote a state of mind that jeopardizes the survival systems and safety ethic of others. Some people do this intentionally to promote submission to their dominance strategies; others do it unintentionally due to ongoing personal issues. Alternatively, we can facilitate a sense of safety in the other, so as to promote affiliative strategies, supporting relational attunement and engagement. This, in turn, supports parent-baby attunement and unleashes the potential of prenatal attachment. The practice of mindful awareness promotes compassionate goals and non-judgmental and non-defensive behavior. This is because the sense of presence and focus on this situation allows for understanding of the process, in this case during pre- and perinatal periods, and connection with the state of mind.
A mindfulness-based integrated pre- and perinatal program proposes a new paradigm of birth and parenting, which creates the conditions for a respected continuum of life and healthy society starting before conception and providing future generations with the capacity for interpersonal connection, compassion and empathy. This paradigm considers maternal mental health and developmental trauma as consequent to the failure of our society to meet our most fundamental needs. This empathy-inspired program has not only a social and human impact but also a huge economic impact, since governments can save on the extremely high costs of premature births, the pre- and perinatal depression related to them and to unexpected caesarean births, difficult births or poor maternity and baby care, as well as the high costs of child ill health.
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