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Antenatal Hypnosis Training and Childbirth Experience: A Randomized Controlled Trial Anette Werner, MHSc, PhD, Niels Uldbjerg, MDSc, PhD, Robert Zachariae, MSc, MDSc, PhD, Chun Sen Wu, MD, PhD, and Ellen A. Nohr, MHSc, PhD ABSTRACT: Background: Childbirth is a demanding event in a woman’s life. The aim of
this study was to explore whether a brief intervention in the form of an antenatal course in self-hypnosis to ease childbirth could improve the childbirth experience. Method: In a randomized, controlled, single-blinded trial, 1,222 healthy nulliparous women were allocated to one of three groups during pregnancy: A hypnosis group participating in three 1-hour sessions teaching self-hypnosis to ease childbirth, a relaxation group receiving three 1-hour lessons in various relaxation methods and Mindfulness, and a usual care group receiving ordinary antenatal care only. Wijmas Delivery Expectancy/Experience Questionnaire (WDEQ) was used to measure the childbirth experience 6 weeks postpartum. Results: The intention-to-treat analysis indicated that women in the hypnosis group experienced their childbirth as better compared with the other two groups (mean W-DEQ score of 42.9 in the Hypnosis group, 47.2 in the Relaxation group, and 47.5 in the Care as usual group (p = 0.01)). The tendency toward a better childbirth experience in the hypnosis group was also seen in subgroup analyses for mode of delivery and for levels of fear. Conclusion: In this large randomized controlled trial, a brief course in self-hypnosis improved the women’s childbirth experience. (BIRTH 40:4 December 2013) Key words: antenatal training, childbirth, childbirth experience, hypnosis, relaxation Background Childbirth is one of the most intense and demanding events that a woman is likely to experience, requiring not only physical but also psychological resources to cope with the labor process (1). The childbirth experience can be affected by several factors, including unexpected medical problems, emergency operative Anette Werner is a midwife and Niels Uldbjerg is a professor at the Department of Gynecology and Obstetrics, Aarhus University Hospital Skejby, Aarhus N, Denmark; Robert Zachariae is a professor with the Unit for Psychooncology and Health Psychology, Department of Oncology, Department of Psychology, Aarhus University Hospital, Aarhus University, Aarhus C, Denmark; Chun Sen Wu is post doctoral and Ellen A. Nohr is a professor with the Department of Public Health, Section for Epidemiology, Aarhus University, Aarhus C, Denmark; Ellen A. Nohr is also affiliated with the Department of Gynecology and Obstetrics, Odense University Hospital, Odense C, Denmark. Funding The project was made possible by funding from: Nordea Fonden, Aaseog Ejnar Danielsens foundation, The Danish Society for Clinical Hypnosis, VIFAB (Knowledge and Research Center for Alternative Medicine), King Christian X’s foundation and The Danish Association of Midwives. We are very thankful to all contributors.
delivery, low levels of support from partner or caregivers, pain, and loss of control (2–4). The woman’s own expectations about the upcoming childbirth have also been found to influence the subsequent birth (2). An optimistic and positive attitude has, for example, been associated with a positive birth experience, whereas fear of or worries about the upcoming childbirth were found to be risk factors for a negative experience
Ethical approval This trial was approved on December 15, 2008, by the Scientific Ethical Committee for the Region of Central Jutland, nr. M-200080200 in Denmark and by the Danish Data Protection Agency on November 5, 2008, nr. 2088-41-2797. The trial was also reported to ClinicalTrials.gov, number NCT00914082. Address correspondence to Anette Werner, Department of Gynecology and Obstetrics, Aarhus University Hospital Skejby, Brendstrupgaardsvej 100, 8200 Aarhus N, Denmark.
© 2013, Copyright the Authors Journal compilation © 2013, Wiley Periodicals, Inc.
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(5–7). Reducing the risk of a negative birth experience is important because the costs for the society and the individual may be substantial. Negative and traumatic birth experiences have been associated with both shortterm and long-term consequences, including bonding problems between mother and child, childbirth-related posttraumatic stress, postpartum depression, poor health, preference for delivery by cesarean birth in future pregnancies, or refraining from having more children (6,8–11). Hypnosis has been used as intervention in many different clinical settings, including childbirth (12–22), and appears to be a safe tool when applied to healthy women (23,24). The hypnotic state is considered to be a common and natural mental state (25), and is commonly described as “an altered state of consciousness characterized by markedly increased receptivity to suggestion, the capacity for modification of perception and memory, and the potential for systematic control of a variety of usually involuntary physiological functions” (26). The ability to experience hypnosis varies (27,28), and hypnotic susceptibility has been found to increase during pregnancy (29,30). Hypnosis could therefore potentially be a useful tool for parturient women. Hypnosis typically not only involves a hypnotist and a person being hypnotized, but can also be self-administered as self-hypnosis. Women can thus be trained to guide themselves through a hypnotic procedure (31). Several studies have shown beneficial effects of antenatal hypnosis training conducted both in individual sessions and as group training (12–22). The results indicate that hypnosis may have a positive influence on maternal and neonatal outcomes such as labor pain (12–16,19–23), duration of birth (12,19,32), complications, and interventions (16,17,23,33,34), the child’s condition (12,21), and postpartum depression (12,35). Although several of these studies have also assessed aspects of the childbirth experience and reported a positive effect of hypnosis (14–16,32), interpretation of the results is limited by methodological shortcomings, including lack of random assignment (14,32), insufficiently described hypnotic methods (14–16,32), and relatively small sample sizes (14,15,32). Our aim was therefore to develop a brief course in antenatal selfhypnosis to provide women with skills to cope with childbirth and to evaluate the effects on the childbirth experience in a large randomized controlled trial.
Methods The study was conducted at the Obstetrics Department at Aarhus University Hospital, Denmark, which is responsible for approximately 5,000 deliveries per year. The participants gave birth in the period from August
2009 through August 2011. The trial was randomized, controlled, single-blinded, and used a three-arm group design. The primary outcomes of the trial were use of epidural analgesia and self-reported pain during delivery and have previously been reported (36). The effect on childbirth experience, reported in this article, was a secondary prespecified outcome. The detailed description of the methods has been presented elsewhere (36). Briefly, a total of 1,222 healthy first-time mothers participated in this study. The participants were randomly allocated to either the intervention group (n = 497), the active comparison group (n = 495), or the usual care control group (n = 230) using a computer-generated interactive voice response telephone randomization system (37) (see Flowchart, Fig. 1). The intervention group (the hypnosis group) attended three 1-hour classes on self-hypnosis for childbirth held over three consecutive weeks. A test for hypnotic susceptibility (38,39) was conducted during the first session, which therefore lasted 2.5 hr. A program inspired by the Australian HATCh project (1) was developed and taught by two midwives trained in hypnosis. In addition, the women received three audio recordings, including a 20-minute section especially meant for labor. The active comparison group (named the “relaxation group” in the following) also attended three antenatal classes, each lasting 1 hour. The program was taught by the same midwives as in the intervention group and included a variety of body awareness, relaxation, and mindfulness techniques. This course also included audio recordings for homework and labor. The usual care group received only ordinary antenatal care, which included a nuchal translucency scan about gestational week 12, an anomaly scan about gestational week 19, four to five visits at the midwifery clinics, and a tour of the birth department. A detailed description of the intervention is available on request from the corresponding author. The project was presented to the participants and the staff at the Obstetric Department as a research project on mind-body training investigating self-hypnosis and relaxation techniques as two equally effective approaches. The midwives assisting the birth were blinded to the participant’s allocated treatment.
Data Collection and Outcome The Wijmas Delivery Expectancy/Experience Questionnaire, version A (W-DEQ A) and version B (W-DEQ B) were used to assess the childbirth experience. This instrument is a well-validated tool. W-DEQ A measures fear, confidence, and expectations concerning the upcoming childbirth and W-DEQ B evaluates the same aspects of the actual childbirth experience (40,41). Both
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Enrollment
274 Assessed for eligibility and invited (n = 3,554) Did not respond to the invitation (n = 2,443) Recruited from posters and website
Responded to the invitation (n = 1,111)
(n = 134)
Not included (n = 23) -not meeting inclusion criteria (n = 22) -other reasons (n = 1) Randomized
Allocation
Hypnosis (n = 497) Excluded, not meeting inclusion criteria (n = 4)
Relaxation (n = 495) Excluded, not meeting inclusion criteria (n = 1)
Received allocated intervention (n = 493) 3 sessions (n = 420, 85.2%) 2 sessions (n = 40, 8.1%) 1 session ( n = 22, 4.5%) 0 sessions (n = 11, 2.2%)
Received allocated intervention (n = 494) 3 sessions (n = 394, 79.8%) 2 sessions (n = 61, 12.4%) 1 session (n = 21, 4.3%) 0 sessions (n = 18, 3.9%)
Follow up
Completed W-DEQ 6 weeks postpartum: 98.4% (n = 485) All 33 items (n = 468)
Completed W-DEQ 6 weeks postpartum: 98.4 % (n = 482) All 33 items (n = 448)
Completed W-DEQ 6 weeks postpartum: 97.0% (n = 222) All 33 items (n = 210)
Did not complete W-DEQ (n = 8)
Did not complete W-DEQ (n = 12)
Did not complete W-DEQ (n = 8)
Analysis
(n = 1,222)
Control (n = 230)
Included in analysis (n = 485)
Included in analysis (n = 482)
Included in analysis (n = 222)
Fig. 1. Flow diagram of enrollment, allocation, and study participation.
versions include 33 items measured on 6-point Likert scales ranging from 0 to 5 with the endpoints indicating “not at all…” and “extremely…”. Total sum scores range from 0 to 165 with a higher score indicating a less satisfying experience. A special 20-item B version has been developed for women giving birth by cesarean delivery, featuring 20 of the 33 items from the original W-DEQ B with total scores ranging from 0 to 100 (42). For W-DEQ A, a total score of more than 84 was considered to represent severe fear of childbirth, and a score of more than 99 extreme fear of childbirth (40,41). At recruitment, the participants completed a questionnaire assessing baseline information. It included the W-DEQ A (40) and two measures of emotional wellbeing: the 10-item Perceived Stress Scale (43) and the WHO-5 Well-being questionnaire (44). Baseline characteristics were also drawn from this questionnaire. To compare participants with nonparticipants, we used an ongoing, independent data collection, “The Aarhus Birth Cohort,” which includes a questionnaire sent to all women early in pregnancy among those signed up for birth at the hospital.
Immediately after completing the antenatal course, the women were asked if the training had changed their expectations about the upcoming birth. This outlook was measured on a 5-point Likert scale with 1 and 2 indicating change in a positive direction, 3 no change, and 4 and 5 change in a negative direction. Because no women reported a negative change, the variable was dichotomized into: “Change in a positive direction/No change.” Information about the childbirth was derived from “The Aarhus Birth Cohort.” In case of missing information or if the woman gave birth at another hospital, the necessary data were extracted from medical records. Six weeks postpartum, the women completed a second questionnaire that included information about the childbirth and the W-DEQ B (40).
Statistical Analysis Characteristics of the participants and the nonparticipants are presented as frequencies and medians. The baseline characteristics, including the baseline scores for the
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W-DEQ A and expectations after training, are presented as frequencies, means, and medians. In the analysis of expectations about childbirth, W-DEQ A scores were included as a continuous variable (total scores) and as a categorical variable ( severe fear of childbirth) with severe fear defined as a total score of more than 84. Data were analyzed according to the intention-to-treat principle in accordance with the CONSORT Statement (45). In the intention-to-treat analysis of the childbirth experience, the mean scores of all participants who had completed the 33-item version of the W-DEQ B were compared. If women giving birth by emergency cesarean delivery had experienced labor and were able to answer all 33 items of the W-DEQ B, they were also included in the analysis. If they had not experienced labor, they would only be able to answer the 20-item version, modified for women delivering by cesarean birth. For this 20item version, subgroup analyses were conducted in all women undergoing scheduled cesarean delivery and in all women giving birth by emergency cesarean delivery. Subgroup analyses were also performed in women who had completed the 33-item version of the W-DEQ B with regard to mode of delivery (vaginal, spontaneous, assisted vaginal, scheduled cesarean delivery, and emergency cesarean birth) and women with a severe fear of childbirth. In all analyses, the data were compared across study groups using chi-square tests for binary data. Rank scores and continuous data were analyzed with ANOVAs when data were normally distributed, otherwise with Kruskal–Wallis one-way ANOVAs. If main effects were statistically significant, Bonferroni-adjusted post hoc comparisons were conducted. Participants were compared with nonparticipants with Mann–Whitney rank sum tests. Associations between expectations about childbirth at baseline and the actual childbirth experience were analyzed using the Spearman correlation coefficient within each of the three trial groups. Between-group comparisons were conducted with univariate regression and Wald’s post hoc tests. In all analyses, a two-sided p value (84) (See Table 3).
postpartum was high, 97.0 percent in the control group and 98.4 percent in both intervention groups. The analysis of the childbirth experience included 485 in the hypnosis group, 482 in the relaxation group, and 222 in the usual care group, yielding a total of 1,189 women (See Fig. 1).
Attendance to the Training and its Impact on Expectations of the Upcoming Birth Attendance to the training was 85.2 percent in the hypnosis group and 79.8 percent in the relaxation group. Immediately after completing the antenatal course, 86.9 percent of the women in the hypnosis group reported that the training had changed their expectations of the upcoming birth in a positive direction. The number was 76.8 percent in the relaxation group (p < 0.01).
Baseline Characteristics With respect to baseline characteristics, the participants in the three groups were generally comparable. A statistically significant difference across the three groups was, however, seen for mode of delivery. Compared with the other two groups, the frequency of scheduled cesarean delivery was lower and the frequency of emergency cesarean delivery higher in the hypnosis group (Table 2). The duration from the woman’s arrival at the birth department to emergency delivery and the indications for performing an emergency cesarean delivery and a scheduled cesarean delivery did not differ across the three groups.
How Childbirth was Experienced
Expectations at Baseline Concerning the Upcoming Childbirth The women in the three groups all had the same expectations about the upcoming birth (W-DEQ A) and this antic-
All 33 items of the W-DEQ B were completed by 468 women in the hypnosis group, 448 in the relaxation group, and 210 in the usual care group. The intentionto-treat analysis of the 33 item W-DEQ B showed that the hypnosis group had a better childbirth experience compared with the mean score of the other two groups (mean W-DEQ score of 42.9 in the Hypnosis group, 47.2 in the Relaxation group, and 47.5 in the Care as usual group [p = 0.01]) (Table 4 and Fig. 2). All subgroup analyses of the 33-item version according to birth type and level of fear also revealed lower
Table 2. Characteristics of the participants
Age (years), median (iqr) Prepregnant BMI (kg/m2), median (iqr) Smoking Before pregnancy, % During pregnancy, % Higher education (years beyond high school), % None 1–4 years 4 years and longer Living with partner, % Previously treated for a mental health disorder, % WHO-5 well-being index, (max score 100), median (iqr) PSS-10 Stress test, (max score 50), median (iqr) Mode of delivery Spontaneous, % Assisted vaginal, % Cesarean section, scheduled, % Cesarean section, emergency, % Iqr, Inter quartile range.
Hypnosis (n = 485)
Relaxation (n = 482)
Usual Care (n = 222)
p value
29.9 (4.7) 22.0 (3.3)
29.9 (4.2) 21.9 (3.5)
29.4 (4.6) 21.7 (3.7)
0.31 0.65
10.3% 0.8%
8.5% 1.0%
10.4% 1.8%
0.58 0.51
3.5% 50.1% 46.4% 96.5% 14.4% (16) (6)
2.0% 53.3% 44.6% 96.9% 15.2% (20) (6)
0.9% 57.2% 41.9% 99.1% 10.8% (20) (6)
0.09 0.20 0.53 0.14 0.29 0.08 0.83
68.2% 11.8% 2.2% 17.9%
67.6% 14.6% 5.7% 12.1%
68.3% 15.7% 4.4% 11.7%
0.98 0.27 0.02 0.02
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Table 3. Expectations of childbirth (W-DEQ A) at baseline according to the three intervention groups
All, mean score W-DEQ A (stddev) Women with severe fear of childbirth, (W-DEQ A mean score >84), No. (%)
Hypnosis group (n = 485)
Relaxation group (n = 482)
Usual Care group (n = 222)
p value
60.5 (19.9) (56) 11.6%
61.9 (20.3) (68) 14.1%
61.9 (18.8) (29) 13.1%
0.38 0.90
Table 4. Childbirth experience (W-DEQ B) according to the three intervention groups
Hypnosis group (n = 485)
Relaxation group (n = 482)
Usual Care group (n = 222)
(n = 468) 42.9 (23.5) (n = 388) 41.5 (23.7) (n = 330) 39.4 (23.0) (n = 58) 53.4 (24.0) (n = 79) 50.3 (21.5) (n = 54) 59.7 (24.9)
(n = 448) 47.2 (25.0) (n = 398) 47.2 (25.0) (n = 326) 42.8 (22.9) (n = 71) 57.9 (26.6) (n = 45) 59.3 (26.7) (n = 63) 64.9 (29.2)
(n = 210) 47.5 (22.7) (n = 187) 47.5 (22.7) (n = 154) 44.4 (22.3) (n = 33) 54.6 (23.8) (n = 21) 58.2 (18.2) (n = 28) 63.9 (20.8)
(n = 86) 29.0 (20) (n = 11) 29.0 (32)
(n = 59) 37.0 (29) (n = 25) 31.0 (24)
(n = 25) 35.0 (14) (n = 10) 28.5 (34)
W-DEQ 33 item 6 weeks postpartum (p.p.) All, mean (stddev)* Vaginal birth, mean (stddev)** Spontaneous birth, mean (stddev)*** Assisted vaginal birth, mean (stddev) Cesarean section, emergency, mean (stddev) Women with fear of childbirth, all, mean (stddev)
W-DEQ 20 item 6 weeks postpartum Cesarean section, emergency, median (iqr) Cesarean section, scheduled, median (iqr)
p value 0.01 0.01 0.04 0.58 0.08 0.12
0.06 0.06
Iqr, Inter quartile range. *Post hoc test: Hypnosis vs Relaxation (p = 0.02); Hypnosis vs Care as Usual (p = 0.06); Relaxation vs Care as Usual (p = 1.00). **Post hoc test: Hypnosis vs Relaxation (p = 0.02); Hypnosis vs Care as Usual (p = 0.06); Relaxation vs Care as Usual (p = 1.00). ***Post hoc test: Hypnosis vs Relaxation (p = 0.16); Hypnosis vs Care as Usual (p = 0.07); Relaxation vs Care as Usual (p = 1.00).
p=0.01
p=0.01
1
2
p=0.58
4
5
p=0.04
0
W-DEQ B mean score 20 40
60
p=0.12 p=0.08
Hypnosis
3
Relaxation
6 Usual
1:All birth; 2:Vaginal; 3:Spontaneous birth; 4:Assisted birth; 5:Emergency Cesarean; 6:Fear of childbirth
Fig. 2. Childbirth experience (W-DEQ B 33 item), mean score per group.
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278 mean scores in the hypnosis group compared with the other groups (Table 4 and Fig. 2). The differences, however, were only statistically significant for vaginal birth and spontaneous birth. When the subgroup analyses were performed for the 20-item version, a lower median score was found in the hypnosis group after emergency cesarean deliveries compared with the other groups (Table 4 and Fig. 3). For women experiencing scheduled cesarean delivery, the differences across groups were small.
The Relations Between Expectations of the Childbirth and the Childbirth Experience The expectations at baseline of the upcoming childbirth (W-DEQ A) were related to the subsequent childbirth experience (the 33-item W-DEQ B) (Spearman’s rho: 0.47 (p < 0.01) in the hypnosis group, 0.41 (p < 0.01) in the relaxation group, and 0.31 (p < 0.01) in the usual care group). Further analysis revealed that this relation was stronger for the hypnosis group than for the relaxation group and the usual care group (Wald’s test, p = 0.01, p = 0.04) and that it did not differ between the relaxation and usual care group (Wald’s test, p = 0.97).
Blinding
40
To examine the effectiveness of the blinding, the midwives assisting at birth were asked to estimate the woman’s allocated treatment immediately after the delivery (response rate: 59.8%). The percentages of correctly estimated treatment allocation were 58.4 percent in the relaxation group, 31.5 percent in the hypnosis group, and 38.0 percent in the usual care group.
p=0.06
0
W-DEQ B median score 20 30 10
p=0.06
Emergency Cesarean Section Hypnosis
Scheduled Cesarean Section Relaxation
Usual
Fig. 3. Childbirth experience (W-DEQ B 20 item), median score per group.
Discussion The results revealed a positive effect of a brief antenatal course in self-hypnosis on the childbirth experience. The magnitude of the improvement was about 5 points on the W-DEQ, which can be considered clinically relevant because of the importance of this experience as the basis for mother and child interaction and for the woman’s mental and physical well-being (11,46,47). Both types of training appeared to modify the attitude toward the upcoming birth in a positive direction. This result could, however, also be because of a naturally occurring change over time, because we only asked women who had received training, and we were unable to identify the changes in attitude in the sample as a whole. It is, however, of interest that the hypnosis group reported a statistically significantly greater change in attitude than did the relaxation group. The W-DEQ instrument used to assess the childbirth experience has been developed and tested in clinical practice, and previous studies support its reliability and validity (40,48). The instrument assesses the total experience of the childbirth by embracing several aspects such as pain, fear, and confidence. This study is the first to quantitatively assess the effect of a hypnosis intervention on the total childbirth experience. Previous studies of hypnosis and childbirth have only concerned single aspects of the childbirth experience, for example, labor pain (12–16,19–23), anxiety and stress during birth (14,16), satisfaction with labor (15), or satisfaction about the childbirth (32). In general, the available studies have found, in accord with our results, a positive effect of hypnosis (12–14,16,19–22,32). The present results can be considered reliable because they were based on a large, randomized, single-blinded, controlled trial with a high adherence to the antenatal training. We had baseline and obstetric information available to us for all participants and a high response rate at follow-up of almost 100 percent. We also appeared to be successful in blinding the midwives from the participants’ true allocation. The outcomes reported here were, however, secondary, and although we had sufficient statistical power for the intention-to-treat analysis of the W-DEQ 33, the power for some of the subgroup analyses was low. The blinding of the staff to the allocated treatment may also be a limitation. As the midwives had no or little knowledge about hypnosis but were more familiar with relaxation they might have able to support women in the relaxation group in a more appropriate way. In this study, we focused on a broad group of women. In addition, we focused on developing a low-cost training program that could be implemented in a general obstetric setting. Consequently, the content and intensity
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of the intervention may have been too limited. It is possible that tailoring the training for more specific needs, for instance for women with the highest levels of fear and intensifying the intervention, could have yielded a more pronounced result. Other randomized controlled studies with positive results have generally used more time-consuming interventions (12,15,16). The generalizability of our results could be limited, because our study sample consisted of first-time mothers with no previous childbirth experience and with considerable resources. Furthermore, compared with our participants, nonparticipants were more likely to use epidural analgesia and have a cesarean section on maternal request. This probability could possibly reflect a different attitude toward childbirth, with participants being more likely to want to give birth naturally and to have more resources available to cope with the childbirth. The effectiveness of the intervention to improve the birth experience in the group represented by our participants could thus be limited because the improvement potential in such women may be small (i.e., a ceiling effect). The mean scores at baseline on the W-DEQ A were approximately 60 for all three groups, which is similar to the results from two Swedish studies (42,49). The mean score for the childbirth experience was lower (42.9–47.59), suggesting that many participants expected the childbirth to be worse than their actual experience. We conducted subgroup analyses for different modes of delivery and for women with high levels of fear because these are well-known predictors of the childbirth experience (5–7). In general, the mean scores for all groups followed the same tendencies shown in other studies, namely that an uncomplicated birth leads to a better childbirth experience than assisted delivery or emergency cesarean delivery (49). Women suffering from severe fear reported the highest mean scores, suggesting a more negative childbirth experience. In the intention-to-treat analysis, we included all participants who had completed the 33-item version of the W-DEQ B, regardless of the mode of delivery, even though this version has been developed for women giving vaginal birth, and some previous studies have excluded this group of women from the analysis of the 33-item version (40,48). When we excluded women giving birth by cesarean delivery, the differences between the groups were more pronounced. For emergency cesarean delivery, the mean score for the 33-item W-DEQ B was 8–9 points lower in the hypnosis group than the scores in the two remaining groups. The result was, however, only borderline significant. For the 20-item W-DEQ B version, the median score was 6 and 8 points lower and also borderline significant. It seems reasonable to assume that the women were empowered by the self-hypnosis training to cope with a stressful birth situation, but, because of the rela-
tively small number of women receiving an emergency cesarean, the statistical power of these analyses was limited. We did not find any effect of hypnosis or relaxation in women having an assisted vaginal birth. As expected, and in concordance with previous results (5–7), the childbirth expectations at baseline correlated with the actual childbirth experience. The association, however, was stronger in the groups receiving training, and strongest for the hypnosis group. This substantiality suggests that the intervention affected these groups by decreasing the variation and that especially the hypnosis group was the most uniform. In conclusion, to clarify the efficacy of antenatal hypnosis training to manage childbirth, we conducted a large, randomized, controlled trial of a brief course in self-hypnosis for nulliparous women that would be realistic to implement and perform at low cost in most antenatal care settings. Our results showed that the intervention had a positive impact on the childbirth experience. Future studies could focus on more intensive interventions and perhaps tailor these to different subgroups, as for instance, women with a fear of childbirth.
Acknowledgments We thank Poul Lundgaard Bak for seeding this project and Allan Cyna for sharing his inspiring work and knowledge with us. Besides, we thank all the women who took part in the project and the staff at the maternity ward at Aarhus University Hospital Skejby.
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Supporting Information Additional Supporting Information may be found in the online version of this article: Appendix S1. Training program.
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Antenatal Hypnosis Training and Childbirth Experience: A Randomized Controlled Trial Anette Werner, MHSc, PhD, Niels Uldbjerg, MDSc, PhD, Robert Zachariae, MSc, MDSc, PhD, Chun Sen Wu, MD, PhD, and Ellen A. Nohr, MHSc, PhD ABSTRACT: Background: Childbirth is a demanding event in a woman’s life. The aim of
this study was to explore whether a brief intervention in the form of an antenatal course in self-hypnosis to ease childbirth could improve the childbirth experience. Method: In a randomized, controlled, single-blinded trial, 1,222 healthy nulliparous women were allocated to one of three groups during pregnancy: A hypnosis group participating in three 1-hour sessions teaching self-hypnosis to ease childbirth, a relaxation group receiving three 1-hour lessons in various relaxation methods and Mindfulness, and a usual care group receiving ordinary antenatal care only. Wijmas Delivery Expectancy/Experience Questionnaire (WDEQ) was used to measure the childbirth experience 6 weeks postpartum. Results: The intention-to-treat analysis indicated that women in the hypnosis group experienced their childbirth as better compared with the other two groups (mean W-DEQ score of 42.9 in the Hypnosis group, 47.2 in the Relaxation group, and 47.5 in the Care as usual group (p = 0.01)). The tendency toward a better childbirth experience in the hypnosis group was also seen in subgroup analyses for mode of delivery and for levels of fear. Conclusion: In this large randomized controlled trial, a brief course in self-hypnosis improved the women’s childbirth experience. (BIRTH 40:4 December 2013) Key words: antenatal training, childbirth, childbirth experience, hypnosis, relaxation Background Childbirth is one of the most intense and demanding events that a woman is likely to experience, requiring not only physical but also psychological resources to cope with the labor process (1). The childbirth experience can be affected by several factors, including unexpected medical problems, emergency operative Anette Werner is a midwife and Niels Uldbjerg is a professor at the Department of Gynecology and Obstetrics, Aarhus University Hospital Skejby, Aarhus N, Denmark; Robert Zachariae is a professor with the Unit for Psychooncology and Health Psychology, Department of Oncology, Department of Psychology, Aarhus University Hospital, Aarhus University, Aarhus C, Denmark; Chun Sen Wu is post doctoral and Ellen A. Nohr is a professor with the Department of Public Health, Section for Epidemiology, Aarhus University, Aarhus C, Denmark; Ellen A. Nohr is also affiliated with the Department of Gynecology and Obstetrics, Odense University Hospital, Odense C, Denmark. Funding The project was made possible by funding from: Nordea Fonden, Aaseog Ejnar Danielsens foundation, The Danish Society for Clinical Hypnosis, VIFAB (Knowledge and Research Center for Alternative Medicine), King Christian X’s foundation and The Danish Association of Midwives. We are very thankful to all contributors.
delivery, low levels of support from partner or caregivers, pain, and loss of control (2–4). The woman’s own expectations about the upcoming childbirth have also been found to influence the subsequent birth (2). An optimistic and positive attitude has, for example, been associated with a positive birth experience, whereas fear of or worries about the upcoming childbirth were found to be risk factors for a negative experience
Ethical approval This trial was approved on December 15, 2008, by the Scientific Ethical Committee for the Region of Central Jutland, nr. M-200080200 in Denmark and by the Danish Data Protection Agency on November 5, 2008, nr. 2088-41-2797. The trial was also reported to ClinicalTrials.gov, number NCT00914082. Address correspondence to Anette Werner, Department of Gynecology and Obstetrics, Aarhus University Hospital Skejby, Brendstrupgaardsvej 100, 8200 Aarhus N, Denmark.
© 2013, Copyright the Authors Journal compilation © 2013, Wiley Periodicals, Inc.
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(5–7). Reducing the risk of a negative birth experience is important because the costs for the society and the individual may be substantial. Negative and traumatic birth experiences have been associated with both shortterm and long-term consequences, including bonding problems between mother and child, childbirth-related posttraumatic stress, postpartum depression, poor health, preference for delivery by cesarean birth in future pregnancies, or refraining from having more children (6,8–11). Hypnosis has been used as intervention in many different clinical settings, including childbirth (12–22), and appears to be a safe tool when applied to healthy women (23,24). The hypnotic state is considered to be a common and natural mental state (25), and is commonly described as “an altered state of consciousness characterized by markedly increased receptivity to suggestion, the capacity for modification of perception and memory, and the potential for systematic control of a variety of usually involuntary physiological functions” (26). The ability to experience hypnosis varies (27,28), and hypnotic susceptibility has been found to increase during pregnancy (29,30). Hypnosis could therefore potentially be a useful tool for parturient women. Hypnosis typically not only involves a hypnotist and a person being hypnotized, but can also be self-administered as self-hypnosis. Women can thus be trained to guide themselves through a hypnotic procedure (31). Several studies have shown beneficial effects of antenatal hypnosis training conducted both in individual sessions and as group training (12–22). The results indicate that hypnosis may have a positive influence on maternal and neonatal outcomes such as labor pain (12–16,19–23), duration of birth (12,19,32), complications, and interventions (16,17,23,33,34), the child’s condition (12,21), and postpartum depression (12,35). Although several of these studies have also assessed aspects of the childbirth experience and reported a positive effect of hypnosis (14–16,32), interpretation of the results is limited by methodological shortcomings, including lack of random assignment (14,32), insufficiently described hypnotic methods (14–16,32), and relatively small sample sizes (14,15,32). Our aim was therefore to develop a brief course in antenatal selfhypnosis to provide women with skills to cope with childbirth and to evaluate the effects on the childbirth experience in a large randomized controlled trial.
Methods The study was conducted at the Obstetrics Department at Aarhus University Hospital, Denmark, which is responsible for approximately 5,000 deliveries per year. The participants gave birth in the period from August
2009 through August 2011. The trial was randomized, controlled, single-blinded, and used a three-arm group design. The primary outcomes of the trial were use of epidural analgesia and self-reported pain during delivery and have previously been reported (36). The effect on childbirth experience, reported in this article, was a secondary prespecified outcome. The detailed description of the methods has been presented elsewhere (36). Briefly, a total of 1,222 healthy first-time mothers participated in this study. The participants were randomly allocated to either the intervention group (n = 497), the active comparison group (n = 495), or the usual care control group (n = 230) using a computer-generated interactive voice response telephone randomization system (37) (see Flowchart, Fig. 1). The intervention group (the hypnosis group) attended three 1-hour classes on self-hypnosis for childbirth held over three consecutive weeks. A test for hypnotic susceptibility (38,39) was conducted during the first session, which therefore lasted 2.5 hr. A program inspired by the Australian HATCh project (1) was developed and taught by two midwives trained in hypnosis. In addition, the women received three audio recordings, including a 20-minute section especially meant for labor. The active comparison group (named the “relaxation group” in the following) also attended three antenatal classes, each lasting 1 hour. The program was taught by the same midwives as in the intervention group and included a variety of body awareness, relaxation, and mindfulness techniques. This course also included audio recordings for homework and labor. The usual care group received only ordinary antenatal care, which included a nuchal translucency scan about gestational week 12, an anomaly scan about gestational week 19, four to five visits at the midwifery clinics, and a tour of the birth department. A detailed description of the intervention is available on request from the corresponding author. The project was presented to the participants and the staff at the Obstetric Department as a research project on mind-body training investigating self-hypnosis and relaxation techniques as two equally effective approaches. The midwives assisting the birth were blinded to the participant’s allocated treatment.
Data Collection and Outcome The Wijmas Delivery Expectancy/Experience Questionnaire, version A (W-DEQ A) and version B (W-DEQ B) were used to assess the childbirth experience. This instrument is a well-validated tool. W-DEQ A measures fear, confidence, and expectations concerning the upcoming childbirth and W-DEQ B evaluates the same aspects of the actual childbirth experience (40,41). Both
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Enrollment
274 Assessed for eligibility and invited (n = 3,554) Did not respond to the invitation (n = 2,443) Recruited from posters and website
Responded to the invitation (n = 1,111)
(n = 134)
Not included (n = 23) -not meeting inclusion criteria (n = 22) -other reasons (n = 1) Randomized
Allocation
Hypnosis (n = 497) Excluded, not meeting inclusion criteria (n = 4)
Relaxation (n = 495) Excluded, not meeting inclusion criteria (n = 1)
Received allocated intervention (n = 493) 3 sessions (n = 420, 85.2%) 2 sessions (n = 40, 8.1%) 1 session ( n = 22, 4.5%) 0 sessions (n = 11, 2.2%)
Received allocated intervention (n = 494) 3 sessions (n = 394, 79.8%) 2 sessions (n = 61, 12.4%) 1 session (n = 21, 4.3%) 0 sessions (n = 18, 3.9%)
Follow up
Completed W-DEQ 6 weeks postpartum: 98.4% (n = 485) All 33 items (n = 468)
Completed W-DEQ 6 weeks postpartum: 98.4 % (n = 482) All 33 items (n = 448)
Completed W-DEQ 6 weeks postpartum: 97.0% (n = 222) All 33 items (n = 210)
Did not complete W-DEQ (n = 8)
Did not complete W-DEQ (n = 12)
Did not complete W-DEQ (n = 8)
Analysis
(n = 1,222)
Control (n = 230)
Included in analysis (n = 485)
Included in analysis (n = 482)
Included in analysis (n = 222)
Fig. 1. Flow diagram of enrollment, allocation, and study participation.
versions include 33 items measured on 6-point Likert scales ranging from 0 to 5 with the endpoints indicating “not at all…” and “extremely…”. Total sum scores range from 0 to 165 with a higher score indicating a less satisfying experience. A special 20-item B version has been developed for women giving birth by cesarean delivery, featuring 20 of the 33 items from the original W-DEQ B with total scores ranging from 0 to 100 (42). For W-DEQ A, a total score of more than 84 was considered to represent severe fear of childbirth, and a score of more than 99 extreme fear of childbirth (40,41). At recruitment, the participants completed a questionnaire assessing baseline information. It included the W-DEQ A (40) and two measures of emotional wellbeing: the 10-item Perceived Stress Scale (43) and the WHO-5 Well-being questionnaire (44). Baseline characteristics were also drawn from this questionnaire. To compare participants with nonparticipants, we used an ongoing, independent data collection, “The Aarhus Birth Cohort,” which includes a questionnaire sent to all women early in pregnancy among those signed up for birth at the hospital.
Immediately after completing the antenatal course, the women were asked if the training had changed their expectations about the upcoming birth. This outlook was measured on a 5-point Likert scale with 1 and 2 indicating change in a positive direction, 3 no change, and 4 and 5 change in a negative direction. Because no women reported a negative change, the variable was dichotomized into: “Change in a positive direction/No change.” Information about the childbirth was derived from “The Aarhus Birth Cohort.” In case of missing information or if the woman gave birth at another hospital, the necessary data were extracted from medical records. Six weeks postpartum, the women completed a second questionnaire that included information about the childbirth and the W-DEQ B (40).
Statistical Analysis Characteristics of the participants and the nonparticipants are presented as frequencies and medians. The baseline characteristics, including the baseline scores for the
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W-DEQ A and expectations after training, are presented as frequencies, means, and medians. In the analysis of expectations about childbirth, W-DEQ A scores were included as a continuous variable (total scores) and as a categorical variable ( severe fear of childbirth) with severe fear defined as a total score of more than 84. Data were analyzed according to the intention-to-treat principle in accordance with the CONSORT Statement (45). In the intention-to-treat analysis of the childbirth experience, the mean scores of all participants who had completed the 33-item version of the W-DEQ B were compared. If women giving birth by emergency cesarean delivery had experienced labor and were able to answer all 33 items of the W-DEQ B, they were also included in the analysis. If they had not experienced labor, they would only be able to answer the 20-item version, modified for women delivering by cesarean birth. For this 20item version, subgroup analyses were conducted in all women undergoing scheduled cesarean delivery and in all women giving birth by emergency cesarean delivery. Subgroup analyses were also performed in women who had completed the 33-item version of the W-DEQ B with regard to mode of delivery (vaginal, spontaneous, assisted vaginal, scheduled cesarean delivery, and emergency cesarean birth) and women with a severe fear of childbirth. In all analyses, the data were compared across study groups using chi-square tests for binary data. Rank scores and continuous data were analyzed with ANOVAs when data were normally distributed, otherwise with Kruskal–Wallis one-way ANOVAs. If main effects were statistically significant, Bonferroni-adjusted post hoc comparisons were conducted. Participants were compared with nonparticipants with Mann–Whitney rank sum tests. Associations between expectations about childbirth at baseline and the actual childbirth experience were analyzed using the Spearman correlation coefficient within each of the three trial groups. Between-group comparisons were conducted with univariate regression and Wald’s post hoc tests. In all analyses, a two-sided p value (84) (See Table 3).
postpartum was high, 97.0 percent in the control group and 98.4 percent in both intervention groups. The analysis of the childbirth experience included 485 in the hypnosis group, 482 in the relaxation group, and 222 in the usual care group, yielding a total of 1,189 women (See Fig. 1).
Attendance to the Training and its Impact on Expectations of the Upcoming Birth Attendance to the training was 85.2 percent in the hypnosis group and 79.8 percent in the relaxation group. Immediately after completing the antenatal course, 86.9 percent of the women in the hypnosis group reported that the training had changed their expectations of the upcoming birth in a positive direction. The number was 76.8 percent in the relaxation group (p < 0.01).
Baseline Characteristics With respect to baseline characteristics, the participants in the three groups were generally comparable. A statistically significant difference across the three groups was, however, seen for mode of delivery. Compared with the other two groups, the frequency of scheduled cesarean delivery was lower and the frequency of emergency cesarean delivery higher in the hypnosis group (Table 2). The duration from the woman’s arrival at the birth department to emergency delivery and the indications for performing an emergency cesarean delivery and a scheduled cesarean delivery did not differ across the three groups.
How Childbirth was Experienced
Expectations at Baseline Concerning the Upcoming Childbirth The women in the three groups all had the same expectations about the upcoming birth (W-DEQ A) and this antic-
All 33 items of the W-DEQ B were completed by 468 women in the hypnosis group, 448 in the relaxation group, and 210 in the usual care group. The intentionto-treat analysis of the 33 item W-DEQ B showed that the hypnosis group had a better childbirth experience compared with the mean score of the other two groups (mean W-DEQ score of 42.9 in the Hypnosis group, 47.2 in the Relaxation group, and 47.5 in the Care as usual group [p = 0.01]) (Table 4 and Fig. 2). All subgroup analyses of the 33-item version according to birth type and level of fear also revealed lower
Table 2. Characteristics of the participants
Age (years), median (iqr) Prepregnant BMI (kg/m2), median (iqr) Smoking Before pregnancy, % During pregnancy, % Higher education (years beyond high school), % None 1–4 years 4 years and longer Living with partner, % Previously treated for a mental health disorder, % WHO-5 well-being index, (max score 100), median (iqr) PSS-10 Stress test, (max score 50), median (iqr) Mode of delivery Spontaneous, % Assisted vaginal, % Cesarean section, scheduled, % Cesarean section, emergency, % Iqr, Inter quartile range.
Hypnosis (n = 485)
Relaxation (n = 482)
Usual Care (n = 222)
p value
29.9 (4.7) 22.0 (3.3)
29.9 (4.2) 21.9 (3.5)
29.4 (4.6) 21.7 (3.7)
0.31 0.65
10.3% 0.8%
8.5% 1.0%
10.4% 1.8%
0.58 0.51
3.5% 50.1% 46.4% 96.5% 14.4% (16) (6)
2.0% 53.3% 44.6% 96.9% 15.2% (20) (6)
0.9% 57.2% 41.9% 99.1% 10.8% (20) (6)
0.09 0.20 0.53 0.14 0.29 0.08 0.83
68.2% 11.8% 2.2% 17.9%
67.6% 14.6% 5.7% 12.1%
68.3% 15.7% 4.4% 11.7%
0.98 0.27 0.02 0.02
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Table 3. Expectations of childbirth (W-DEQ A) at baseline according to the three intervention groups
All, mean score W-DEQ A (stddev) Women with severe fear of childbirth, (W-DEQ A mean score >84), No. (%)
Hypnosis group (n = 485)
Relaxation group (n = 482)
Usual Care group (n = 222)
p value
60.5 (19.9) (56) 11.6%
61.9 (20.3) (68) 14.1%
61.9 (18.8) (29) 13.1%
0.38 0.90
Table 4. Childbirth experience (W-DEQ B) according to the three intervention groups
Hypnosis group (n = 485)
Relaxation group (n = 482)
Usual Care group (n = 222)
(n = 468) 42.9 (23.5) (n = 388) 41.5 (23.7) (n = 330) 39.4 (23.0) (n = 58) 53.4 (24.0) (n = 79) 50.3 (21.5) (n = 54) 59.7 (24.9)
(n = 448) 47.2 (25.0) (n = 398) 47.2 (25.0) (n = 326) 42.8 (22.9) (n = 71) 57.9 (26.6) (n = 45) 59.3 (26.7) (n = 63) 64.9 (29.2)
(n = 210) 47.5 (22.7) (n = 187) 47.5 (22.7) (n = 154) 44.4 (22.3) (n = 33) 54.6 (23.8) (n = 21) 58.2 (18.2) (n = 28) 63.9 (20.8)
(n = 86) 29.0 (20) (n = 11) 29.0 (32)
(n = 59) 37.0 (29) (n = 25) 31.0 (24)
(n = 25) 35.0 (14) (n = 10) 28.5 (34)
W-DEQ 33 item 6 weeks postpartum (p.p.) All, mean (stddev)* Vaginal birth, mean (stddev)** Spontaneous birth, mean (stddev)*** Assisted vaginal birth, mean (stddev) Cesarean section, emergency, mean (stddev) Women with fear of childbirth, all, mean (stddev)
W-DEQ 20 item 6 weeks postpartum Cesarean section, emergency, median (iqr) Cesarean section, scheduled, median (iqr)
p value 0.01 0.01 0.04 0.58 0.08 0.12
0.06 0.06
Iqr, Inter quartile range. *Post hoc test: Hypnosis vs Relaxation (p = 0.02); Hypnosis vs Care as Usual (p = 0.06); Relaxation vs Care as Usual (p = 1.00). **Post hoc test: Hypnosis vs Relaxation (p = 0.02); Hypnosis vs Care as Usual (p = 0.06); Relaxation vs Care as Usual (p = 1.00). ***Post hoc test: Hypnosis vs Relaxation (p = 0.16); Hypnosis vs Care as Usual (p = 0.07); Relaxation vs Care as Usual (p = 1.00).
p=0.01
p=0.01
1
2
p=0.58
4
5
p=0.04
0
W-DEQ B mean score 20 40
60
p=0.12 p=0.08
Hypnosis
3
Relaxation
6 Usual
1:All birth; 2:Vaginal; 3:Spontaneous birth; 4:Assisted birth; 5:Emergency Cesarean; 6:Fear of childbirth
Fig. 2. Childbirth experience (W-DEQ B 33 item), mean score per group.
BIRTH 40:4 December 2013
278 mean scores in the hypnosis group compared with the other groups (Table 4 and Fig. 2). The differences, however, were only statistically significant for vaginal birth and spontaneous birth. When the subgroup analyses were performed for the 20-item version, a lower median score was found in the hypnosis group after emergency cesarean deliveries compared with the other groups (Table 4 and Fig. 3). For women experiencing scheduled cesarean delivery, the differences across groups were small.
The Relations Between Expectations of the Childbirth and the Childbirth Experience The expectations at baseline of the upcoming childbirth (W-DEQ A) were related to the subsequent childbirth experience (the 33-item W-DEQ B) (Spearman’s rho: 0.47 (p < 0.01) in the hypnosis group, 0.41 (p < 0.01) in the relaxation group, and 0.31 (p < 0.01) in the usual care group). Further analysis revealed that this relation was stronger for the hypnosis group than for the relaxation group and the usual care group (Wald’s test, p = 0.01, p = 0.04) and that it did not differ between the relaxation and usual care group (Wald’s test, p = 0.97).
Blinding
40
To examine the effectiveness of the blinding, the midwives assisting at birth were asked to estimate the woman’s allocated treatment immediately after the delivery (response rate: 59.8%). The percentages of correctly estimated treatment allocation were 58.4 percent in the relaxation group, 31.5 percent in the hypnosis group, and 38.0 percent in the usual care group.
p=0.06
0
W-DEQ B median score 20 30 10
p=0.06
Emergency Cesarean Section Hypnosis
Scheduled Cesarean Section Relaxation
Usual
Fig. 3. Childbirth experience (W-DEQ B 20 item), median score per group.
Discussion The results revealed a positive effect of a brief antenatal course in self-hypnosis on the childbirth experience. The magnitude of the improvement was about 5 points on the W-DEQ, which can be considered clinically relevant because of the importance of this experience as the basis for mother and child interaction and for the woman’s mental and physical well-being (11,46,47). Both types of training appeared to modify the attitude toward the upcoming birth in a positive direction. This result could, however, also be because of a naturally occurring change over time, because we only asked women who had received training, and we were unable to identify the changes in attitude in the sample as a whole. It is, however, of interest that the hypnosis group reported a statistically significantly greater change in attitude than did the relaxation group. The W-DEQ instrument used to assess the childbirth experience has been developed and tested in clinical practice, and previous studies support its reliability and validity (40,48). The instrument assesses the total experience of the childbirth by embracing several aspects such as pain, fear, and confidence. This study is the first to quantitatively assess the effect of a hypnosis intervention on the total childbirth experience. Previous studies of hypnosis and childbirth have only concerned single aspects of the childbirth experience, for example, labor pain (12–16,19–23), anxiety and stress during birth (14,16), satisfaction with labor (15), or satisfaction about the childbirth (32). In general, the available studies have found, in accord with our results, a positive effect of hypnosis (12–14,16,19–22,32). The present results can be considered reliable because they were based on a large, randomized, single-blinded, controlled trial with a high adherence to the antenatal training. We had baseline and obstetric information available to us for all participants and a high response rate at follow-up of almost 100 percent. We also appeared to be successful in blinding the midwives from the participants’ true allocation. The outcomes reported here were, however, secondary, and although we had sufficient statistical power for the intention-to-treat analysis of the W-DEQ 33, the power for some of the subgroup analyses was low. The blinding of the staff to the allocated treatment may also be a limitation. As the midwives had no or little knowledge about hypnosis but were more familiar with relaxation they might have able to support women in the relaxation group in a more appropriate way. In this study, we focused on a broad group of women. In addition, we focused on developing a low-cost training program that could be implemented in a general obstetric setting. Consequently, the content and intensity
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of the intervention may have been too limited. It is possible that tailoring the training for more specific needs, for instance for women with the highest levels of fear and intensifying the intervention, could have yielded a more pronounced result. Other randomized controlled studies with positive results have generally used more time-consuming interventions (12,15,16). The generalizability of our results could be limited, because our study sample consisted of first-time mothers with no previous childbirth experience and with considerable resources. Furthermore, compared with our participants, nonparticipants were more likely to use epidural analgesia and have a cesarean section on maternal request. This probability could possibly reflect a different attitude toward childbirth, with participants being more likely to want to give birth naturally and to have more resources available to cope with the childbirth. The effectiveness of the intervention to improve the birth experience in the group represented by our participants could thus be limited because the improvement potential in such women may be small (i.e., a ceiling effect). The mean scores at baseline on the W-DEQ A were approximately 60 for all three groups, which is similar to the results from two Swedish studies (42,49). The mean score for the childbirth experience was lower (42.9–47.59), suggesting that many participants expected the childbirth to be worse than their actual experience. We conducted subgroup analyses for different modes of delivery and for women with high levels of fear because these are well-known predictors of the childbirth experience (5–7). In general, the mean scores for all groups followed the same tendencies shown in other studies, namely that an uncomplicated birth leads to a better childbirth experience than assisted delivery or emergency cesarean delivery (49). Women suffering from severe fear reported the highest mean scores, suggesting a more negative childbirth experience. In the intention-to-treat analysis, we included all participants who had completed the 33-item version of the W-DEQ B, regardless of the mode of delivery, even though this version has been developed for women giving vaginal birth, and some previous studies have excluded this group of women from the analysis of the 33-item version (40,48). When we excluded women giving birth by cesarean delivery, the differences between the groups were more pronounced. For emergency cesarean delivery, the mean score for the 33-item W-DEQ B was 8–9 points lower in the hypnosis group than the scores in the two remaining groups. The result was, however, only borderline significant. For the 20-item W-DEQ B version, the median score was 6 and 8 points lower and also borderline significant. It seems reasonable to assume that the women were empowered by the self-hypnosis training to cope with a stressful birth situation, but, because of the rela-
tively small number of women receiving an emergency cesarean, the statistical power of these analyses was limited. We did not find any effect of hypnosis or relaxation in women having an assisted vaginal birth. As expected, and in concordance with previous results (5–7), the childbirth expectations at baseline correlated with the actual childbirth experience. The association, however, was stronger in the groups receiving training, and strongest for the hypnosis group. This substantiality suggests that the intervention affected these groups by decreasing the variation and that especially the hypnosis group was the most uniform. In conclusion, to clarify the efficacy of antenatal hypnosis training to manage childbirth, we conducted a large, randomized, controlled trial of a brief course in self-hypnosis for nulliparous women that would be realistic to implement and perform at low cost in most antenatal care settings. Our results showed that the intervention had a positive impact on the childbirth experience. Future studies could focus on more intensive interventions and perhaps tailor these to different subgroups, as for instance, women with a fear of childbirth.
Acknowledgments We thank Poul Lundgaard Bak for seeding this project and Allan Cyna for sharing his inspiring work and knowledge with us. Besides, we thank all the women who took part in the project and the staff at the maternity ward at Aarhus University Hospital Skejby.
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Supporting Information Additional Supporting Information may be found in the online version of this article: Appendix S1. Training program.
