Unexpected Consequences

Women's Experiences of a Self-hypnosis Intervention to Help With Pain Relief During Labour

Kenneth Finlayson; Soo Downe; Susan Hinder; Helen Carr; Helen Spiby; Peter Whorwell

Disclosures

BMC Pregnancy Childbirth. 2015;15(229) 

In This Article

Results

Participants

During the 12 month data collection period 48 women were randomly selected for interview from the lead Trial site. Of these, 21 did not answer our initial request to take part, 6 declined to be interviewed (usually citing lack of time), four did not complete the self-hypnosis training programme (three of these went into labour prematurely and were unable to attend the second training session) and one did not attend for the interview. A total of 16 women and three birth companions agreed to be interviewed.

The participants were all first time mothers aged between 23 and 38 with an average age of 29.6. All of the women gave their ethnic origin as 'white British'. Although this is unreflective of the general population at the study site, where around 21 % self-identify as non-white (mainly Asian), it is reflective of the trial population where only 6.4 % identified themselves as something other than 'White British'. All of the women had a birth companion (either husband or partner) who came to the training sessions with them. This was very similar to the intervention group as a whole where 89 % had a birth partner who attended. 12 of the 16 women received midwife-led care, similar to the trial average of 72 %, and the Trust average of 70 %. Three of the 16 (19 %) used epidural analgesia for labour, lower than the trial average of 28 % and the Trust average of 30 %.

Analysis

For the data analysis we used thematic network analysis, a technique that adopts a less abstract approach to qualitative data analysis and presents the findings in a methodical, transparent and organized manner.[18] Using this method each interview was transcribed by a member of the research team (KF, SD, SH, HC) and, after coding the data, preliminary themes were generated by each author independently. These preliminary themes were then discussed among the team and, using an iterative process, draft basic themes were developed by consensus. Following the review and analysis of 16 transcripts the team felt that no new themes were emerging and data collection was suspended. The draft themes were finalized and discussed by all members of the team and following further consensus discussions the basic themes were amalgamated (collapsed) into broader, more abstract, organizing themes. These were then used to develop a principal organizing metaphor or global theme.

The findings are represented by five organizing themes: 'Calmness in a Climate of Fear', 'From Sceptic to Believer', Finding my Space', 'Delays and Disappointments' and 'Personal Preferences'. These organizing themes are further encapsulated by the global theme of 'Unexpected Consequences'. These themes are displayed in Fig. 1 and are discussed below.

Figure 1.

Summary of organising themes and global theme

Calmness in a Climate of Fear

All of the women described feeling anxious or fearful about labour and birth before they attended the self-hypnosis training sessions. These feelings were often compounded by hearing negative stories about childbirth in the media as well as from friends and family members. A number of women specifically highlighted the influence of maternity based reality TV programmes like 'One Born Every Minute' and recalled how these types of programmes elevated existing levels of fear and anxiety.

"'One Born Every Minute' is a stupid thing to watch, but I was compelled to watch it and I was petrified of losing all dignity and being ridiculous and rude to people and all the rest of it". [Julie]
"I kept watching that 'One Born Every Minute' programme and it makes you more frightened". [Shirley]

However, after the self-hypnosis sessions women reported feeling calmer and more confident about their upcoming birth.

"I remember being a lot more worried and then after these sessions [Self-Hypnosis] I wasn't as worried. Afterwards it was completely different but definitely it changed my thoughts towards it. It made me more…I don't know…I wasn't as scared". [Katy]

Many of the women recognized that they might still feel scared when they went into labour but would now have something they could use to reduce and control any feelings of anxiety.

"So I trusted that if I could focus and manage my pain through thinking my way through it, then I had something to use basically….without that I think I would have panicked a lot because I wouldn't have had anything" [Julie].

From Sceptic to Believer

Although a few of the women indicated that they joined the trial because of a general interest in complementary medicine, the majority of the interviewees felt ambivalent about the intervention, and took part in the trial because it was perceived to be 'safe' and 'wouldn't do any harm'. Some admitted to being more sceptical, and a few even felt dismissive before the training programme began. However, after the first session these rather ambivalent views were often superseded by a much more positive outlook.

"I went into it thinking 'this is going to be a load of rubbish' and I came out of the first session thinking, 'that could actually work'. [Debbie]

The more sceptical participants frequently mentioned a specific 15 min section of the first training session as being of particular significance. This component of the training included a very simple description of the physiology of labour and birth and was intended to provide a basic grounding before the self-hypnosis training began. Despite the mass of information many of the participants had already encountered by this stage of their pregnancy, it was striking how many of them found this information new and fascinating:

"I was a bit sceptical about it [Self-hypnosis] but when I went to the first class and she explained the physiological sort of thinking behind it I thought 'ooh, it makes sense'….I understood, and I felt a lot more positive about it". [Ruth]
"….she talked about the fight or flight sort of response, and how it was supposed to keep everything calm….the blood flow to the uterus to make it less painful and what have you,… so yeah we felt really positive after that one" [the first session] [Gemma]

Several women who had initially been quite dismissive of self-hypnosis prior to the training, went on to explain how they had been able to use the technique in other contexts or situations where they felt particularly anxious or fearful, such as going to the dentist, or to help with breastfeeding difficulties.

"After I had him we were having problems with breastfeeding… I couldn't sleep because I was that stressed about not being able to feed him, so putting that [CD] on the headphones helped me to relax". [Julie]

Finding my Space

This theme captures the variety of ways in which participants expressed their sense of finding space, in both a literal and a metaphorical sense. From a practical perspective women found it a struggle to incorporate the daily routine of listening to the self-hypnosis CD into their already busy lives. Listening to it at work or in a shared living space often proved difficult and, with work, social and pregnancy related schedules to maintain, finding the required 25 min often meant leaving practice until the last thing at night. This meant that they played it to themselves in their bedrooms, sometimes in bed, and invariably fell asleep before the end of the CD.

"I wouldn't have had any time before I went to bed to be honest….that was the only time because I was a teacher so you've got all your work to do at night time and everything so I did find it quite easy to just stick it on [CD], listen to it and fall asleep and….yeah, it was good for me". [Katy]

When women found a way to incorporate the daily practice into their schedule they began to look forward to it and appreciate the associated feelings of relaxation, irrespective of whether they fell asleep or not.

I'd sort of get ready and think, 'right, now you've been to the toilet and you've switched the phone off', and then its relaxing time and I sort of really enjoyed it….definitely. [Shirley]

From a hypnotic perspective, the participants described how the daily practice eventually generated an imaginary space or place in their minds that they could visit while in a hypnotic state. This became both a source of strength as well as a place of refuge and was used by some of the women to manage feelings of anxiety and pain during labour.

I think visualising a place to go to helped, because at the height of the contractions if you've nowhere else to go you're just in that pain….visualising that place helped me with those contractions because my waters broke quite quickly and it was quite intense…. my contractions were very frequent and strong throughout really, so having somewhere to go when another one was coming back, when I hadn't had a minute in between, was really helpful to me. [Julie]

Delays and Disappointments

Although all of the participants were largely positive with their comments about the self-hypnosis programme, several women described potential shortcomings when it came to using the techniques they had learned in a clinical setting. This was particularly evident when they arrived at a hospital or birth centre, apparently in active labour, and were not taken seriously by the admissions staff because they were 'too relaxed'.

This is a side effect of the self- hypnosis …I mean I may be completely wrong, but the way I read it was, because I wasn't a gibbering wreck she [the midwife] thought that I wasn't as bad as I thought I was because I was able to say, 'yes I am ready, please don't send me home', but I wasn't really upset about things. So, yeah, I do think that was a side effect of being relatively calm. [Julie: Sent home and returned to be admitted in established labour 45 mins later).
"I found that frustrating that they'd be like, 'oh no, you don't look…you know…sad enough to be in labour', and I'm like, 'I can feel the pain, I'm just smiling', so…I felt like you had to be screaming and shouting. I felt like if you were calm then maybe they didn't think you were in labour". [Sandra] Went on to have an emergency caesarean section

For other participants the reassurance and confidence they had learned during the training programme was shattered when they arrived in the labour ward. Self-hypnosis raised their expectations of the type of birth they could experience and when this did not materialise they were left with feelings of frustration and disappointment.

"Situations didn't flow how I expected them to, you know….umm… they say to you when you go to these [Self-hypnosis] sessions, 'be positive', 'it's all about you', you know, 'you'll be going into the birth suite and it's all going to happen all naturally and easily' and it doesn't always happen like that does it?" [Caroline] Had induction followed by caesarean section.

Personal Preferences

Although the practice CD was exactly the same and the structure and content of the training sessions were standardized to ensure fidelity, participants developed a number of ways to utilize the training resources. Some women transferred the CD content on to a mobile device so they could listen to it in different locations, such as at work, or in a particular setting, like the bedroom, where there was no access to a CD player.

"I just put it [CD] on my phone, it was much easier and more convenient…I've still got it on there"! [Vicky]

Participants became particularly creative with their choice of listening place and sometimes tried to tie this in with their expected birth location to make the practice more meaningful.

"When I realised I wanted a water birth I started listening to it in the bath" [Joanne]

Listening to the same voice for 25 min each day for 7–10 weeks gave rise to some comments about the quality and tone of the voice and the urge to change the way they listened to the CD. Some women would 'get stuck' on a particular word or phrase, because it amused them or grated on them or was pronounced in a distinct regional accent. These participants suggested it might be better to have the same voice as the training sessions on the CD (the midwife) or to have background music instead of the voice alone.

"I thought maybe if it had like background music on it to make it a bit more… because everything is so quiet and it's just a voice…because I think sometimes when you listen to music you're a bit more relaxed" [Ruth]

Other participants were keen to make suggestions about the length of the sessions or the timing of them or the number they received. Most felt that two were not enough and that an additional one closer to the delivery date would have been of benefit.

"…don't get me wrong there was a lot of information in those two sessions, but I think we probably would've benefitted from a few more really" [Caroline]

Unexpected Consequences

The global theme of 'unexpected consequences' emerged from the data at multiple levels. Firstly the women were surprised by the increased sense of calmness and relaxation they experienced after the first training session, and by the applicability of the techniques in a range of stressful situations, even when they had been relatively unconvinced about the value of self-hypnosis when they agreed to enter the trial. Secondly, the research team were surprised to find that the element of the sessions that was most often remembered as useful was the short introduction to labour physiology. Finally, the women's accounts suggest that the midwives they met when they arrived on the labour ward were unprepared for their relaxed appearance, and, therefore, assumed that their labour was not advanced.

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