I’m feeling slightly bemused again by the obstetric interest in whether hypnosis for childbirth has been shown to ‘work’ via randomised controlled trial (RCT), following the on-line advanced publication of another large RCT in the BJOG (Cyna et al 2013). They’ve flown straight into the hen house again, stirring up a lively Twitter debate, made more timely because the Duchess of Cambridge apparently used hypnobirthing in the successful birth of her first child.
But was she following evidence based medicine (EBM)? No, she was not. Women do not follow EBM when it comes to labour coping strategies. They follow social medicine. They look around for women who they feel are ‘like’ themselves, women who share the same philosophy towards birth as they do, women who have experienced birth in the way they hope to. They explore available coping strategies and pick a few which are in tune with the coping strategies they use outside of the microcosmic birth world. And of course, they look to their midwives on the day.
Our risk-focused maternity culture is particularly poor at sending the message to women: “Your body was designed to do this. You can do this, you are strong, and you will cope. And if you need help, it will be there.” Instead we give women the message that they will need to ‘do’ something extra in order to be able to birth normally. When it comes to pharmacological pain relief, many would rather have ‘nothing,’ and hypnosis is about as close to nothing as you can get. Apparently the data back me up.
My major problem with Cyna et al’s study is that it takes what seems to work in a social setting, e.g. a group of women who share similar beliefs and are looking for similar things out of childbirth, and a facilitator who nurtures self-belief and enhances new and familiar coping strategies over a period of time, and they medicalise it. The 3 hypnosis sessions in this study were delivered by a doctor trained in hypnosis, only 50% attended all three sessions, and some allocated to the training even chose to attend a different hypnosis training group outside of the intervention. This suggests to me that the intervention was not very appealing on a social level. Every article published seems to acknowledge that the pared down version used in an RCT isn’t quite like what is practised in today’s hypnobirthing and natal hypnotherapy classes which are so popular with women, where women receive on-going support from their classmates and instructors.
Additionally, these researchers blinded health professionals involved to group allocation, a fault I have discussed the last time this debate flew up (although in the Cyna study it is difficult to imagine how health professionals remained blinded to allocation when some groups were asked to use a CD in labour and others were not). Again, my issue is with the medicalisation of a social art. Part of my job as a midwife is to facilitate an environment which supports a woman’s natural coping skills. If I do not know what coping strategies she is using, I am much less likely to get that right. Blinding in a trial like this is neither possible nor desirable.
With various types of research trials turning up conflicting information, the pragmatic in me deals with this by imagining how certain conversations might play out.
Woman: Does hypnobirthing work?
Me: It depends on what you mean by ‘work’ (and what you mean by ‘hypnobirthing,’ but that’s more complicated so I’m not going to say it out loud – yet).
If by ‘work,’ you mean you want it to relieve your labour pain, in a general population it has not been shown to be as effective as water or Entonox.
If by ‘work,’ you mean you are hoping to avoid unnecessary interventions such as instrumental or surgical delivery, in a general population hypnobirthing has not been shown to do that. Home birth and continuity have both been shown to do that very effectively. If your Trust is not practising evidence based medicine by ensuring you have access to these, having another woman support you and your partner during labour is also helpful. She need not have special training. Someone just being there the whole time will have the same effect.
If by ‘work,’ you mean you will look back on your childbirth experience and decide that was effective for you, the answer is, “Many women feel hypnobirthing has been effective for them, but whether it will be for you is down to many individual factors. I suggest you follow your instincts on this one.”
Woman: My friend recommended this hypnobirthing class to me, but I don’t really like it. What do you think? I really want a natural birth.
Me: I think you ought to spend the evenings out doing something lovely with your partner instead. Your body was designed to give birth, you will be able to do it when the time comes, and we will do our best to support you. If you need help, we will be here. (See also above suggestions re: ‘working.’)
Woman: I started doing a hypnobirthing class, which I really like, but when I talked about it with my consultant, he said it was quackery. What do you think?
Me: If you can’t be a bit quacky in labour, when can you? He may have never watched someone use hypnobirthing effectively in labour. I think you ought to follow your instincts on this one and do what gives you confidence. We will support you.
Commissioner: Should we fund hypnosis antenatal classes for the women using our maternity services?
Me: No. We should not fund complementary therapies which have not been proven effective, but we should educate midwives in appropriately supporting women who choose to use them. We should also stop funding unnecessary extra ultrasounds which are requested against available evidence of their lack of effectiveness in improving outcomes, and significant effectiveness in increasing unnecessary interventions, incurring further associated costs. We should then channel the money we have saved into a more reliable home birth service (which has been proven to be the least costly option with no change in outcomes for multips, and a significant decrease in interventions) and more continuity services (also proven to improve outcomes), targeted first at those who need them most. Midwives should then use their clinical judgement and experience to support the individual women in their care, rather than referring them all to bare bones antenatal classes.
(Or some such similar argument, depending on which non-evidence-based intervention is currently most overused while many midwives run around like headless chickens trying to provide evidence based one-to-one care, desperately clinging to techniques like hypnosis which might help more women to do it by themselves when midwives cannot be at their sides providing individualised care.)
Upcoming study day: Promoting Normal Birth & Hypnobirthing Conference, 19/6/14