Effect of self-hypnosis on fear and pain of natural childbirth: a randomized controlled trial

Background

The fear and anxiety a mother may experience as childbirth approaches is known as the “fear of childbirth” (FOC). FOC prevalence varies by country due to differences in the definition of concepts, FOC measurement time, and cultural diversity [1]. In European countries, the overall rate of FOC was 1.9–14 % [2], with moderate and severe FOC rates reported to be 19.6 and 6.1 % respectively in Iran [3]. FOC can be particularly prevalent in women who have not previously given birth. The most common causes contributing to this anxiety are fear of labor pain and the baby’s health [1]. Fear can lead to increased catecholamine release during labor, resulting in a cycle of fear-tension-pain [4]. Among the side effects of this cycle are severe labor pain, dystocia, and prolonged labor [5].

In Iran, many women choose cesarean sections due to FOC, leading to a high rate of C-sections (48 %, compared to the WHO’s 15 % recommendation) [6], 7]. This can result in maternal complications such as infection and bleeding, as well as fetal issues like low APGAR scores [8], 9]. To address this, natural childbirth promotion programs, including pain relief methods, have been introduced in Iranian maternity hospitals since 2014 [10], 11]. Epidural analgesia is the most effective pain relief method during labor. However, patient preferences, contraindications, limited availability, and technical issues may necessitate the use of alternative methods. These alternatives include systemic pharmacologic agents, typically administered by inhalation (like nitrous oxide) or injection, and nonpharmacologic approaches such as yoga, music therapy, massage, reflexology, shiatsu, acupuncture, birthing balls, transcutaneous electrical nerve stimulation, and hypnosis [12].

Hypnosis is a state of focused attention and reduced peripheral awareness that enhances one’s responsiveness to suggestions [13]. Hypnosis is affordable, safe, effective, and it does not require any special equipment. It can be used with various patient groups and in different clinical settings. Its therapeutic benefits, particularly in anesthesia, can typically be experienced within minutes or even seconds. Additionally, hypnosis can be practiced independently through self-hypnosis, offering further convenience and accessibility [14].

Despite being considered a benign process, certain studies have identified potential side effects such as headache, dizziness, nausea, anxiety, or panic. These complications can vary in intensity and duration and are classified as short-term or long-term complications. Ambivalence, which is a conflict between the desire to be hypnotized and the anxiety or wish not to be, may result in a headache, as suggested by Hilgard (1974) [15].

To understand how someone responds to hypnosis, it’s important to consider personal risk factors like unmet sexual or social needs, alcohol or drug addiction, and personal biases. Professional risk factors, inadequate knowledge, training, and skills, also play a role. The environment or research settings can significantly impact an individual’s experience with hypnosis [15]. To assess an individual’s hypnotic ability, a range of tests, like the Hypnotic Induction Profile, and the Elkins Hypnotizability Scale can be employed [16], 17].

Hypnosis is an effective tool in obstetrics, helping manage conditions like nausea, labor pain, hypertension, and preterm labor [18]. Self-hypnosis during childbirth empowers women to control anxiety and stress levels [19]. According to previous research by Downe et al. (2015), hypnosis is characterized by a decrease in the experience of FOC in the two weeks following delivery. Moreover, to the best of our knowledge, no studies have investigated the effect of hypnosis or self-hypnosis on FOC during pregnancy and labor. So, this study sought to explore the potential benefits of self-hypnosis in managing these issues.

Methods

This study was a parallel, not blinded, randomized controlled trial conducted in 2019 in Mashhad, Iran. In this study, participants were randomly assigned to two groups: the intervention and the control groups. The intervention group received usual care along with self-hypnosis training, while the control group received usual care. It is worth noting that neither the researchers nor the participants were blinded in this research design.

Results

Ninety-three mothers were enrolled in the study, 30 of whom were excluded (12 from the self-hypnosis group and 18 from the control group), leaving 30 and 33 women in the self-hypnosis and control groups, respectively, who completed the study. Although all women in both groups were able to perform self-hypnosis during childbirth, only one pregnant woman in the self-hypnosis group could not accomplish self-hypnosis during pregnancy (Figure 1).

Figure 1:

CONSORT flow diagram.

Discussion

This research aimed to study the impact of self-hypnosis on fear and pain levels in first-time mothers during childbirth. Prior studies have suggested that FOC during pregnancy may lead to fear during labor [26]. Therefore, teaching self-hypnosis during pregnancy could potentially reduce pain and FOC. This study is unique in that it assessed the influence of self-hypnosis on FOC during both pregnancy and labor for the first time.

In this study, we examined the hypnotizability of participants utilizing the “conditioning technique.” Our results demonstrated that conditioning mothers during pregnancy to associate contractions with a specific cue, such as their right thumb, enabled them to enter a hypnotic trance unconsciously during labor, allowing for posthypnotic suggestions without conscious awareness. The absence of a standardized methodology for hypnosis protocols complicates comparisons of different techniques and their effectiveness, which may explain the difference in our findings compared to some prior research, although the majority of literature aligns with our results [27], [28], [29], [30].

It is important to note that only the data analyst was blinded in this study. Previous studies have suggested that hospital staff caring for the self-hypnosis group often misattributed calmness to a lack of labor progress tied to stress among intervention participants [31]. Additionally, research by Werner et al. indicates that blinding physicians, particularly midwives, may interfere with the hypnosis process [32]. Consequently, the other researchers and hospital staff were aware of the participants’ self-hypnosis. To eliminate bias, participants who received pain relief (spinal, epidural, Entonox, and narcotics) were explicitly excluded from the study. In such cases, it was clear that any observed pain reduction could not be attributed to self-hypnosis, but rather to the pain relief methods themselves.

A key strength of this study was the monitoring of participants’ daily self-hypnosis practice, which may have contributed to the reduction in pain at 4–5 and 8–10 cm cervical dilatation. In the study by Beevi et al. (2017), none of the participants in the intervention group requested an epidural [33]. In contrast, Downe et al. (2015) found that only one-third of participants recorded their practice, while Cyna et al. (2013) noted that less than one-third attended all hypnosis sessions, indicating low adherence and limited pain reduction [34], 35]. The results of Werner et al.’s study indicated that hypnotizability was solely evaluated in the self-hypnosis group, and the three groups were not homogeneous in terms of hypnotizability [36]. However, research has demonstrated that the capacity to alleviate pain through hypnosis is significantly influenced by hypnotizability, with highly hypnotizable participants being more capable of reducing pain than their less hypnotizable counterparts under identical circumstances [37]. It should be noted that the hypnosis technique used in Werner et al.’s (2013) study countered the one employed in the present study, as they utilized the suggestion of forgetfulness during labor, which is a challenging hypnosis phenomenon that only 20–25 % of individuals can fully experience [38]. Nevertheless, Werner et al.’s (2013) study was a large randomized trial with a high response rate of nearly 100 % at follow-up, while our study had a smaller sample size.

In our study, we evaluated the severity of labor pain during childbirth. However, two previous studies, namely, Downe et al. (2015) and Cyna et al. (2013), measured this pain at two and six weeks after delivery, respectively [34], 35]. The literature suggests that the severity of pain experienced during labor is not necessarily correlated with either the anticipated pain experienced during pregnancy or the postpartum pain experienced by the mother [26].

Thus, measuring childbirth pain may not represent actual delivery pain. Downe et al.’s (2015) study on self-hypnosis for labor was the largest randomized controlled trial, but the decreased response rate after two weeks may limit the generalizability of their findings.

Excessive anxiety during childbirth can increase catecholamines, particularly epinephrine, leading to muscle spasms, vasoconstriction, visceral injuries, and intensified pain [39]. However, hypnosis can disrupt the connection between the amygdala-limbic system and the cerebral cortex, inhibiting the interpretation of emotions such as fear and pain [40]. In hypnosis, there is a reduction in positive tonus within the cortex, attributed to radiating inhibition. When a word or command from the hypnotist is directed at a specific region of the cortex, it concentrates the excitatory process at that site. This concentration is swiftly followed by negative induction, allowing the effect to propagate across the entire cortex without resistance. Consequently, the directive word or command becomes entirely isolated from external influences, acting as an absolute and compelling stimulus, even after the subject has returned to a waking state [41]. Research shows that hypnosis is a safe method for mitigating pain during labor and postpartum [42], enhancing the likelihood of vaginal birth and reducing the need for cesarean section.

Conclusions

Research indicates that self-hypnosis can help reduce the fear of childbirth and labor pain for first-time pregnant women. It can alleviate anxiety and stress, increase self-confidence, and positively impact the well-being of both mothers and fetuses. This cost-effective method shows potential for improving pregnancy outcomes, especially for medium to highly hypnotizable mothers. However, more research is needed to understand its effects on a larger sample of women and how it compares to other pain management techniques during labor.