Dr Ka Po CHAN
MBBS, FRCOG ( UK ), FHKAM(OBS & GYN)
PhD Candidate
Centre of Buddhist Studies
The University of Hong Kong
E-mail: drchankapo@yahoo.com.hk
Accepted by International Buddhist Conference, the Fifth United Nations Day of Vesak 2008 Celebration, May 13th – 18th, 2008, Hanoi , Vietnam
ABSTRACT
Pregnancy health is multidimensional and is closely related to fetal health and future child health. Buddhist practices are well known in enhancing spiritual and mental health. Incorporation of Buddhist practices in routine antenatal care can improve maternal health and fetal health. Evidence suggests that stress and depression during pregnancy results in adverse outcomes for mother and fetus or infant well-being. Buddhist meditation like mindfulness practice and Four Immeasurables meditation are well proven in relieving stress. Pregnancy is a unique situation having maternal foetal relationship. Emotional problems during pregnancy affect family relationship and family health. Cultivation of the Four Immeasurables as part of antenatal exercise is expected to improve marital relationships and social contacts. It is also expected that such practice may improve maternal and child bonding in future. A randomized control study about the effect of Four Immeasureables Meditative Intervention (FIMI) on maternal and foetal health has been conducted since September 2007 in Obstetric Unit, Queen Elizabeth Hospital , Hong Kong . The responses of pregnant women are encouraging and we expect to have positive results during end of study in 2009.
INTRODUCTION
Pregnancy is an important life time for women. It has the distinction of being an event that is culturally, socially, and physically transformative. To effectively deal with pregnancy, women must engage in a complex reorganization at the biological, physical, cognitive, and emotional levels (Cohen & Slade, 2000). Spiritual health of pregnant women is also an important issue in promoting pregnancy health (Chan, 2006; Edmondson et al, 2005; Ellis & Campbell, 2005). A broad bio-psychosocial-spiritual approach (Grason et al, 1999) to understanding pregnancy and birth as well as the mental and physical health outcomes of mother and infant is appropriate but this is an under researched topics especially in relation to religious aspect.
Stress is well known as an independent risk factor for adverse pregnancy outcomes (Haas et al, 2005; Khashan et al, 2008). Research also shows that antenatal events can have profound influences on the subsequent development of mood disorders (Hammen, 2003). A relationship between antenatal maternal anxiety and stress and the neurobehavioral development of the fetus and child is now quite definite and so psycho education programs to reduce maternal stress in pregnancy are therefore warranted (Austin et al, 2005; Van den Bergh et al, 2005). The concept of holistic health is well fit into the practice of Buddhism with its origin from India , which aim at purification of mind, speech and body. Example like practice of mindfulness is one form of intervention from Buddhist origin that receives much attention in the West (Leigh et al, 2005).
Pregnancy can be viewed as a bio-psycho-socio-spiritual model (Rini et al, 1999). Utilization of knowledge of spirituality, clinical health psychology and mind body therapy can promote maternal and foetal health and future child development. Many integrated psychosocial spiritual model were suggested in various clinical entities like cancer pain management, hypertension, diabetes mellitus etc (Lin et al, 2003; Velsor-Friedrich et al, 2005; Vos et al, 2005). However, we do not give psycho-education the same as we prescribe antenatal vitamins to pregnant mother. Is it possible to integrate mindfulness-based practice into routine antenatal care because this modality of meditative intervention is well trial in other clinical conditions (Astin, 1997; Cohen et al, 2004, 2005, 2005; Ostafin et al, 2006; Surway et al, 2005; Weiss et al, 2005)? In recent years, health professions have great interest in positive psychology (Seligman et al, 2000); does this apply also to pregnancy? Loving-kindness is one form of positive emotion. What is the effect of loving-kindness meditation in pregnancy (Buddharakkhita Acharya, 1989)? Development of a Buddhist based model of mind body therapy for pregnant women fulfils the current trend to integrate psychological services in primary medical care practice settings (Maruish, 2000). According to the Holistic intervention model, maternal and infant health (both spiritual, mental and physical) can be improved through empowerment of the body, mind, and spirit of the pregnant women by psycho-education. Giving psycho-education to pregnant women is worthwhile trying because this may benefit both mother and fetus.
I am an Obstetrician with more than 20 years experience in the field of obstetrics. I am Chinese and was born in Hong Kong . I am a Buddhist since age twelve. I am the chairman of Buddhist Institute of Enlightenment Ltd (Hong Kong) for more than ten years and one of the directors of Prajna Paramita Charity Association Ltd ( Hong Kong ). I am one of the founders of Buddhist Studies Society, University of Hong Kong in 1981. I have more than 20 years of meditative experience, receiving instruction from both Chinese and Tibetan masters. I give public lectures and conduct psycho-education classes yearly. I have published articles on Buddhism and medicine (Chan, 2003; Chan, 2006). I have the feeling and experience that many practice in Buddhism is applicable to daily life for everybody, not just Buddhist. I hope that the present study can bridge the gap between East and West, religion and health. I design the program aim at an example of how Western medicine, Social science and Buddhist practice can beneficial one another.
I propose to develop a Four Immeasurables Meditative Intervention with integration of Western psychosocial education for pregnant Chinese women. The rationale behind is to develop a model of systematic treatment that is practical, applicable and acceptable for all pregnant women irrespective of their religion. Intervention can be incorporated into routine antenatal care system. The model is based on the Practice of Four Immeasurables of Buddhism and mindfulness practice (Pannyavaro, 2004; Nagarjuna, T 25.208c 9 -211c 27 [fasc.20]; Nanamoli, 1975; Nanamoli, 1987; Sangye, 1996; Silove & Zwi, 2005; Wallace, 2004). These were chosen as interventions because these fit well into the bio-psycho-socio-spiritual model of pregnancy. There is also strong theoretical background relating these Buddhist based intervention and counseling and psychotherapy (Lee, 2002).
A qualitative and quantitative study is designed to evaluate the effect of this Four Immeasurables meditative intervention on maternal and foetal health status. Research on pregnant Chinese women has conducted since September 2007 in Queen Elizabeth Hospital ( Hong Kong ). Using interview, questionnaire analysis and clinical assessment of maternal and foetal status, we can have factual data about these interrelating factors. The model of how meditative intervention related to physical and mental health of both mother and foetus can be examined.
BUDDHISM, PSYCHOTHERAPY AND MIND BODY MEDICINE
Mind is the forerunner of all (evil) conditions.
Mind is their chief, and they are mind-made.
If, with an impure mind, one speaks or acts,
then suffering follows one
Even as the cart wheel follows the hoof of the ox.
Mind is the forerunner of all (good) conditions.
Mind is their chief, and they are mind-made.
If, with a pure mind, one speaks or acts,
then happiness follows one
like a never-departing shadow.
These words, which are the opening lines of the Dhammapada, were spoken by Gotama Buddha 2500 years ago. They illustrate the central theme of Buddhist teaching, the human mind.
Buddhism does not deny the reality of material existence, nor does it ignore the very great effect that the physical world has upon us. On the contrary, it refutes the mind-body dichotomy of the Brahmans and says that mind and body are interdependent (Burns, 1994). The major idea that was discovered and put forward by Buddha is that of “Causes and Conditions” (Snelling, 1987). He experiences that everything in this world is constantly changing and nothing is permanent, they come into being, change, decay and non-existence. The important implication is that when one’s mind experiences the meaning of “impermanence”, one can manage the discomfort and pain associated with our life, both biological and psychological. Notice that the word “experience”, it doesn’t mean ONLY understanding or grasping the meaning of impermanence, it means “enlightenment” in religious term and “empowerment” in psychological term. In order to attain the state of enlightenment, one can practice according to the “Noble Eightfold Path” which can be viewed as a systematic model of cognitive and behavioral based intervention in terms of recent counseling psychology.
One of the most important implications of Buddha’s teaching is that everybody can attain the state of enlightenment because we all possess “Buddha Nature” (Pine, 1992). The principle of “Causes and Conditions” is not possessed by Buddha alone or any Buddhists. Anyone can understand what does “impermanence” means. Everyone can practice the “Noble Eightfold Path” if he wants to even he is not Buddhist. Although we have to make an effort to put these teachings into practice, we all possess the innate capacity of realizing Wisdom. In the humanistic approach of psychotherapy, Rogers also believes that man has a natural ability to actualize himself, and to move towards a state of psychological adjustment and health given an environment of unconditioned positive regard, not-judgmental attitude, and empathic understanding (Avery, 1996). The tendency to actualize oneself is defined as the inherent tendency of the organism to develop all its capacities in ways which serve to maintain or enhance the organism (Patterson, 1972). This concept of self-actualization and that of the innate capacity of Wisdom have some similarities, it appears that the latter is more encompassing and holistic than the former because it incorporates a deeper level of the psychological and spiritual aspects of an individual ( Wisdom versus self).
Another characteristic of Buddha teaching is that he said relatively little about Nibbana (the ultimate state of enlightenment) and instead directed most of his teachings towards two lesser goals which are empirical realities of readily demonstrable worth. These were, first, the increase, enhancement, and cultivation of positive feelings such as love, compassion, equanimity, mental purity, and the happiness found in bringing happiness to others. Secondly, he advocated the relinquishment and renunciation of greed, hatred, delusion, conceit, agitation, and other negative, unwholesome states (Burns, 1994). The cultivation of positive feelings is going in line with the development of positive psychology (Seligman & Csikszentmihalyi, 2000) today and in Buddhist’s practice, there are techniques and interventions that we can follow. Williams (2000) describes the Buddhist path as the overcoming of greed, hatred and ignorance through the cultivation of their opposites, non-attachment, compassion, and wisdom. This is exactly a multidisciplinary approach of psychotherapeutic interventions according to a bio-psycho-socio-spiritual model.
The National Institutes of Health (NIH) define mind-body therapies (MBTs) as “interventions that use a variety of techniques designed to facilitate the mind’s capacity to affect bodily function and symptoms”. “Meditation” is one of the Mats that many medical practitioners have interest. Meditation refers to achieving a positive mental state, and incorporates Right Effort, Right Mindfulness and Right Concentration in the Noble Eightfold Path. Buddhist meditation deals exclusively with the everyday phenomena of human consciousness. In the words of the Venerable Nyanaponika Thera, a renowned Buddhist scholar and monk:
In its spirit of self-reliance, Satipatthana does not require any elaborate technique or external devices. The daily life is its working material. It has nothing to do with any exotic cults or rites nor does it confer “initiations” or “esoteric knowledge” in any way other than by self-enlightenment.
Using just the conditions of life it finds, Satipatthana does not require complete seclusion or monastic life, though in some who undertake the practice, the desire and need for these may grow (Thera, 1962). Varela and associates (1991), paying tribute to the thinking of Merleau-Ponty, bring together ideas from cognitive science and Buddhist philosophy, in a work which describes our double sense of embodiment, mind in nature as described by cognitive science and mind in everyday lived experience: this later may be examined within the meditative tradition. Varela adds: ‘The possibilities for transformation of ordinary life need to be presented in a context that makes them available to science’. Zen Meditation and Mindfulness based meditation have received much attention and have stimulated lots of scientific studies (Kim et al, 2005; Koszycki, 2008; Mason et al., 1997; Pagnoni, 2008; Reibel, 2008; Takahashi et al., 2005). Meditation can help you train your mind in the same way exercise can train your body. Studying Buddhist monks while they meditate in MRI machines has led to startling conclusions, among them that the “monks” mediatation practice, which changes their neural physiology, enables them to respond with equanimity to sources of stress. Another study of Buddhists by scientists at the University of California has also found that meditation might tame the amygdala, the part of the brain involved with fear and anger (Conlin, 2004). Meditation appears to stimulate the left prefrontal lobe, which is related to feelings of well-being and happiness (Conner, 2003).
Many studies had published in order to access the effect of meditation (Astin, 2003; Canter, 2003). A substantial body of evidence suggests that regular meditation has a strong relationship to positive health outcomes, self-transcendence, and overall well-being (Andresen, 2000). Many studies were concerned about chronic medical illness like hypertension (Schneider, 1995), coronary artery disease (e.g. cardiac rehabilitation) (Castillo-Richmond, 2000), headaches, chronic low back pain, arthritis, chronic asthma (Manocha et al., 2002), incontinence, insomnia, epilepsy, disease and treatment-related symptoms of cancer (Meyer, 1995) and improving post-surgical outcomes (Carlson, 2003). Other studies were about depressive and anxiety disorders (Miller, 1995; Teasdale, 1995). There were also studies in the field of longevity (Alexander, 1989) and psychological health (Gelderloos et al., 2001). There is also research on the biological concomitants of meditation practice (Davidson et al., 2003; Solberg et al, 2004).
PSYCHOEDUCATION AND MATERNAL AND FETAL HEALTH
Stress, social support and depressive symptoms have been well documented as affecting pregnant women’s psychosocial well-being (Norbeck & Tilden, 1983). Attitudes and beliefs about the fetus, pregnancy, motherhood, and body image are significant in three psychosocial theories of pregnancy (Rubin, 1984). Also health behaviours and work status are important behavioural aspects of women’s lives in relation to pregnancy (Grason et al., 1999). Counselling is an effective tool in promoting health in various health cares setting (Bor, 1989). Pregnant women may seek counselling because pregnancy has intruded into their life and affected their view of themselves, their relationships with others and how they see themselves coping and adjusting both in the short term and in the future when they become mothers (Bor, 1989: p.40). Supportive counselling like providing support to pregnant mother with complications and has opportunity for them to air their opinion is helpful. There was study found that women receiving individualized care, led by midwives, had significantly better psychological wellbeing and a 40% reduction in risk of postpartum depression (MacArthur, 2002).
Historically, the expectant mother has been advised to keep herself cheerful, listen to good music, and frequent art galleries. Indeed, it was suggested “that if a woman about to become a mother plays the piano day, her baby will be born a Victor Herbert” (Nathan & Mencken, 1921), and that a tearful mother is likely to produce a mournful (Shakespeare, Henry VI (3), Act IV, Scene iv). In Chinese, we also heard of the slogan “agitated mother will give birth to a bad temper baby（忟羗生忟仔） ”. More recently, empirical findings of fetal experience in utero have generated widespread interest and excitement. There is now general consensus that considerable sensory input impinges upon the fetus in utero, and that the mother’s behavior and physiology make significant contributions to prenatal sensory experience (Fifer & Moon, 1988; Ronca, Lamkin & Alberts, 1993).
The predominant causes of neurological or behavioral deficits during infant and child development are known to occur prenatally (BBC News, 2005; Larsson et al, 2005; Thoresen, 2000;), and disruptions in the processes occurring at any of the stages noted previously can have profound developmental consequences. There are strong pointers to the importance of the fetal adaptations invoked when the maternoplacental nutrient supply fails to match the fetal nutrient demand (Godfrey & Barker, 2000). Prenatal maternal stress has been shown to impair functioning in nonhuman primate offspring (Kaiser & Sachser, 2005). Research (O’keane and Scott, 2005; Van den Bergh et al, 2005; Wadhwa, 2005; Weinstock, 2005) proposes that maternal stress exerts a negative influence on fetal developmental outcome that is mediated by the HPA system (Wadhwa et al, 2005). Central to an understanding of how overdrive of the maternal HPA axis may alter fetal development is the knowledge that maternal-fetal communication during gestation is endocrine rather than neural, and cortisol levels in the fetus correlate with those in the maternal circulation (Gutteling et al, 2005; Thompson et al, 2001). Laplante et al (2004) suspect that high levels of prenatal stress, particularly early in pregnancy, may negatively affect the brain development of the fetus, reflected in the lower general intellectual and language abilities in the toddlers. Austin et al (2005) showed that maternal trait anxiety was predictive of ‘difficult’ infant temperament, independent of ‘concurrent’ depression and key sociodemographic and obstetric risk factors. Yehuda et al (2005) found that pregnant women who were exposed to the World Trade Center collapse during the 11th September attacks in 2001 may have passed a biological risk factor for post-traumatic stress disorder (PTSD) onto their unborn children. Both exposed mothers and their babies at less than 1 year old, had lower than average levels of the stress hormone cortisol, which has been linked to PTSD. Recent research (Yehuda et al, 2008) found that maternal, not paternal, PTSD is related to increased risk for PTSD in offspring of Holocaust survivors.
Walker et al (2004) had conducted a randomized controlled study on the development of Term Low-Birth Weight Infants receiving psychosocial intervention and had positive outcome. Bledose & Grote (2006) had done a meta-analysis to evaluate treatment effects for nonpsychotic major depression during pregnancy and postpartum comparing interventions by type and timing. The following interventions are included in this review based on their use in treatment trials: (1) medication in combination with cognitive behavioral therapy (CBT); (2) medications (3) group therapy with cognitive behavioral, educational, and transactional analysis components; (4) interpersonal psychotherapy (IPT); (5) CBT; (6) psychodynamic therapy; (7) counseling; and (8) educational interventions. Recently, Urizar Jr et al (2004) had done a pilot study to examine whether giving stress reduction instructions to pregnant women would be effective in regulating stress, mood, and cortisol levels during pregnancy. We can do one step in advance to have intervention during pregnancy, to improve the fetal health status via maternal fetal interaction.
DEVELOPMENT OF FOUR IMMEASURABLESS MEDITATIVE INTERVENTION FOR PREGNANT CHINESE WOMEN
In the West, antenatal education or childbirth education programmed are the traditional methods of information sharing about pregnant women. They also give an opportunity for health professionals to intervene and are designed to reduce anxiety about labor and birth (Fabian et al, 2005). The intervention is mainly at psycho-educational level. Recently there is a unique prenatal program running in Lonavla of India based on the teaching of Swami Vijnananand (Whitwell & Doula, 2004). Music and sound is interwoven in this curriculum in the forms of chants, mantras and prayers, what we would call vibrational medicine today. Antenatal care in Tibet and Sri Lanka has strong elements of Buddhism. Pregnant women will continue their normal religious practice with added ritual during pregnancy. In Tibet , they believe that prayers can work on a physiological level. The repetition of mantras can nurture an altered spiritual state by balancing the “winds” that make up a person’s psychophysical anatomical system. When out of balance, these winds result in what was described as “nervous energy”, producing such negative emotions as anger and jealousy (Pinto, 1999).
Hong Kong is a prosperous and metropolitan city and the main population are Chinese. Development and implementation into present antenatal care system of a Buddhist based model of meditative intervention with integration of psychosocial education (Walsh & Shapiro, 2006) for pregnant Chinese women will be a new research area. Buddhist practice has the characteristics that it is applicable and acceptable to most people even they are not Buddhists. The rationale behind is to develop a model of systematic treatment that is practical, applicable and acceptable for all pregnant Chinese women irrespective of their religious beliefs. Intervention can be incorporated into the routine antenatal care system. The model of Four Immeasurables meditative intervention (FIMI) is based on integration of the Buddhist practice of the Four Immeasurables and mindfulness practice (Pannyavaro, 2004; Nanamoli, 1975; Nanamoli, 1987; Thera, 1962; Sangye, 1996; Silove & Zwi, 2005; Wallace, 2004) with psychoeducation techniques.
MINDFULNESS PRACTCE AND PREGNANCY HEALTH
Historically, mindfulness has been called “the heart” of Buddhist meditation (Thera, 1962). The practice of mindfulness (Gunaratana, 1992; Hanh, 1999; Nanamoli & Bodhi, 1995; Thera, 1962) is fully known in both Theravada and Mahayana Buddhism. It has a complete model of practice which is easily modified to fit into the pregnancy bio-psycho-socio-spiritual model and daily life practice. The value of practice Mindfulness based on its universal acceptance. This kind of “self-help practice” is work for everybody, even non-Buddhist and people believing other religions or having different value on mankind and existence.
Mindfulness-based practice is one form of spiritual practice and psycho-education with its Buddhist origin that receives much attention in the West. Research showed that mindfulness is a useful intervention in stress reduction and improved coping among populations such as chronic pain patients (Astin, 1997), individuals with panic disorder (Kabat-Zinn et al., 1992), overworked medical students (Shapiro & Bonner, 1998), stressed and burnt out nurses(Cohen et al, 2004, 2005). Mindfulness is probably the best understood meditation in the clinical field. Mindfulness-based intervention is incorporated into treatment regime in clinical conditions like hypertension, depression, stress reduction, menopause, oncology etc (Bruce et al, 2005; Carmody et al, 2006; Eldelman et al, 2006; Kabat-Zlnn, 2003; Leigh et al, 2005; Lindberg et al, 2005; Ma & Teasdale, 2004; Ostafin et al, 2006; Proulx, 2003; Surway et al, 2005; Weiss et al, 2005). It is obvious that MBSR programme (Kabat-Zinn et. al, 1985) which is found to be useful in stress reduction can be introduced into antenatal care setting after modification.
Mindfulness, basically aim at stress and mood disorder may be helpful in promoting pregnancy health and various stress related conditions of pregnancy. Mindfulness practice can be combined with other Buddhist based intervention for trial in pregnant women. Mindfulness practice can be integrated into antenatal exercise program. Useful techniques including mindfulness eating, mindfulness breathing and mindfulness exercise. The aim of practicing mindfulness is to increase awareness. Of course, the effect of mindfulness may including relaxation, both body and mind and may have effect on relieving physical symptoms like nausea and vomiting and fatigue (Surawy et al., 2005).
FOUR IMMEASURABLES MEDITATIVE INTERVENTION FOR PREGNANT WOMEN
The practice of the Four Immeasurables is fully known in both Theravada and Mahayana Buddhism. It has a complete model of practice which is easily modified to fit into the pregnancy bio-psycho-socio-spiritual model and daily life of pregnant women.
Practicing the Four Immeasurables means cultivating Bodhicitta, this is the heart of Mahayana Buddhism. Bodhicitta is a mind (including thought, feeling and speech) totally dedicated to others and to achieving full enlightenment in order to benefit all sentient beings as fully as possible. It is the combination of many positive attributes such as the application of compassion, kindness, right view and wisdom. Many in the West use Buddhist techniques as a self-help tool, to purify our negativity and come to understand ourselves better. But without the accompanying desire to help others through compassion and understanding, practicing in this way may serve only to support and harden a sense of self and to make our egos stronger and seemingly more real, instead of transparent (Sean, 2005). Pregnant women are particular suitable in cultivating Bodhicitta because of her relationship with her fetus (maternal fetal relationships). Pregnant woman is preparing two births: her baby’s and her own rebirth.
Maternal expectations and maternal self-efficacy have been found to play an important role in infant development and parenting (Marilyn & Matt, 2003: 260-261). Cultivation of the Four Immeasurables may have positive effect on maternal expectations and maternal self-efficacy. Practice of the Four Immeasurables can improve the social well being of pregnant women. It’s a kind of relational therapy (Ho, 2002) or Dialogic Action Therapy (Ho, 2004) and is a Self help program (Riessman, 1997). Through meditation, one can improve one’s relationship with others through the root of mind training. It can also see to be a kind of social support, supporting oneself and others through inner sense. For pregnant women, her specific situation is that she is closely related to her fetus. There are also changes in her social environment as the whole family is preparing for a newborn. Meditating on all sentient beings including herself, her fetus, her family & friends, other people and even enemies will help her to improve the relationship with others. The basic principle of practice is that helping oneself is equivalent to helping others. Doing well to herself and others is doing well to the fetus. As recent studies shown interests in maternal fetal relationships (Ronca, Lamkin & Alberts, 1993), the practice of the Four Immeasurables is particularly suitable because its major concern is the relationship with others and is easily acceptable to pregnant women because of their feeling of their fetus in uteri. Meditation is well known to have biological and psychological effects (Davidson et al., 2003; Lou et al., 1999; Solberg et al, 2004). It is interesting to assess the effects of the Four Immeasurables meditative intervention on fetal development through changes of the maternal conditions.
The National Institute of Mental Health states, “Clinical experience suggests that for many patients with panic disorder, a combination of cognitive behavioral therapy and medication may be the best treatment. Cognitive–behavioral techniques may enlist a patient’s religious belief structure as an aid to therapy (Gangdev P., 1998). As we utilize the model of the Four Immeasurables to pregnant women, we are not aid at the level of psychotherapy but at the level of primary prevention health education. Some of the interventions are focus on ‘thoughts’ that is similar to cognitive therapy. Cognitive therapy focuses on thoughts, assumptions and beliefs. With cognitive therapy, people may learn to recognize and change faulty or maladaptive thinking patterns (Cathleen Henning, 2004). Others are focus on behavior. In behavioral therapy, people learn how to change behavior and meditation can be treated as a kind of behavioral therapy. Practice of the Four Immeasurables also related to the presence studies of cultivation of positive psychology.
A science of positive subjective experience, positive individual traits, and positive institutions promises to improve quality of life and prevent the pathologies that arise when life is barren and meaningless. The exclusive focus on pathology that has dominated so much of our discipline results in a model of the human being lacking the positive features that make life worth living. Hope, wisdom, creativity, future mindedness, courage, spirituality, responsibility, and perseverance are ignored or explained as transformations of more authentic negative impulses (Seligman, 2000). Pregnancy is known to be a state of stress and negative emotions like anger and fear or depressed mood can easily aroused. Practice of the Four Immeasurables meditation means cultivation of positive emotions. Cultivation of positive emotions (e.g. joy, interest, and contentment) broaden an individual’s momentary thought-action repertoire, which in turn can build that individual’s enduring personal resources, resources that also served the ancestral function of promoting health. Positive emotions have an undoing effect on negative emotions. By broadening the momentary thought-action repertoire, positive emotions loosen the hold that negative emotions gain on an individual’s mind and body by undoing the narrowed psychological and physiological preparation for specific action ( Fredrickson, 1998; Fredrickson, 2000).
The practice of LOVING KINDNESS is a specific meditation practice that can be used both to develop concentration and to develop the quality of kindness. It is easy for pregnant women to practice loving-kindness meditation because of her connection with the foetus. It is a common belief that if you are not happy, how you can give birth to a cheerful baby. For pregnant women to practice the meditation on loving-kindness (慈觀), (1) the pregnant women should begin with oneself. It is easy for pregnant women to cultivate the wish to be happy and they enjoy motherhood. It is a common belief that if you are not happy, how you can give birth to a cheerful baby. Gradually, this practice will enable one to eliminate unwholesome attitudes and actions that produce unhappiness in one’s life. (2) When one has developed feeling of loving-kindness towards oneself, one should go on to develop it towards a close relative and friend. In case of pregnant women, her fetus is one of the subjects of meditation. (3) When this is accomplished, one can move on to the more difficult task of developing, loving-kindness towards strangers and even enemies. (4) One then extends this attitude to all members of one’s community and nation and finally to all sentient beings in all the realms of existence. For pregnant women, it is easy to develop compassion towards the fetus. This is expected to strength the maternal-fetal bonding and promotes good maternal child development. This kind of positive emotion is best cultivated in the morning after wake up so that its influence can extend the whole day. Cultivation of Loving-kindness is both a behavioral intervention as it involves meditation and also cultivation of positive psychology (Fredrickson, 1998; Fredrickson, 2000). Forgiveness is the ability to release from the mind all the past hurts and failures, all sense of guilt and loss. Forgiveness is the first step on the pathway to healing, enables one to banish resentment (Karren, 2002: 436). Metta meditation is one of the most efficient ways to cultivate forgiveness. Studies have shown that the immune system was affected significantly by both happiness and sadness, in other words, by both positive and negative emotions. Happiness has its healing power (Karren, 2002). Cultivation of Loving kindness is the leading pathway to happiness. The practice of Loving kindness meditation can also neutralize the effect of anger, which will lead to ill health (Karren, 2002).
In Buddhism, compassion (karuna in both Pali and Sanskrit) is distinguished from loving kindness (Brazier, 1995; Fischer-Schreiber et al, 1991).The definition of COMPASSION wants others to be free from suffering. This compassion happens when one feels sorry with someone, and one feels an urge to help. The near enemy is pity, which keeps the other at a distance. The opposite is wishing others to suffer, or cruelty. A result which one needs to avoid is sentimentality (Omplace, 2006). It is easy for pregnant women to develop compassion because they usually suffer both mentally and physically during pregnancy. To develop compassion (悲觀), (1) one may begin with an individual whose suffering naturally aroused a feeling of compassion. Once compassion has been aroused in this way, one can go on to develop it step by step towards (2) her fetus, her husband, relatives, friends, (3) strangers and (4) even enemies. Finally, like loving-kindness, compassion can be extended to all human beings without exception. To develop compassion in daily life, it’s mean to prepare the mother psychological to accept the suffering, both physical and mental, causes by the pregnancy and also have psychological preparation for any complications happen. Research begins to examine the construct of self-compassion as an adaptive form of self-to-self relating (Neff et al, 2005; Neff et al, 2006). Cultivation of compassion is a kind of “cognitive preparation”. Through mindfulness practice and meditation on compassion, the mother can discover the changing relationship between mother and fetus and all human beings. This awareness of “Impermanence” can empower the meditated one to turn “curse into blessing”, knowing that things can go worse or the other way round. It is the practice of always having crisis feeling and prepare for the crisis.
The definition of EMPATHETIC JOY is being happy with someone’s fortune and happiness. Here refers to the potential of bliss and happiness of all human beings, as they can all become Buddha. The near enemy is hypocrisy or affectation. The opposite is jealousy. A result which one needs to avoid is spaced-out bliss (Omplace, 2006). It is easy for pregnant women to develop empathetic joy as they can easily share and feel the happiness of pregnancy and bringing a new life to the earth with other pregnant women. When one cultivates empathetic joy (喜觀), pregnant women can begin with (1) one’s own good fortunate. Thereafter, one can extend one’s attitude of appreciative joy to (2) her fetus, close friend, relatives, (3) strangers, (4) enemies and then to all human beings. To cultivate empathetic joy in daily life is a kind of behavior therapy and pregnant women are taught how to practice “bliss” (Morrell, 2005). This is an example of how we integrate the practice of meditation into daily life activity. Empathetic joy is a great antidote to depression for oneself as well. The practice of empathetic joy meditation may lead to more appreciation of life .This is particular effective in pregnant women as a new life will born in few months time. The effect of cultivation of empathetic joy will lead to a happy life. It is an unselfish, very positive mental attitude which is beneficial for oneself and others. By rejoicing in others’ progress on the spiritual path, one can actually share in their positive action. In this case, it also refers specifically to rejoicing the giving birth of next generation. In long term practice, this may have an anesthetic effect over physical suffering during pregnancy and labor pain.
The definition of EQUANIMITY is not to distinguish between friend, enemy or stranger, but regard every human being as equal. It is a clear-minded tranquil state of mind, not being overpowered by delusions, any mental dullness or agitation. The near enemy is indifference. The opposite is anxiety, worry, stress and paranoia. A result which one needs to avoid is apathy. Impartiality is perhaps the better English translation, for it contrasts with the biased way we usually view other (Wallace, 2004: 149). Equanimity is the basis for unconditional, altruistic love, compassion, joy for other’s happiness and Bodhicitta (mind of awakening) (Omplace, 2006). The Path of Purification presents a technical discussion of equanimity as a specific contemplative achievement that is developed after you have attained the third meditative stabilization in Four Immeasurables. At this point, you start by attending to a neutral person toward whom you feel no particular attraction or repulsion. Then, you attend to a person you love and then to a hostile person, and see in each case if you can bring the same calm evenness of mind to bear, with no attraction or aversion (Wallace, 2004:150). In cultivating equanimity (捨觀), (1) one is advised to begin with a stranger because one is naturally free from strong feelings of clinging or aversion to him. This is especially important for pregnant women with ultimate relationship with her fetus. (2) Then, having aroused to begin with a stranger, one can extend it to her friends and relatives (3) Having arouses the wholesome attitude of equanimity, one can extend it to her enemy; (4) finally, one can extend it to her fetus and oneself. Equanimity is an unselfish, detached state of mind which also prevents one from doing negative actions. Equanimity is the basis of unconditional acceptance. This is particular helpful for pregnant women in case there is complications arise during pregnancy or they found that their fetus and child have problems. Cultivation of equanimity is to practice non-attachment; it can be viewed as a kind of cognitive behavior approach. The idea of “Put it down” is common in Buddhist philosophy, especially in Zen practice in daily life, from moment to moment. The idea of “let go” in social work practice may share the same idea of this practice. Equanimity is closely related to empathy and altruism. Empathy is a central notion in psychotherapy and recent research focus on its importance for the provider-patient alliance and for the success of psychotherapy (Findlay et al, 2006; Wakabayashi et al, 2006; Wynn & Wynn, 2006). Empathy and sympathy fit perfectly with medical practice (Mathiasen, 2006). Empathy in health care is the capacity to understand and respond to client’s emotions and their experience of illness. Cultivation of equanimity is the door leading to the power of empathy. Altruism can be defined as the capacity to perform costly acts that confer benefits on others. Altruistic behavior can be viewed as a natural strategy for improving survival (Rozenfeld et al, 2006; Sanchez & Cuesta, 2005; West et al, 2006). Equanimity meditation, on the other hand, can form the basis of altruism.
The characteristic of the developed Four Immeasurables meditative intervention is that through meditative practice, we can change training and transforming our mind. As our mind change, our daily life also changes. Descriptions of mindfulness and methods for cultivating it suggest that mindfulness can be developed through the regular practice of meditation, and that increases in positive qualities such as awareness, insight, wisdom, compassion, and equanimity are likely to result ( Goldstein, 2002; Kabat-Zinn, 2000). Recently there are research exploring the role of meditative practice in cultivating experiences of compassion, empathy, and altruism (Kristeller & Johnson, 2005). Table 1 showed the ideas of analogy between Four Immeasurables meditative intervention and psycho-education.
TABLE 1
FOUR IMMEASURABLES MEDITATIVE INTERVENTION & PSYCHOEDUCATION
| FOUR IMMEASURABLES MEDITATIVE INTERVENTION | COMPONENTS OF PSYCHO EDUCATION |
| Mindfulness | Stress reduction program like behavior therapy |
| Loving kindness meditation | ForgivenessHappinessAnger management |
| Compassion meditation | Crisis interventionTurn curse into blessing |
| Cultivation of Empathetic joy | BlissHappinessAppreciation of life |
| Equanimity meditation | Let goEmpathyAltruismUnconditional acceptance |
A QUALITATIVE AND QUANTITATIVE ANALYSIS OF THE EFFECT OF FOUR IMMEASURABLESS MEDITATION INTERVENTION ON MATERNAL AND FETAL HEALTH
A randomized control study has been conducted in Obstetric Unit, Queen Elizabeth Hospital , and Hong Kong . Participants will be randomized into two antenatal classes until 50 cases are included in each group. One antenatal class will have the added elements of Four Immeasurables meditative intervention conducted by the researcher. All cases that participate in the study will have a detailed history taking including a spiritual history during first visit. They will fill in the questionnaire chosen, the Prenatal Distress Questionnaire (Yali & Lobel, 1999), the Prenatal Coping Inventory (Yali & Lobel, 1999), the Body-Mind-Spirit Well-Being Inventory (BMSWBI) (Ng et al, 2005), Edinburgh Postnatal Depression Scale (EPDS), General Health Questionnaire (GHQ-12)), and Kansas Marital Satisfaction Scale. The pregnant women will be instructed on how to check their first salivary cortisol level. Second salivary cortisol level and second questionnaire study will be taken around 36 weeks. All cases will fill in the questionnaires again and have the salivary cortisol samples taken at six weeks and five months after delivery. Clinical data including blood pressure and mode of delivery will be collected. For fetal assessment, birth weight, Apgar score and cord blood for cortisol level will be collected. Salivary cortisol level of the infants will be examined around six weeks and five months old. Mothers will be asked to fill in the Carey Infant Temperament Questionnaire at the five- month’s visit. Twenty participants will be chosen from the group with intervention randomly for detailed interview during first visit and 36 weeks for qualitative analysis.
FUTURE PERSPECTIVES
Historically speaking, the main role of religion was to take care of health and social matters of all the disciples. Nowadays in our complex societies, social science also has its contributions. Recently, increased attention has been given to meditative intervention to improve physical health, mental health and foster spiritual growth (Lindberg, 2005). In 2003, the Society for the Exploration of Psychotherapy Integration celebrated its 20th birthday and at the same time affirms the future goal of psychotherapy integration. Combinations of techniques currently on the cutting edge such as the assimilation of mindfulness methods would be standard (Norcross & Goldfried, 2005).
The implication of the study is great. Is it possible that this model of treatment prevent prenatal and postnatal psychiatric problems? We know that mindfulness-based practice may have effect on hypertensive patient. The hypothesis tested can also apply to pregnancy complication like hypertension complicating pregnancy. Research shows that stress has been associated with recurrent abortion (Sugiura-Ogasawars et al, 2002), infertility (Fido & Zhaid, 2004; Peterson et al, 2004), preterm labor (Rich-Edwards et al, 2005) and future human development (Laplante, 2004; Van den Bergh et al, 2005; Yehuad, 2005). Can Buddhist base meditative intervention benefit those mothers with such history? Actually if the model tests found to be effective, it has great implication in women’s health, other life events like preconception, infertility and post-menopausal life time and healthcare provision. Particular attention can be paid to preconception care, which is the promotion of the health and well being of a woman and her partner before pregnancy (Gregory, 1999).
It is the right time for Buddhist to keep open mind and introduce Buddhist practice to health profession and public. Medicine, religion and social science are helping professions. The project proposed has the objective of contributing to our health care from all these specialities. I hope that in the future we can see more and more studies performed in this direction.
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