Background
The experience of labour pain is highly variable [
1,
2]. Although studies consistently show that many women would prefer to labour without pharmacological pain relief, the percentage of labouring women who actually receive medication for childbirth is rising steadily [
3,
4]. However, the link between effective pain relief and maternal satisfaction with labour is not straightforward. Women who have inadequate pain relief during labour are at increased risk of post-traumatic stress in the postnatal period [
5] but those who use epidural analgesia are, overall, less satisfied with their experience of labour and birth compared to those who do not [
2].
A range of alternative pain relieving solutions has been proposed for labour including acupuncture, immersion in water and hypnosis. Hypnosis, in particular, has been used in maternity care for a number of years with case studies highlighting its benefits as an analgesic dating back to the late nineteenth century [
6]. More contemporary studies using a variety of methodologies have produced mixed results. In a large case matched study involving a total of 520 participants across six US states, women receiving antenatal hypnosis training were significantly less likely to need pharmacological analgesia (including epidurals) during labour when compared to controls receiving usual antenatal care [
7]. The benefits of hypnosis for pain relief during labour were tentatively supported in a 2010 Cochrane review of complementary and alternative therapies (CAM’s) which found that ‘acupuncture and hypnosis may be beneficial for the management of pain during labour’ [
8]. A more specific review of hypnosis for labour and delivery pain, published a year later and including thirteen trials also found evidence to support its use in this context [
9]. However, recent findings from two large randomized controlled trials (RCT’s) conducted in Denmark and Australia [
10‐
12], and the most recent UK Self-Hypnosis for Intra-partum Pain (SHIP) trial [
13] all found no difference in epidural use between an intervention group receiving self-hypnosis training during the antenatal period and a control group receiving usual antenatal care. Furthermore, in the most recent overview of systematic reviews for labour pain management conducted in 2012 the authors found insufficient evidence to support the use of a variety of CAM’s including hypnosis [
1].
Despite the inconsistency of the evidence base, the use of hypnosis in labour appears to be increasing in popularity [
14,
15]. Frequent anecdotal accounts of the benefits of self-hypnosis for pregnant and laboring women continue to emerge from practice and the technique remains popular in spite of the current evidence base. Qualitative accounts from women on the use of hypnosis could illuminate areas that are currently being overlooked by quantitative outcomes data. Neither of the two studies of hypnosis for labour that were published immediately prior to the SHIP trial included qualitative data [
10,
11] although some of the quantitative findings in Werner’s study suggest that the women in the self-hypnosis group were much more satisfied with their birth experience compared to the controls [
16].
Indeed, with the exception of one or two case studies, the only published qualitative research accounts relating to women’s experiences of using self-hypnosis for labour come from a very small Iranian study that included 6 women. The participants reported feeling more confident, less fearful, less anxious and more satisfied with their birth after a course of antenatal hypnosis training [
17]. However, the potential transferability of these findings is limited.
Given the lack of evidence in this area, we aimed to explore the views and experiences of a group of women receiving an antenatal self-hypnosis training programme for labour pain relief to inform the results of the SHIP Trial (Downe et al. [
13]).
Methods
Design
One to one qualitative interviews
Setting
Interviews were conducted alongside the main SHIP Trial, a randomized controlled trial investigating the effect of an antenatal self-hypnosis training programme on rates of epidural use amongst laboring women. The 678 participants in the trial were randomly assigned to the intervention group (self-hypnosis training;
n = 343) or the usual care group (
n = 335). Both groups received the standard package of antenatal education delivered by the NHS Trust and, in addition, intervention participants received group tuition in the use of self-hypnosis for anxiety and pain relief during labour. The tuition consisted of two 1.5 h training sessions at around 32 weeks and 35 weeks pregnancy, supported by a take-home, practice CD that participants were encouraged to listen to on a daily basis from the first training session until the birth of their baby. All of the women (in both groups) were aged 18 or more and were experiencing their first pregnancy. Birth companions/partners were recruited alongside the women in both groups and, where possible, attended the intervention or educational training sessions in a supportive role. Clinical data relating to the outcomes of the trial were collected at the Trust site and additional data were collected from the trial participants via questionnaires distributed at four time points: baseline (27 weeks gestation), 36 weeks (after the intervention) and 2 and 6 weeks post-natal (Downe et al. [
13]).
The trial was conducted over a three year period (2010 – 2013) in three NHS Trusts covering six different clinical sites (three consultant unit, two free standing units, one alongside unit) in the North West of England.
Ethical approval
Ethical approval for the trial, including the qualitative interviews, was obtained from the National Research Ethics Service (NRES) (Study Reference 10/H1011/31) and the University of Central Lancashire Research Ethics Committee, and all relevant governance procedures were approved by the participating Trusts prior to recruitment. The trial was registered on a publically available database in accord with National Institute for Health Research (NIHR) guidelines and given the number ISRCTN27575146.
Procedures
Participants in the interview phase of the study were recruited over a 12 month period (Feb 2012 – Jan 2013) from the primary NHS site. Four participants from the intervention group were randomly selected each month and contacted by a member of the research team to see if they would be willing to take part. Those who agreed were sent a consent form prior to the interview and, once a signed copy was returned, arrangements were made to interview the participants in a private location of their choosing. Although we expected to recruit around 20 women, the intention was to continue selection of participants until our iterative process of analysis revealed that no new themes were emerging from the data. Where possible, we sought to interview women with their birth partner/ companion, and, in these cases an additional consent form was sent to the birth companion for information and signature.
The interviews were semi-structured in format and included two key questions as well as a series of supplementary, follow up questions. The key questions were, ‘Can you tell me about your experience of the self-hypnosis training programme?’ and ‘can you tell me about your labour and birth?’ All interviews were conducted by a member of the research team (KF or HC) and were recorded using a digital device. Each interview took place in a quiet room in the participant’s home and lasted between 35 and 80 min. At the time of the interviews all of the women were between 8 and 14 weeks post-partum. We chose this timeframe because participants were still completing follow-up questionnaires from the SHIP trial (at 2 weeks and 6 weeks post-natal) and we didn’t want to add to their existing trial commitments during this busy period.
Discussion
Women’s experiences of self-hypnosis as part of the SHIP trial were generally very positive. Our findings indicate that women arrived at the first self-hypnosis session feeling anxious, fearful and occasionally sceptical and, after completing the training, felt confident, empowered and reassured. This transition is similar to the findings reported in the only other qualitative study of women’s experiences of an antenatal, self-hypnosis training programme, conducted in Iran in 2009 [
18]. The authors highlight women’s ‘sense of relief’, ‘increased self-confidence’ and ‘satisfaction’ following their involvement with the hypnosis intervention. They also note that women felt less anxious and less fearful after the hypnosis training – findings reflected in our ‘calmness in a climate of fear’ theme. Interestingly, for the women in our study, the initial reduction in levels of fear and anxiety was attributed to a 15 min section in the first training session where the midwife presented a short explanation of the physiology behind labour and birth. This is an interesting finding as although much has been written about the psychological, supportive and practical components of antenatal education [
19,
20], the relevance of women’s understanding of the physiology of labour and birth is less well understood. This relatively simple approach to alleviating anxiety may be significant as there are well established theories propounded over fifty years ago linking raised levels of anxiety and fear during pregnancy with increased levels of pain during labour [
21]. Supporting evidence for this theory is increasing and more recent studies have shown that elevated levels of fear or anxiety during pregnancy can lead to increased rates of medical intervention including epidural use [
22‐
25].
It is also likely that reduced levels of anxiety and increased confidence about labour and birth will lead to a more satisfying birth experience. Although the women in these interviews did not discuss their levels of satisfaction directly it is clear that the majority felt happy with their experience and, when prompted, all 16 said they would use the technique again in any future pregnancies. These findings are similar to those from the recent Danish self-hypnosis trial which showed that women receiving the hypnosis intervention were significantly more satisfied with their birth experience compared to a relaxation group and a control group [
17]. The same authors, and the SHIP trial data, also note that levels of fear and anxiety in specific circumstances were significantly lower in the hypnosis trained intervention group [
11,
14]. This finding is supported by previous trials of this phenomenon [
26], [
8].
For some women, the ability to control their anxiety and act in a calm and composed manner led to confusion at hospital admission where staff were more used to seeing women arriving in a state of distress. The important role of labour ward staff as gatekeepers has been identified in previous studies of women’s experience of attempting to gain access to intrapartum maternity care [
27]. The perception that some staff misinterpreted signs of labour due to the unexpectedly relaxed state women were in when under hypnosis is an important finding. It strongly suggests that any Trust intending to set up antenatal self-hypnosis sessions should ensure that all of the staff women may encounter are aware of the altered behavioural norms for women using self-hypnosis when in active labour.
For other women, an unexpected consequence of using self-hypnosis was that it raised expectations and led to disappointment when labour and birth failed to live up to these enhanced expectations. We were aware of this during the planning stage of the study and tried to address the issue at both of the training sessions by highlighting the unpredictability of labour and birth. However, the hypnosis scripts were deliberately designed to emphasize feelings of confidence, empowerment and relaxation as these are considered essential components of self-hypnosis training in this context. It may be that any form of antenatal intervention that seeks to reduce levels of fear and anxiety will invariably raise expectations, with subsequent disappointment for a sub-set of women who do not meet their revised expectations. Alternatively, this may be a more general issue, independent of how a woman prepares for labour and birth; if women underestimate or downplay the intensity of the pain they expect to encounter during labour this may influence their experience of birth in a negative way [
5].
At a methodological level, we were intrigued to note the range of strategies women used to individualize the adoption of self-hypnosis practice into their lives during the antenatal period. This raises questions about how far randomised trials of complex interventions can, or, indeed, should, permit flexibility in the means of delivery of an intervention, when the aim of the study is pragmatic: ie, when the intention is to find out if the intervention would work in the uncontrolled realities of everyday lives. [
28,
29]
Strengths and limitations
Apart from one small study of 6 women undertaken in Iran, this is the only published study we are aware of that explores women’s views of using self-hypnosis in labour. The participants were selected randomly, and are representative of those in the index randomised trial. The procedures used for data collection and analysis were rigorous and transparent, and the data interpretation was reached by consensus among the research team. However, less than half of the women invited to take part did so, and they were all from one specific ethnic group (White British). Women who did not access the training did not take part, and it is possible that those with a less positive experience did not respond to the interview invitation. This should also be viewed in the light of the primary data from the SHIP trial in which, for the whole study population, most outcomes were not affected by the hypnosis training [
14]. The contrary findings emerging from the qualitative data could suggest either that interviewed women were unusual in finding the intervention helpful, or that the outcomes chosen for the main study were not those that were most important for women’s sense of well-being.
Although birth partners were invited to the self-hypnosis training and often participated in practice (listening to the CD) we did not interview them directly. Women occasionally referred to the positive contributions of their partners in the interviews but this is not reflected in our data. Findings from a previous study in which birth partners played an active role in prompting self-hypnosis during labour showed that levels of pain were significantly lower in the partner involvement group compared to a control group [
30]. We would therefore recommend that the role of the partner in assisting with hypnosis is explored in future qualitative studies in this context. Despite these limitations, this remains the largest study of women’s views and experiences of self-hypnosis training for labour pain to date.
Acknowledgements
This article presents independent research funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0808-16234). The views expressed are those of the author (s) and not necessarily those of the NHS, the NIHR or the Department of Health.
The authors would like to thank the remaining members of the SHIP Trial team - [in alphabetical order] (Shehzad Ali, Louise Dunn, Gill Gyte, Cathie Melvin, Vivien Miller, Pauline Slade, Dominic Trepel, Andrew Weeks, Maria Williamson for their input and expertise during the trial. We would also like to thank Naseerah Akooji, Frank Longdon, Laura Elizabeth Bangs Hoskin, Fallon Michelle Dyer and Alexandra Scurr at the University of Central Lancashire for their help with data transcription, analysis and administration.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
KF contributed to study conception and design, was involved in data collection and transcription, conducted data analysis and interpretation and drafted the manuscript. SD, HS and PW contributed to study conception and design, interpretation of data and critical revision of the manuscript. SH contributed to study design and conception, was involved in data collection and transcription, contributed to analysis and interpretation of data and critical revision of the manuscript. HC was involved in data collection and transcription and critical revision of the manuscript. All authors approved the final version of the manuscript.
KF – Senior Research Assistant, Research in Childbirth and Health Unit (REACH), School of Health, University of Central Lancashire, Preston, PR1 2HE. UK. Qualifications: BSc (Hons), BSc (Hons).
SD – Professor of Midwifery Studies, Research in Childbirth and Health Unit (REACH), School of Health, University of Central Lancashire, Preston, UK. PR1 2HE. Qualifications: BSc (Hons), RM, MSc, PhD, OBE.
SH – Director of RaFT Research, Lower Hall, Main Street, Downham, Clitheroe, Lancashire, BB7 4BN. UK. Qualifications: BSc, MSc, PhD
HC – Research Midwife, Royal Bolton Hospital, Minerva Road, Farnworth, Bolton, Lancashire BL4 0JR, UK. Qualifications: BA (Hons), RM, Hypno-birthing Practitioner.
HS - Professor of Midwifery: Faculty of Medicine & Health Sciences, University of Nottingham, NG7 2UH UK. Honorary Professor, School of Nursing and Midwifery, University of Queensland, Australia. Qualifications: RGN, RM, MPhil.
PW - Professor of Medicine and Gastroenterology: Centre for Gastrointestinal Sciences, University Hospital of South Manchester NHS Foundation Trust, Manchester, M23 9LT, UK.
Qualifications: BSc, MB, BS, MD, PhD, FRCP.