Key words childbirth education - pregnancy education - birth - childbirth fear - hypnosis
Schlüsselwörter Geburtsvorbereitung - Geburt - Geburtsangst - Hypnose
Introduction
In most high-income countries birth preparation courses are embedded in current health-care
practices [1 ]. Antenatal education programmes have a wide range of aims, such as ways to cope
with pain and stress during childbirth, increasing womenʼs confidence for childbirth
[2 ]. Main reasons for women to take part are to get information on physiological changes
during pregnancy, reduce anxiety, and include discussions on various options and complications
during childbirth [3 ]. Only a few studies have assessed the effectiveness of antenatal education programmes.
A Cochrane systematic review showed no consistent effect of these courses, but only
a tendency towards a better knowledge, confidence, and competence was identified in
small studies [4 ]. Most health professionals recommend the courses [3 ], even though aims, content and processes of antenatal education vary considerably
[5 ]. Evaluation of antenatal courses is difficult since widely adopted standards or
guidelines are missing [5 ], [6 ].
Artieta-Pinedo et al. [7 ] identified decreased anxiety in women attending antenatal education compared with
non-attenders. Similarly, Paz-Pascuale et al. [8 ] also found decreased anxiety in women who attended courses compared to women not
attending.
Hypnosis has been used in various clinical settings including childbirth [9 ], [10 ], [11 ], [12 ], [13 ], [14 ] and external cephalic version [15 ], [16 ] and the fear of patients prior to surgery has also been reduced using hypnosis [17 ], [18 ]. Hypnosis may have a positive influence on maternal and neonatal outcomes, such
as labour pain, duration of birth, complications and postpartum depression, but recent
randomised controlled trials did not show an effect [19 ], [20 ], [21 ], [22 ], [23 ], [24 ], [25 ], [26 ].
The overall aim of this study was to investigate the change in outlook towards birth
after conventional preparation courses in comparison to hypnoreflexogenous self-hypnosis.
The change of the maternal emotional state was evaluated using the Osgood semantic
differential score.
Materials and Methods
This study is a cohort study of pregnant women, who freely chose either midwife led
antenatal birth preparation classes or hypnoreflexogenous self-hypnosis training for
childbirth October 2009 to January 2010.
Course design
The midwife led classes were done by three different senior midwives (work experience
over 10 years [midwife A, B & C]). The maximum number of women allowed in the birth
preparation group was 12 women. A sub-group analysis was also carried out between
the midwife groups. The 10 times 2-hour-sessions had mainly informational content
concerning the pregnancy, the birth and the newborn child. As well as the communication
with other expectant mothers, the course units comprised exercises for body perception
and breathing exercises as coping techniques for labour. The hypnoreflexogenous self-hypnosis
training was carried out by a doctor qualified in hypnosis (JR). The maximum number
of women allowed in the hypnosis course was 8 women. In four 2-hour-sessions women
in their last trimester of pregnancy were taught self-hypnosis techniques. In hypnotic
trance the birthing process was imagined. This method is based on three principles:
negative conditioned terms were substituted through neutral terms,
the level of tension is reduced through hypnotic trance and
the self-confidence and the reliance of the expectant mother is reinforced [10 ].
After the second session a CD with the taught hypnotherapy intervention was given
for home use.
Participants
Women were eligible to take part in the study if they were pregnant, German-speaking,
at least 18-years-old and for the self-hypnosis course the women had to be above 26th
gestational age. Participants were included in the trial after return of a completed
baseline questionnaire and provision of consent. Ethical approval was given by the
local ethics committee.
Outcome and data collection
The Osgood semantic differential score [27 ], [28 ], [29 ] is a validated questionnaire, which has been modified by Ertel and can be used to
quantify emotional changes [30 ], [31 ], [32 ]. On a list of bipolar scales the participants had to score from − 3 to + 3 with
a middle or neutral point. For measurement of attitudes the semantic differential
is nowadays one of the most widely used scales. Three recurrent attitudes have been
identified: Firstly, the “good – bad” adjective defines the evaluation. Secondly,
the potency loads highest on the adjective pair “strong – weak”. Thirdly, the activity
factor defines the adjective pair “active – passive”. These dimensions were found
to be cross-cultural [29 ], [30 ], [31 ]. Before the first class and after the last course unit the Osgood semantic differential
questionnaire was evaluated for the four words: “birth, baby, partner, hypnosis”.
The word birth was chosen due to the fact that the birth preparation course should
positively chance the view towards birth. Similarly the word baby might be changed
due to the course. The word partner was chosen as a reference since this would be
unlikely to be changed due to the intervention. Hypnosis was chosen due to the fact
that this was one of the interventions evaluated in this study. Using the Gießen questionnaire
[33 ] a screening for psychological disorders was carried out. This also enabled us to
evaluate the different cohort groups for personality differences. The dimension activity,
evaluation and potency are the mean value of all factors in that group, respectfully
(see [Fig. 1 a ] to [c ]).
Fig. 1 a to c Osgood semantic differential dimensions before and after the course for the words
“birth, baby, partner and hypnosis” (as coded in different colours) for the midwife
led education programme (n = 155) and hypnoreflexogenous self-hypnosis training (n = 58)
(* p < 0.05; ** p = 0.01): a evaluation (positive values → “bad”; negative values → “good”); b potency (positive values → “weak”; negative values → “strong”); c activity (positive values → “passive”; negative values → “active”).
Statistical analysis
The data analysis used SPSS (Version 21, IBM© SPSS© Statistics). Differences between
groups were tested by a non-parametric Mann-Whitney test. Two-sided p-values were
reported for all tests and a value < 0.05 was regarded as significant.
Ethics approval
Ethics approval was granted by the local university of Witten/Herdecke ethics committee.
Results
213 participants were enrolled in this study. 155 had midwife led education programme
and 58 had self-hypnosis training. Due to the small number of participants for midwife
group C (n = 8) no subgroup analysis was carried out. There was no statistically significant
difference between the two groups in regard of participantsʼ characteristics (age,
school education level, university master degree, parity, pregnancy complications,
premature labour contractions [[Table 1 ]]), Gießen personality score ([Table 1 ]) and initial Osgood semantic differential scores. Similarly, no difference was identified
in the two midwife led education programmes (midwife A and B) ([Table 1 ]).
Table 1 Baseline characteristics of the study population for midwife A (n = 113), midwife
B (n = 34) and hypnosis group (n = 58) (n. s. = no statistically significant difference,
p > 0.05).
Midwife A
Midwife B
Hypnosis
p-value
Maternal age (years)
16.1
11.8
7.4
n. s.
24.1
23.5
22.2
n. s.
39.3
29.4
44.4
n. s.
20.5
35.3
25.9
n. s.
School education
61.3
57.7
62.5
n. s.
21.3
30.8
20.8
n. s.
17.5
11.5
16.7
n. s.
40.5
34.6
41.3
n. s.
Born in Germany
93.8
100
83.7
n. s.
Expecting first child
70.2
66.7
68.8
n. s.
At least one (missed) abortion
8.3
11.1
25
n. s.
Pregnancy without complications
94.0
88.9
89.5
n. s.
Premature labour contractions
20.2
23.1
15.6
n. s.
Premature labour before 34th gestation age
52.9
50
100
n. s.
Gießen test
4.79 ± 0.77
4.65 ± 0.67
4.42 ± 1.02
n. s.
4.29 ± 0.71
4.23 ± 0.73
4.27 ± 0.72
n. s.
4.53 ± 0.66
4.03 ± 0.76
4.13 ± 0.78
n. s.
4.19 ± 0.91
4.07 ± 0.81
4.22 ± 0.66
n. s.
3.48 ± 0.85
3.28 ± 0.82
3.77 ± 1.16
n. s.
3.01 ± 0.78
3.07 ± 0.67
3.63 ± 1.36
n. s.
Midwife courses
Overall the participants of the midwife led courses (n = 155) had a statistically
significant change for the word “birth” only for the dimension evaluation (more negative
outlook; p < 0.05; [Fig. 1 ]). For the word “baby” the dimension activity (p < 0.01), evaluation (p < 0.05) and
potency (p < 0.05) were statistically significant differences detected ([Fig. 1 ]). Similarly, for the word “partner” the dimension activity (p < 0.01) and potency
(p < 0.05) were different. No difference was found for the word “hypnosis” ([Fig. 1 ]). There were no statistically significant differences on the semantic differential
scores of midwife A and B. For the word “birth” the midwife A group (n = 113) had
a statistically significant change towards arousal (p < 0.01), displeasure (p < 0.05)
and tarnishing (p < 0.05). Group A had a positive change (bad outlook into birth)
in dimension evaluation (p < 0.05) and indulgence (p < 0.05) ([Fig. 2 ]). For “birth” the midwife B group (n = 34) only had one statistically significant
change towards quickness (p < 0.05; [Fig. 2 ]).
Fig. 2 a to c Change of Osgood semantic differential scales word “birth” (after the course score
– at the beginning) for midwife A (n = 113), midwife B (n = 34) and hypnosis (n = 58):
a dimension evaluation, b dimension potency and c dimension activity (* p < 0.05; ** p < 0.01).
Hypnosis courses
For the hypnosis group all dimensions were highly statistically significant different
(p < 0.01) apart from the word “baby” the dimension potency and for the word “hypnosis”
the dimension activity ([Fig. 1 ]). The hypnosis CD was listened to at least twice a week (mean 2.5 ± standard deviation
1.8).
For the hypnosis group (n = 58) highly significant changes (p < 0.01) were identified
towards movement, noise, arousal, negative change (more activity) in dimension activity,
pleasure, harmony, negative change (i.e. positive outlook into birth) in dimension
evaluation, emphasis, fortitude, strength, negative change (i.e. positive outlook
into birth) in dimension potency for the word “birth”. Similarly, in the hypnosis
group for the scales allegro and brightness statistically significant changes were
seen (p < 0.05; [Fig. 2 ]).
Discussion
For the first time this study demonstrates the change in emotional outlook towards
birth in women after midwife led preparation courses and hypnoreflexogenous self-hypnosis
training using Osgood semantic differential score. Even though the midwife led courses
had a longer duration, the womenʼs emotional change was less marked in comparison
to the hypnosis course. For the midwife courses the emotional change in regard to
“birth” is in the wrong direction. The women had a statistically significant change
towards the unwanted polarity (displeasure, tarnishing, dimension evaluation; p < 0.05),
whereas in the hypnosis group the participants had a change towards the wanted polarity
(pleasure, harmony, dimension evaluation (p < 0.01 and brightness p < 0.05). These
differences cannot be explained by differences in personality dimensions in the two
groups (Gießen test p > 0.05). Between the two largest midwife course groups there
also was no difference found in the polarity direction. The natural birth approach
aims to decrease muscle tension, which is induced by fear and leads to labour pains
[1 ], [34 ]. Training in relaxation and education of the physiological process of labour is
intended to reduce fear and tension and as a consequence mothers should experience
less labour pain [1 ]. Lamaze [35 ] introduced relaxation as a conditioned response to labour contractions, which includes
various breathing techniques to interfere with the pain signal transmission from the
uterus to the brain and improve oxygenation.
Emotional reactions have also been shown to influence pain experience [24 ], [36 ]. High levels of fear, anxiety and emotional stress are important factors in a womanʼs
experience of childbirth pain [24 ], [37 ], [38 ], which may result in postpartum depression, post-traumatic stress syndrome, future
caesarean section or a reluctance to have more children [24 ], [39 ], [40 ], [41 ], [42 ]. These study results demonstrate that the outlook towards birth can be influenced
by a midwife and hypnosis course. A higher impact has been seen during the hypnosis
course, where the womenʼs outlook onto birth was statistically significantly positive
(dimension evaluation; p < 0.01), stronger (dimension potency p < 0.01) and more active
(dimension activity; p < 0.01) after completion of the hypnosis course. For the midwife
led courses only the dimension potency was changed (p < 0.05), however the womenʼs
Osgood semantic differential score was worse (i.e. towards “bad”). Further investigations
are required as to why the midwife led courses showed negative outlook towards birth.
These study results are consistent with previous study on hypnoreflexogenous birth
preparation in the perception of birth and quicker convalescence time [10 ].
As expected, there was a large positive change in the womenʼs emotional score of “hypnosis”
in the hypnosis group (pleasure, harmony, dimension evaluation [p < 0.01] and brightness
[p < 0.05]), whereas in the midwife led courses no differences were detected in all
factors. Nowadays there are still large reservations and false beliefs with regard
to hypnotherapy even though hypnotherapy has been certified as an effective psychotherapy
in Germany.
The limitation of this study lies in the factor that the study design is only a prospective
cohort study, which tried to exclude a personality bias of birth preparation course
via the Gießen personality test. Furthermore the differences in midwife course sizes
have been evaluated on the ground whether there are any statistically significantly
differences between the groups. Obviously, these results do not demonstrate that the
women do have less birth pain during labour and only show the outlook i.e perception
before birth. Further prospective randomised controlled trials are required to test
these initial findings and evaluate birth outcomes.
Conclusion
Hypnoreflexogenous self-hypnosis training seems to induce larger and more positive
maternal emotional changes towards the outlook to birth in comparison to midwife led
courses if women choose self-hypnosis deliberately. Further prospective randomised
studies are required to test these initial results.
Contribution to Authorship
Contribution to Authorship
JR designed the trial. LAS was responsible for the data collection. JR and LAS performed
the data analysis. JR wrote the first draft. All authors edited the manuscript and
agreed on the final version. JR is guarantor.
Acknowledgements
We would like to thank all midwives for participating and support of the study. We
wish to thank all the women who took part in the project.
