Tag Archives: hypnosis

Hypnosis for childbirth: medical or social intervention?

fundingI’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.

EBM labour coping

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.

in and out of NHS

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.

yoga

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.

blinding and biasAdditionally, 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.

questions

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

When the science of midwifery undermines the art

Self-hypnosis for pain relief in labour

Obstetrician and canoeist through the thick waters of controversy Jim Thornton drew my attention to this recent trial, published by the BJOG in February (Werner et al 2013, read it here), through his blog (read his post here, always though-provoking). Jim calls the trial ‘lovely,’ but I can’t agree. Rather, I think it illustrates how research, if not appropriately designed, can potentially cause more harm than good.

This study was well-conducted in randomised controlled trial (RCT) terms, so we can depend on the results: Take a group of women who are up for it and randomly allocate them to a short course on either self-hypnosis, relaxation, or standard antenatal care. They then give birth supported by a midwife who is not allowed to know how they prepared to self-manage pain in labour. You will find that no one education intervention results in more or less pain, more or less need for epidurals, nor any noticeable difference in satisfaction with their childbirth experience. I’m not surprised.

I was pleased to see the authors shared many of my concerns in retrospect and can only imagine it was over-confidence in a technique they had observed many women use with great satisfaction that led them to proceed with a trial design which featured some predictable flaws. One of my biggest concerns was that staff were blinded about the woman’s allocation. Effect: most of the time the midwives could not guess correctly which group the woman belonged to. This was a piece of midwifery research, but it effectively disabled midwives from practicing their art, sympathetically enhancing the woman’s coping techniques using knowledge gained about that woman through their relationship.

This debate was bugging me until I picked up the latest issue of The Practising Midwife and read midwifery lecturer Charlotte Kenyon’s very sensible piece on ‘Clinical hypnosis for labour and birth: a consideration.’ She discusses the difficulties with conducting research in this area (I refer you to her article for a fuller account; TPM is digitally lacking, so visit your library), but most importantly she points out, “No recent studies could be found which employed individualised hetero-hypnosis” (Kenyon 2013, p12).

Individualised hetero-hypnosis’ is what you get when you give midwives a set of tools (along with women) and enable them to use them to support women on an individualised basis, according to the woman’s needs and values, enhancing the woman’s own coping skills. Delivering individualised care, sympathetically combining experience- and evidence-based knowledge, is the art of midwifery. In contrast – “Where research is undertaken using formulaic scripts, results may be affected by the use of a one size fits all approach to a therapy which by its nature is individualised” (Kenyon 2013, p12). Yep.

Soo Downe is currently conducting an RCT (registered here) on the use of self-hypnosis with a mixed methods design that appropriately includes other strands of contextualising data collection such as interviews, focus groups, logs and questionnaires. Importantly, the midwives supporting women in labour will not be blinded; therefore, the conduct of the trial itself presents an opportunity to expand the practice of midwives providing individualised care. This sounds like a study which will pragmatically improve our understanding of how women use self-hypnosis and how midwives can enhance women’s own efforts, as well as whether or not there is a quantifiable difference in outcomes which would justify increased investment to integrate such services into the NHS. Can’t wait for the results.

So what harm can come from poorly designed research? Well, I wouldn’t have liked a positive outcome for the Werner trial to lead us down a path of advising all women they will have a better time if they use self-hypnosis (without a greater understanding of who it is most likely to help, how and why). But I also don’t like the idea that on the back of this large RCT some individual women’s use of self-hypnosis will inevitably be dismissed by some professionals as ‘not evidence-based,’ rather than respected and appropriately supported. This could undermine a woman’s confidence and feeling of being supported in her chosen coping strategies. For what? Because we know better?

Declaring my personal biases (because it’s my blog): I have never been drawn to using hypnosis (self-administered or otherwise) while giving birth, despite having four home births. If you told me I would never have to listen to a hypnosis CD throughout a night of someone else’s labour again, I wouldn’t complain; they make me feel like I’ve just had a lobotomy. My personal birth mix included Nina Simone, Herbie Hancock, and Madonna’s ‘Like a Virgin,’ just to lighten the mood while I swore like a trucker. But I trust women. Having listened to many women describe how hypnosis-related techniques and programmes helped them feel more confident and in control, and having watched them give birth, I am siding with those who insist their experience be properly accounted for before we close the book on the hypnosis for childbirth debates.

Reference

Kenyon C (2013) Clinical hypnosis for labour and birth: a consideration. The Practising Midwife. 16(5):10-13.

Update 2015 – You can read Downe et al 2015 by following the link.

BJOG. 2015 Aug;122(9):1226-34. doi: 10.1111/1471-0528.13433. Epub 2015 May 11. Self-hypnosis for intrapartum pain management in pregnant nulliparous women: a randomised controlled trial of clinical effectiveness. Downe S, Finlayson K, Melvin C, Spiby H, Ali S, Diggle P, Gyte G, Hinder S, Miller V, Slade P, Trepel D, Weeks A, Whorwell P, Williamson M.