Download The efficacy of hypnosis as an intervention for labor and delivery

Clinical Psychology Review 31 (2011) 1022–1031
Contents lists available at ScienceDirect
Clinical Psychology Review
The efficacy of hypnosis as an intervention for labor and delivery pain:
A comprehensive methodological review
Alison S. Landolt, Leonard S. Milling ⁎
University of Hartford, USA
a r t i c l e
i n f o
Article history:
Received 9 February 2011
Received in revised form 26 May 2011
Accepted 1 June 2011
Available online 23 June 2011
Keywords:
Labor and delivery pain
Hypnosis
Treatment outcomes
Methodology
a b s t r a c t
This paper presents a comprehensive methodological review of research on the efficacy of hypnosis for
reducing labor and delivery pain. To be included, studies were required to use a between-subjects or mixed
model design in which hypnosis was compared with a control condition or alternative intervention in
reducing labor pain. An exhaustive search of the PsycINFO and PubMed databases produced 13 studies
satisfying these criteria. Hetero-hypnosis and self-hypnosis were consistently shown to be more effective
than standard medical care, supportive counseling, and childbirth education classes in reducing pain. Other
benefits included better infant Apgar scores and shorter Stage 1 labor. Common methodological limitations of
the literature include a failure to use random assignment, to specify the demographic characteristics of
samples, and to use a treatment manual.
© 2011 Elsevier Ltd. All rights reserved.
Contents
1.
Introduction . . . . . . . . . . . . . . . . . . . . . . . .
1.1.
Biology of labor and delivery . . . . . . . . . . . . .
1.2.
Common pharmacologic methods of pain control . . .
1.3.
Hypnosis as an intervention for labor and delivery pain
2.
Method of review . . . . . . . . . . . . . . . . . . . . .
3.
Summary of controlled studies . . . . . . . . . . . . . . .
3.1.
Hypnosis versus standard medical care . . . . . . . .
3.2.
Hypnosis versus supportive counseling . . . . . . . .
3.3.
Hypnosis versus Lamaze . . . . . . . . . . . . . . .
3.4.
Hypnosis versus childbirth education classes . . . . .
4.
Methodological considerations . . . . . . . . . . . . . . .
4.1.
Random assignment . . . . . . . . . . . . . . . . .
4.2.
Specification of sample . . . . . . . . . . . . . . . .
4.3.
Treatment manual . . . . . . . . . . . . . . . . . .
4.4.
Hypnotic context . . . . . . . . . . . . . . . . . .
4.5.
Active use of hypnosis . . . . . . . . . . . . . . . .
4.6.
Hypnotic suggestibility . . . . . . . . . . . . . . . .
4.7.
Other methodological considerations . . . . . . . . .
5.
Discussion . . . . . . . . . . . . . . . . . . . . . . . . .
6.
Conclusions . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
1022
1023
1023
1023
1024
1024
1024
1025
1026
1026
1027
1027
1028
1028
1028
1028
1029
1029
1029
1030
1030
1. Introduction
⁎ Corresponding author at: University of Hartford, Department of Psychology, 200
Bloomfield Avenue, West Hartford, CT 06117, USA. Tel.: + 1 860 768 4546; fax: + 1 860
768 5292.
E-mail address: [email protected] (L.S. Milling).
0272-7358/$ – see front matter © 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cpr.2011.06.002
Pain during labor and delivery presents a distinct problem for
expectant mothers. Many pregnant women greatly fear the pain of
childbirth, and this fear, as well as anxiety, is associated with a greater
experience of pain (Leeman, Fontaine, King, Klein, & Ratcliffe, 2003;
A.S. Landolt, L.S. Milling / Clinical Psychology Review 31 (2011) 1022–1031
Simkin, 2000). Labor pain, which is primarily experienced during
contractions in the first and second stages of labor, varies greatly
among women (Niven & Murphy-Black, 2000). Despite this variability, labor pain is usually intense and is often described by women as
the most extreme pain ever experienced (Niven & Murphy-Black,
2000).
For example, during a two-week period in a major Swedish city,
Waldenström, Bergman, and Vasell (1996) asked all women who gave
birth during that time, except for those who did not speak Swedish
and women who underwent elective cesarean sections, about their
experiences of labor pain two days after delivery. Of the 278 women
who participated in the study, 41% rated the discomfort of labor as the
worst pain imaginable. Notably, these findings were obtained despite
the widespread use of pharmacologic interventions to provide relief.
In fact, only 9% of the participants refrained from using analgesia.
1.1. Biology of labor and delivery
The process of childbirth consists of three stages of labor (Harms,
2004). The first stage of labor is characterized by uterine contractions,
which force the baby against the cervix, and cervical dilation, which
allows the baby to descend into the vagina. This stage is divided into
three phases: early labor, active labor, and transition (Harms, 2004).
During early labor, contractions last between thirty and sixty seconds
and range from five to twenty minutes apart. The cervix dilates from
zero to just over three centimeters, comprising the longest but least
intense period of labor. Active labor is shorter than early labor, but is
much more intense as contractions become more painful (Harms,
2004). It is during this phase that many women request pain
medication, and epidurals, if used, are typically administered at this
time. Transition, during which the cervix dilates from seven to the full
ten centimeters, is the shortest, but most difficult phase. Contractions
increase in strength and frequency, lasting from sixty to ninety
seconds. Intravenous and intramuscular pain medication is usually
contraindicated during this phase due to the proximity to birth. This is
because intravenous and intramuscular pain medication could
depress respiratory functioning in the infant (Harms, 2004), although
epidurals may still be given if time permits.
The second stage of labor, also known as the pushing stage, begins
after full cervical dilation is attained and concludes once the infant's
body has been fully birthed (Littleton & Engebretson, 2004; Pillitteri,
2009). This stage is characterized by intense, forceful contractions
and, for some, burning pain in the perineum.
The third stage of labor involves the delivery of the placenta, an
organ inside the uterus that provides nourishment to the fetus
through the umbilical cord (Harms, 2004). In order to facilitate
delivery of the placenta, also called the afterbirth, mild contractions
continue during this stage.
1.2. Common pharmacologic methods of pain control
Both pharmacologic and non-pharmacologic methods are used for
pain management during labor and delivery. Pharmacologic interventions administered during childbirth, however, present special
concerns. For example, the effects on the infant must be considered
and many drugs must be given within certain time frames in order to
satisfy safety and efficacy concerns (Simpson & Creehan, 2008).
In regional anesthesia, injection of local anesthesia is used to block
specific nerve pathways, thus providing pain relief (Pillitteri, 2009).
An advantage of regional anesthesia is that it allows the woman to be
awake and fully aware of the birth experience. One form of regional
anesthesia is the epidural, which is one of the most common
pharmacologic methods of pain relief during childbirth. Although
epidurals provide an effective means of pain control during labor
and delivery, there is some evidence that women who receive
epidural anesthesia experience significantly longer Stage 2 labor
1023
and an increased risk of hypotension, instrumental delivery,
and motor blockade than women who do not utilize epidurals (see
Anim-Somuah, Smyth, & Howell, 2005). Similarly, Thorp and
Breedlove (1996) reported that epidural anesthesia was associated
with longer labor and an increased risk of instrumental delivery.
According to Littleton and Engebretson (2004), epidural anesthesia
may interfere with a woman's ability to push forcefully. This may
explain why the second stage of labor – the pushing stage – is longer
when an epidural is used.
Another pharmacologic intervention, low spinal anesthesia, also
called saddle block, is easy to administer, works rapidly, and provides
an effective form of pain relief (Creasy, Resnik, & Iams, 2004).
However, it often interferes with the expectant mother's ability to
push during labor — even more so than epidural anesthesia. Some
narcotic analgesics such as Meperidine (Demerol) and Morphine
Sulfate provide beneficial analgesic effects during labor; however,
they may result in respiratory depression in the newborn (Pillitteri,
2009). Indeed, the neurobehavioral depression (e.g., poor sucking
response, depressed respiration, decreased alertness and attention,
poor muscle tone) in the newborn caused by Meperidine can last for
several days (Simpson & Creehan, 2008).
1.3. Hypnosis as an intervention for labor and delivery pain
Hypnosis is an intervention that has been shown to be effective for
reducing a variety of forms of pain (reviewed in Patterson & Jensen,
2003). Hypnosis is defined as “a procedure during which a health
professional or researcher suggests that a client, patient, or subject
experience changes in sensations, perceptions, thoughts or behavior”
(Kirsch, 1994, p. 143). Hypnosis typically involves two individuals—a
hypnotist and a person who is being hypnotized (i.e., hetero-hypnosis).
However, in self-hypnosis, a single individual assumes both roles and
the patient or client delivers suggestions for changes in experience to
herself or himself.
Every hypnotic procedure consists of a hypnotic induction and
suggestions (Hilgard, 1965). The induction establishes a hypnotic
context and typically includes instructions for relaxation and wellbeing, accompanied by statements that the person is becoming
hypnotized. A suggestion invites the person to experience some
imaginary state of affairs as if it were real (e.g., “your hand is numb
and insensitive, as if you were wearing a thick glove, and you can't feel
much of anything through that glove.”). Typically, the patient or client
is invited to experience the suggestion during the course of a hypnotic
session. However, when the person is invited to experience a
suggestion at some point after the hypnotic session has ended, it is
referred to as a posthypnotic suggestion.
The purpose of this article is to provide a comprehensive
methodological review of controlled research on the efficacy of
hypnosis for reducing labor and delivery pain. Over the last ten to
fifteen years, a variety of reviews have been published on the use of
hypnosis for pain associated with labor and delivery. Brown and
Hammond (2007) reported a selective review of empirical research
and case studies, emphasizing the effect of hypnosis on gestation at
delivery, cessation of premature labor, and the health status of the
neonate, rather than focusing on labor pain. Oster and Sauer (2000)
described different approaches to hypnotic childbirth preparation and
presented case studies. Finally, Cyna, McAuliffe, and Andrew (2004)
conducted a meta-analysis of three randomized trials and concluded
that hypnosis is effective in reducing the use of analgesics during
labor. However, Cyna et al. do not provide an in-depth critique of
methodological patterns in the entire body of controlled studies and
do not include investigations published since 2004. To our knowledge,
this article is the first comprehensive methodologically-informed
review of all controlled research on the efficacy of hypnosis for
managing labor pain.
1024
A.S. Landolt, L.S. Milling / Clinical Psychology Review 31 (2011) 1022–1031
versus supportive counseling; (c) hypnosis versus Lamaze; and
(d) hypnosis versus childbirth education classes.
2. Method of review
To be included in this review, studies were required to use a
between-subjects or mixed model design in which a hypnosis
intervention was compared with at least one alternative intervention,
or a placebo, attention, standard care, or no-treatment control
condition in reducing labor and delivery pain. An “alternative
intervention” is defined as an established psychological or medical
treatment for labor and delivery pain, such as epidural anesthesia. An
“attention” control condition is defined as a minimal intervention
lacking a significant amount of active treatment and is designed to
control for the pain reducing effects of paying attention to a patient.
No studies were included that failed to use pain as a dependent
variable. Also, studies that did not report statistical tests of differences
between comparison conditions were not included (e.g., Brann &
Guzvica, 1987).
An exhaustive search of the PsycINFO and PubMed databases, as
well as an examination of related reviews in this area, identified 13
studies satisfying these criteria. Search terms included combinations
of hypnosis, labor, delivery, pain, analgesia, interventions, and
treatment outcomes. Table 1 summarizes the major characteristics
of these studies, including sample size, treatment conditions,
dependent measures of pain, and key findings. The studies can be
organized based on the comparison condition into the following four
groups: (a) hypnosis versus standard medical care; (b) hypnosis
3. Summary of controlled studies
3.1. Hypnosis versus standard medical care
Several studies compared hypnosis with standard medical care in
reducing the pain experienced by women during childbirth. While
many women do seek childbirth education classes on their own, the
reviewed studies comparing hypnosis with standard medical care did
not report whether or not the mothers-to-be received childbirth
education from an outside source. Education was not offered as an
intervention during these studies, and only routine medical care was
given.
Cyna, Andrew, and McAuliffe (2006) evaluated the birth outcomes
of women undergoing hypnotic preparation for labor and delivery
pain in the obstetrics and gynecological service of an acute care
teaching hospital in Australia. Seventy-seven primigravid (i.e., having
a first baby) and parous (i.e., having given birth more than once)
women self-selected to receive training in hypnosis. These individuals
received up to four 40- to 60-minute training sessions after 35 weeks
gestation. During the first session, these women were educated about
hypnosis myths and were taught how to use hypnosis as an adjunct to
other analgesia methods. In later sessions, they received suggestions
Table 1
Characteristics of studies of hypnosis for managing labor pain.
Study
Sample
Treatment conditions
Pain measures
Summary of key findings
Cyna et al. (2006)
3326 women
Epidural analgesia
HP used epidurals less often than C
VandeVusse et al. (2007)
101 women
HP — Hypnotic preparation
C — Std. med. care
SH — Self-hypnosis
C — Std. med. care
Epidural analgesia;
analgesic medication
Jenkins and Pritchard (1993)
862 women
SH — Self-hypnosis
C — Std. med. care
Analgesic medication
Guthrie et al. (1984)
16 women
Self rating of pain
Rock et al. (1969)
40 women
HH+ SH — Hetero-hypnosis
plus self-hypnosis
C — Std. med. care
HH — Hetero-hypnosis
C — Std. med. care
SH used less analgesic medication,
sedatives, and epidurals than C;
SH had better
Apgar scores than C
SH used less analgesic medication
and experienced shorter
Stage 1 labor than C
HH + SH reported less pain than C
Letts et al. (1993)
495 women
Epidural analgesia
Martin et al. (2001)
42 adolescents
18 yrs or younger
Mehl-Madrona (2004)
520 women
Venn (1987)
122 women
Freeman et al. (1986)
65 women
Mairs (1995)
55 women
Davidson (1962)
210 women
Harmon et al. (1990)
60 women
SH — Self-hypnosis
SC — Supportive counseling
C — Std. med. Care
HP — Hypnotic preparation
including posthypnotic
suggestions
SC — Supportive counseling
HP — Hypnotic preparation
SC — Supportive counseling
C — Std. med. care
HP — Hypnotic preparation
including posthypnotic
suggestions
L — Lamaze
LHP — L plus HP
HP — Hypnotic preparation
CE — Childbirth education
classes
SH — Self-hypnosis
CE — Childbirth education
classes
SH — Self-hypnosis
CE — Childbirth education
classes
C — Std. med. care
SH — Self-hypnosis
CE — Childbirth education
classes
Analgesic medication;
resident rating of pain
Analgesic medication
HH used less analgesic medication
and were rated as experiencing less
pain than C
SH used fewer epidurals than SC and C
Analgesic medication;
nurse and self ratings
of pain
HP had fewer birth complications and
surgical interventions than SC;
HP no different from SC in use of
analgesic medication
HP used less analgesic medication and
epidurals than SC; SC did not differ
from C
HP no different from
L or LHP in analgesic medication use
or ratings of pain
Epidural analgesia;
self rating of pain
HP no different from
CE in pain reports or use of epidurals
Analgesic medication
and epidural analgesia;
self rating of pain
Analgesic medication
SH reported less pain and anxiety
than CE; SH no different from CE in
analgesic use
SH experienced shorter Stage 1 labor
and used less analgesic medication
than CE and C.
Analgesic medication;
self rating of pain
SH used less analgesic medication,
experienced shorter Stage 1 labor,
and had higher Apgar scores than CE
Epidural analgesia;
analgesic medication
A.S. Landolt, L.S. Milling / Clinical Psychology Review 31 (2011) 1022–1031
for pleasant imagery and relaxation, dissociation from the pain,
analgesia, time distortion, and to experience contractions in a positive
way. The hypnosis intervention was labeled as “self-hypnosis”,
although it is unclear that expectant mothers were explicitly shown
how to use self-hypnosis to re-experience the suggestions they had
been given during training sessions.
Participants in the hypnosis group were compared with a control
group of 3249 women, matched for parity and gestational age, who
had received standard medical care. Information on the control group
was collected from retrospective chart data. Results showed that
primigravid women who received hypnosis utilized epidural anesthesia significantly less frequently and had a decreased need for labor
augmentation with oxytocics compared with controls. These findings
suggest that hypnotic preparation may be effective for reducing
epidural use during labor and delivery.
VandeVusse, Irland, Berner, Fuller, and Adams (2007) conducted a
retrospective chart review of one obstetrician's case load. All patients
had given birth at a tertiary medical center located in a midwestern
U.S. city. The hypnosis condition consisted of 50 participants who
self-selected to receive self-hypnosis training during five sessions.
The training sessions included basic information about hypnosis
and instruction in the use of self-suggestions for pain management.
The training sessions were provided either in group format by an
obstetrician and clinical social worker, or in individual sessions by the
physician or one of two clinical social workers. The control group, which
only received standard medical care, was comprised of 51 participants
who were parity and mode of delivery matched so that they resembled
participants in the hypnosis group.
Results showed that women receiving training in self-hypnosis were
administered significantly fewer doses of analgesics and sedatives
compared to women in the control group. Women in the hypnosis
condition also received significantly fewer epidurals than those in the
control condition. Finally, infants in the hypnosis condition had
significantly better 1-minute Apgar scores than those in the control
condition, although there were no differences in 5-minute Apgar scores.
An Apgar score refers to a numerical rating of the infant's health made
immediately after birth and ranging from 0 to 10, based on the following
criteria: skin color, pulse rate, response to stimulation, muscle tone, and
breathing. The study suggests the use of self-hypnosis may have benefits
for both mothers and infants.
Jenkins and Pritchard (1993) assessed the effects of self-hypnosis
training on labor duration and analgesic use. The study was conducted
in the maternity unit of a general hospital in Wales. Participants
included 126 primigravid women and 300 age-matched controls, as
well as 136 parous women and 300 age-matched controls. Participants in the hypnosis condition self-selected to receive six 30-minute
training sessions provided by a medical hypnotherapist. These
sessions focused on self-administered suggestions for analgesia and
relaxation. The control group received standard medical treatment.
Primigravid women in the self-hypnosis condition experienced
significantly shorter Stage 1 and Stage 2 labor than women in the
control group. Although parous women receiving self-hypnosis
training experienced significantly shorter Stage 1 labor than controls,
there was no difference in the length of Stage 2 labor. Compared with
their controls, analgesic use was significantly reduced in both
primigravid and parous women in the hypnosis condition. The
study suggests that self-hypnosis may decrease analgesic use and
shorten the length of labor, particularly in primigravid women.
Guthrie, Taylor, and Defriend (1984) compared the experiences of
mothers-to-be who utilized both self-hypnosis and hetero-hypnosis
delivered by their husbands during labor with the experiences of
mothers receiving routine medical care. The investigation was conducted in a teaching hospital located in Scotland. Eight women selfselected to participate in the hypnosis condition. The control group was
comprised of eight women who matched the treatment group in terms
of age, social class, parity, and length of labor. Women in the hypnosis
1025
condition and their husbands attended six to eight 30-minute training
sessions, beginning at about 30 weeks of pregnancy. In the first sessions,
a clinician taught the expectant mothers relaxation techniques and
delivered suggestions for normality of pregnancy and delivery,
diminished awareness of discomfort, satisfaction and pleasure of
childbirth, and the ability of the participant's husband to relieve
discomfort by stroking her abdomen. In later sessions, the clinician
taught the expectant mothers to induce self-hypnosis and to have
hypnosis induced by their husbands.
Within 24 h of delivery, mothers were asked to rate the degree of
pain experienced during labor. Women receiving hypnosis reported
significantly less pain than those receiving standard medical care.
However, there was no difference between the groups on childbirth
satisfaction. Because husbands are not professional clinicians, the use
of husbands as hypnotists may underestimate the potential benefits of
hypnosis. Conceivably, even more pain reduction might have been
achieved had professional clinical hypnotists performed hypnosis
during labor.
Finally, Rock, Shipley, and Campbell (1969) evaluated the
effectiveness of hetero-hypnosis for reducing labor and delivery
pain. Forty obstetrical patients at an urban university hospital located
in major U.S. city were randomly assigned to either hypnosis or a
standard medical care control condition. The hypnosis intervention
was delivered by a medical student after the onset of labor and
hospital admission. Hypnosis was induced by focusing on breathing,
relaxation, and eye closure. Suggestions were given for glove
anesthesia, which was transferred to the abdomen. Results showed
that the hypnosis group required significantly smaller amounts of
analgesic medications and rated the labor experience as significantly
less painful than the control group. Also, patients in the hypnosis
group were rated by medical staff as being significantly more
comfortable at various points during the labor and delivery process.
These results indicate that hetero-hypnosis provides more pain relief,
including decreased epidural and analgesic use, during labor than
standard medical care alone.
Together, these studies suggest that hypnotic preparation (Cyna
et al., 2006), self-hypnosis (Jenkins & Pritchard, 1993; VandeVusse
et al., 2007), a combination of self-hypnosis and hetero-hypnosis
delivered by husbands (Guthrie et al., 1984), and hetero-hypnosis
delivered by medical staff (Rock et al., 1969) may be more effective
than routine medical care in reducing pain and analgesic use during
labor and delivery. However, because only one of these studies used
random assignment to condition (Rock et al., 1969), the results should
be considered promising rather than conclusive.
3.2. Hypnosis versus supportive counseling
A small number of studies compared hypnosis with supportive
counseling. Generally, the supportive counseling interventions used
in the reviewed studies afforded expectant mothers with an
opportunity to discuss pregnancy-related concerns and were
intended to control for interpersonal contact and social support.
Letts, Baker, Ruderman, and Kennedy (1993) evaluated whether
the use of self-hypnosis led to the use of fewer obstetric interventions,
more spontaneous deliveries, and greater satisfaction during delivery.
Eighty-seven obstetric patients at a women's hospital located in a
major Canadian city self-selected to receive hypnosis, while the
supportive counseling group was comprised of fifty-six women who
opted not to receive this training. Hypnosis participants attended two
90-minute training sessions at 32 and 34 weeks gestation in which
they were instructed about the childbirth process and experienced
verbal rehearsal of labor and delivery. These individuals were taught
by a hypnotist how to use self-hypnosis to relax themselves and how
to transfer glove anesthesia to the abdomen. The supportive
counseling group was instructed about childbirth. Both groups were
given care under the same physician. The hypnosis group was also
1026
A.S. Landolt, L.S. Milling / Clinical Psychology Review 31 (2011) 1022–1031
compared to a second control group of 352 patients delivered by
another physician at the hospital. This group received only standard
medical care. Compared to the supportive counseling and standard
medical care groups, participants in the self-hypnosis group experienced significantly lower epidural rates. There was no difference
between the self-hypnosis group and the control groups in patient
satisfaction or spontaneous deliveries.
Martin, Schauble, Rai, and Curry (2001) evaluated how hypnotic
preparation incorporating posthypnotic suggestions affected labor
and delivery in pregnant adolescents receiving prenatal care in the
county public health department of a southern U.S city. Forty-two
participants under the age of 18 were randomly assigned to one of
two conditions. The hypnosis group received a four-session training
sequence between 20 and 24 weeks gestation that included posthypnotic suggestions for a normal labor and delivery, feelings of comfort
and confidence, an increased sense of control, and the ability to reenter hypnosis and to experience pleasant hypnotic imagery during a
painful contraction (see Schauble, Werer, Rai, & Martin, 1998).
However, the hypnosis group was not taught self-hypnosis and no
direct intervention was made during labor and delivery. The hypnosis
intervention was provided by a marriage and family therapist. The
control group received supportive counseling, which provided an
opportunity for patients to discuss issues of concern related to
childbirth. Participants assigned to the hypnotic preparation condition had significantly shorter hospital stays, fewer birth complications, and fewer surgical interventions during delivery. However,
there were no statistical differences between the hypnotic preparation and supportive counseling groups in the use of analgesic
medication and admissions to the neonatal intensive care unit.
Finally, Mehl-Madrona (2004) evaluated whether hypnosis could
reduce birth complications and length of labor. Conducted over a tenyear period in three different U.S. states, the study examined 520
pregnant women who were still in either their first or second
trimester. Participants were randomly assigned to hypnotic preparation with the author of the paper (a physician) or supportive
psychotherapy with a female intern. The hypnosis intervention
emphasized suggestions for diminished anxiety and fear, as well as
increased feelings of relaxation, social support, and confidence in the
ability to cope with the pain of labor. Visualization was used to guide
the woman through an imaginary experience of giving birth.
However, it is unclear whether hypnosis participants received formal
posthypnotic suggestions or training in self-hypnosis. Unquestionably, there was no direct intervention during labor and delivery. The
supportive psychotherapy treatment involved discussions of issues
related to pregnancy. A no-treatment control group was matched to
women in the supportive psychotherapy group based on age, parity,
socioeconomic status, race, and birth risk status.
Results showed that women in the hypnotic preparation group
experienced fewer complicated deliveries and cesarean sections than
those in the supportive psychotherapy and no-treatment control
groups. Also, the hypnotic preparation group used oxytocin, epidural
anesthesia, and analgesics less frequently. The lack of differences
between the supportive psychotherapy and the no-treatment groups
suggests that supportive psychotherapy was ineffective.
Studies comparing hypnosis and supportive counseling provide
mixed results. While Letts et al. (1993) and Mehl-Madrona (2004)
reported benefits of hypnosis in reducing analgesic medication use,
Martin et al. (2001) did not. However, the findings of Martin et al.
(2001) do not disqualify hypnosis. Similar to Mehl-Madrona (2004),
Martin et al. (2001) found that hypnotic preparation was associated
with fewer birth complications and surgical interventions. Of note,
confidence in the findings of both Mehl-Madrona (2004) and Martin
et al. (2001) is strengthened by the use of random assignment to
condition. In general, these studies argue that hypnosis may be more
effective than supportive counseling. Because supportive counseling
was used as an attention-control group in these studies, the results
suggest that hypnosis is effective due to factors that go beyond the
attention that patients received from the hypnotists.
3.3. Hypnosis versus Lamaze
Lamaze is a specialized form of preparation that emphasizes
natural childbirth methods as an alternative to the use of medical
intervention. It involves cognitive restructuring of the women's
perceptions of childbirth by focusing on confidence-building and
educating mothers-to-be about anatomy and the process of giving
birth (Lowe & Frey, 1983). Lamaze often involves the use of a coach
and teaches breathing and relaxation exercises.
Venn (1987) assessed whether a combination of Lamaze and
hypnosis reduced pain and enhanced satisfaction more than either
method alone. Participants were 122 patients at a U.S. Naval hospital
who self-selected into one of three conditions: Lamaze-only,
hypnosis-only, or Lamaze-plus-hypnosis. Women in the hypnosis
conditions received hypnotic preparation for childbirth beginning in
the third trimester of pregnancy, which incorporated Erickson's
(1966) interspersal induction of analgesia. They also experienced age
progression through the birth experience, posthypnotic suggestions
to re-enter hypnosis during labor and delivery, and guided imagery to
achieve analgesia by walking into a pool of cold water. Hypnotically
prepared individuals did not receive formal training in self-hypnosis,
nor was there any direct intervention during labor.
Results showed that there was no difference between the three
interventions on patient ratings of pain and satisfaction with the
delivery process, nurse ratings of pain, and analgesic medication use.
To measure hypnotic suggestibility, the Stanford Hypnotic Clinical
Scale for Adults was administered to women in the hypnosis
conditions, but these scores were not significantly correlated with
the outcome measures. Because there was no difference between the
three interventions on any of the outcome measures, and in the
absence of a no-treatment control condition, the findings can best be
described as inconclusive.
3.4. Hypnosis versus childbirth education classes
Childbirth education classes provide women with information
about labor, birth, and coping strategies for emotional distress and
pain (Spiby, Slade, Escott, Henderson, & Fraser, 2003). These classes
often teach breathing and relaxation techniques and discuss various
positions for the expectant mother to assume to increase comfort
during the first stage of labor. Women participating in childbirth
education classes generally experience greater benefits during labor
than women who have not taken these classes (Harmon, Hynan, &
Tyre, 1990). A number of studies compared hypnosis with childbirth
education classes in decreasing the pain experienced by women
during labor and delivery.
Freeman, Macaulay, Eve, and Chamberlain (1986) assessed the
effect of hypnotic preparation on pain, satisfaction and analgesic
requirements for primigravid women. Participants were randomly
assigned to one of two conditions. A hypnotic preparation group of
twenty-nine individuals received hypnotic suggestions for relaxation
and pain relief in weekly individual sessions beginning at 32 weeks
gestation. It is unclear whether these individuals were formally
instructed in self-hypnosis, but they were encouraged to imagine
warmth or anesthesia in one hand and shown how to transfer these
feelings to the abdomen. There was no direct intervention during
labor and delivery. A comparison group of thirty-six participants
attended weekly childbirth education classes.
Results showed there was no difference between women receiving
hypnotic preparation and those attending childbirth education classes
in terms of the proportion given epidural anesthesia or on reports of
pain relief. Women in the hypnotic preparation group who scored in
the high and medium ranges of hypnotic suggestibility based on the
A.S. Landolt, L.S. Milling / Clinical Psychology Review 31 (2011) 1022–1031
Stanford Hypnotic Clinical Scale utilized epidurals less frequently than
those scoring in the low range. However, women in the childbirth
education group were not tested to determine hypnotic suggestibility
and formal moderator analyses were not undertaken. In sum, the
results of this study suggest that hypnotic preparation is no more
effective than traditional childbirth education classes in reducing
labor and delivery pain.
Mairs (1995) measured the differences in experiences of pain and
anxiety during childbirth between 55 primigravid women who either
received self-hypnosis training or attended childbirth education
classes at a city hospital in Northern Ireland. Expectant mothers
who self-selected into the hypnosis group attended four sessions,
beginning between 26 and 37 weeks of gestation. In the first session,
hypnosis was explained and induced using eye closure, and deepened
via progressive relaxation and imagery. In the remaining sessions,
participants practiced transferring numbness and experiencing laborappropriate imagery suggestions. The comparison group attended
routine childbirth education classes. Although there were no
significant differences between the groups in terms of drug usage,
self-hypnosis participants reported significantly less pain and anxiety
during labor.
Davidson (1962) assessed the effects of self-hypnosis on the
duration and need for medication during labor. Participants selfselected into one of three groups: self-hypnosis, physiotherapy (i.e.,
childbirth education classes), and a no-treatment control group.
Although a choice was given, patients who were older, anxious about
giving birth, or had had distressing labors were encouraged to join
the hypnosis group. Each condition consisted of 45 primigravid and
25 parous women.
The self-hypnosis participants attended six sessions at the hospital
in groups of six, beginning early in pregnancy and ending as close to
giving birth as possible. Hypnosis was explained and then induced
through eye-fixation and progressive relaxation. Suggestions were
given for a normal labor experience, decreased awareness of pain, and
decreased need for analgesics. Participants were taught to induce selfhypnosis in the third session. The hypnosis intervention was provided
by an obstetrician. The physiotherapy group received six weekly
classes beginning in the 34th week of gestation. These classes focused
on relaxation, controlled breathing, and pelvic exercises. The control
group received no special childbirth training.
Women in the self-hypnosis condition experienced a significantly
shorter Stage 1 labor and required significantly less analgesic
medication than women in the childbirth education and control
conditions. The author contends that the relaxation and lessening of
fear that occurs as a result of hypnotic training may result in a quicker
and less painful dilation of the cervix, making the overall experience
of labor faster and less painful.
Finally, Harmon et al. (1990) examined the benefits of using selfhypnosis in conjunction with traditional childbirth education classes.
Participants were 60 patients at an obstetrical private practice group
located in a midwestern U.S. state. At the end of the second trimester
of pregnancy, these patients were assessed for hypnotic suggestibility
using the Harvard Group Scale of Hypnotic Susceptibility, Form A.
These women were then randomly assigned to receive either
childbirth education classes or a combination of these classes and
training in self-hypnosis. Each of the two intervention groups was
then subdivided based on high and low suggestibility scores. At the
start of each session participants in the hypnosis condition received a
hypnotic induction and suggestions for relaxation, enjoyment of
childbirth, heaviness of muscles, labor as an enjoyable experience,
numbness in parts of the body, and postpartum wellness delivered by
a psychologist. The childbirth education group practiced muscle
relaxation exercises and techniques for effortless breathing. The
women participated in groups of 15 during six one-hour weekly
sessions at the same hospital. All participants were given an
opportunity to practice the techniques they had learned by using
1027
them to reduce ischemic pain. Furthermore, participants were given
training audio tapes and instructed to practice with the tapes daily.
Results indicated that adding self-hypnosis training to childbirth
education classes produced shorter Stage 1 labor, but did not affect
Stage 2 labor. Self-hypnosis also resulted in the use of less medication
during labor and higher infant Apgar scores. Contrary to expectation,
there was no interaction between treatment condition and suggestibility level. The results suggest that self-hypnosis is a useful addition
to traditional childbirth education classes.
In sum, the findings of these studies point to the effectiveness of
hypnosis as an addition to traditional childbirth education classes.
Although Freeman et al. (1986) failed to show significant benefits for
hypnotic preparation, the use of self-hypnosis was associated with
less pain (Mairs, 1995) and decreased medication use (Davidson,
1962; Harmon et al., 1990) than childbirth education classes. Of note,
Harmon et al., which was distinguished by the use of random
assignment to condition, reported other benefits for self-hypnosis
relative to traditional childbirth education classes, including shorter
Stage 1 labor and higher infant Apgar scores.
4. Methodological considerations
Before forming conclusions about the efficacy of hypnosis as an
intervention for labor and delivery pain, it is necessary to examine the
methodological limitations of this body of research. Table 2 evaluates
the 13 reviewed studies against six key methodological criteria: a)
random assignment; b) specification of sample; c) use of a treatment
manual; d) intervention delivered in hypnotic context; e) active use of
hypnosis during labor and delivery; and f) analysis of hypnotic
suggestibility. Studies that satisfied the criteria listed in Table 2 are
indicated by “Yes”, while those that do not satisfy the criteria are
denoted by “No.” In a few instances, the status of a criterion was not
obvious; these cases are marked as “Unclear.”
4.1. Random assignment
The use of random assignment to condition is critical to sound
treatment outcome research. Without random assignment, there is an
increased risk that observed differences between treatment conditions are due to variables other than the treatments themselves.
Despite this, a major limitation evident in this literature was a failure
to utilize random assignment, with only five of 13 studies employing
it (Freeman et al., 1986; Harmon et al., 1990; Martin et al., 2001;
Mehl-Madrona, 2004; Rock et al., 1969). Because potential confounding variables were not nullified through random assignment in eight
investigations, it is possible that extraneous variables accounted for
reported differences in pain reduction in those studies.
Indeed, in the eight studies that did not use random assignment,
participants self-selected to receive hypnosis. These eight studies
obtained more supportive results than studies in which participants
were randomly assigned to condition. Specifically, in the five studies
using random assignment, two (40%) found no differences in pain
reduction between hypnosis and the comparison conditions (Freeman
et al., 1986; Martin et al., 2001). In contrast, in the eight studies where
participants self-selected into condition, only one (13%) failed to show
a difference in pain reduction between hypnosis and the comparison
condition (Venn, 1987).
A likely reason that participants self-selected to receive hypnosis is
because they had a positive attitude toward it — and those who
refused hypnosis had a negative attitude. Having a positive attitude
toward hypnosis has been shown to be associated with higher
hypnotic suggestibility (Spanos, Brett, Menary, & Cross, 1987) and
better hypnotic treatment outcomes (Schoenberger, Kirsch, Gearan,
Montgomery, & Pastyrnak, 1997). It is therefore possible that studies
which used self-selection into condition overestimated the effectiveness of hypnosis for relieving labor and delivery pain.
1028
A.S. Landolt, L.S. Milling / Clinical Psychology Review 31 (2011) 1022–1031
Table 2
Methodological criteria.
Study
Random
assignment
Specification
of sample
Treatment
manual
Treatment in
hypnotic context
Active use
of hypnosis
Hypnotic suggestibility
as moderator
Cyna et al. (2006)
VandeVusse et al. (2007)
Jenkins and Pritchard (1993)
Guthrie et al. (1984)
Rock et al. (1969)
Letts et al. (1993)
Martin et al. (2001)
Mehl-Madrona (2004)
Venn (1987)
Freeman et al. (1986)
Mairs (1995)
Davidson (1962)
Harmon et al. (1990)
No
No
No
No
Yes
No
Yes
Yes
No
Yes
No
No
Yes
No
Yes
No
No
No
No
No
No
Yes
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Unclear
Yes
Yes
Yes
No
Unclear
Unclear
Unclear
Yes
Unclear
No
No
No
No
Unclear
Unclear
Unclear
No
No
No
No
No
No
No
No
Yes
Yes
No
No
Yes
4.2. Specification of sample
Specifying the age, sex, and racial characteristics of the sample
used in a treatment outcome study is necessary in order to determine
the population to which the findings generalize. Although it is clear
that participants in the reviewed studies consisted of women in their
child-bearing years, only three of the fourteen studies identified the
race of participants (Harmon et al., 1990; VandeVusse et al., 2007;
Venn, 1987). These three studies focused primarily on white females.
Because cultural influences play a role in the perception of pain,
women from other ethnic groups may respond differently to labor and
delivery than white women (Leeman et al., 2003; Woodrow,
Friedman, Siegelaub, & Collen, 1972). As such, the samples used in
these three studies are not representative of the population of all
child-bearing women. Moreover, the lack of specification of race in the
other 10 studies makes it is impossible to determine how well the
results of those investigations generalize to the population of all childbearing females.
4.3. Treatment manual
A valuable practice in psychotherapy outcome research involves
using a treatment manual. A manual operationalizes the treatments and
promotes consistency when different experimenters deliver the interventions within a single study. A manual also allows the study to be
accurately replicated by other research teams. Without a treatment
manual, it is difficult to replicate a study and verify its results. Hypnosis is
a complicated procedure and can be used in a variety of ways for
managing pain, including suggestions for analgesia, time distortion,
amnesia, dissociation, pain displacement and transformation, reinterpretation of the experience, and distraction to pleasant imagery, to name
just a few (see Patterson & Jensen, 2003). Thus, the label “hypnosis” is a
generic term that encompasses many different suggestions and
techniques. Unfortunately, none of the 13 reviewed studies specified
the nature of the interventions by using a treatment manual.
4.4. Hypnotic context
Hypnosis scholars generally agree that the social context in which a
hypnotic suggestion is delivered has at least some impact on the
resulting response (Kirsch & Lynn, 1995). For example, relabeling a
cognitive-behavioral intervention as hypnosis can significantly enhance
its effectiveness (see Kirsch, Montgomery, & Sapirstein, 1995). In 11 of
the 13 reviewed studies, it seemed clear to us that participants knew
that they were receiving hypnosis. However, in two studies it was not
obvious that participants understood they were being hypnotized
(Freeman et al., 1986; Rock et al., 1969). This may have reduced the
effectiveness of hypnosis in those two investigations. Indeed, Freeman
et al. reported that hypnosis was no more effective than childbirth
preparation classes in reducing labor and delivery pain. Until empirical
research shows that establishing a hypnotic context has no impact on
the effectiveness of hypnosis for reducing labor and delivery pain,
researchers should strive to clearly communicate to participants that the
hypnosis intervention actually involves “hypnosis”.
4.5. Active use of hypnosis
Of the 13 reviewed studies, in only one was it obvious to us that
the hypnosis intervention was used during labor and delivery. Rock
et al. (1969) reported that hetero-hypnosis resulted in less pain and
analgesic medication use than standard medical care.
In seven of the reviewed studies, it was unclear to us whether the
hypnosis intervention was used during labor. These studies involved
either explicit training for mothers-to-be in self-hypnosis (Davidson,
1962; Harmon et al., 1990; Jenkins & Pritchard, 1993; Letts et al.,
1993; Mairs, 1995; VandeVusse et al., 2007) or a combination of selfhypnosis training and hetero-hypnosis (Guthrie et al., 1984). All seven
of these studies reported a positive effect for hypnosis on some
indicator of pain.
Finally, in five of the reviewed studies, it seemed likely that
hypnosis was not actively used during labor and delivery. In three of
the five studies, expectant mothers underwent hypnotic experiences
during training sessions (i.e., hypnotic preparation), but apparently
were not explicitly shown how to use self-hypnosis during labor and
delivery (Cyna et al., 2006; Freeman et al., 1986; Mehl-Madrona,
2004). Two studies paired hypnotic preparation with posthypnotic
suggestions for pain relief (Martin et al., 2001; Venn, 1987).
Of the five studies using some form of hypnotic preparation, only
two reported a positive effect for hypnosis on pain. Cyna et al. (2006)
found that hypnotically prepared women used epidurals less often
than those receiving standard medical care. Mehl-Madrona (2004)
observed that hypnotic preparation was more effective than supportive counseling or standard medical care in reducing the use of
analgesic medications and epidurals. Of note, including posthypnotic
suggestions in the hypnotic preparation did not help to make it a
significantly more effective intervention than supportive counseling
(Martin et al., 2001) or Lamaze (Venn, 1987).
Some research has shown that when a hypnotic suggestion for
pain reduction is delivered continuously throughout a pain stimulus,
it produces more relief than when the suggestion is given once at the
outset of the pain (Price & Barber, 1987). Similarly, the findings of the
reviewed studies suggest that when hypnosis could be experienced
throughout labor in the form of either hetero-hypnosis or selfhypnosis, it consistently had a beneficial effect on pain. However,
when hypnosis was administered only in advance of the labor process,
as is characteristic of hypnotic preparation, the benefits were far less
consistent.
A.S. Landolt, L.S. Milling / Clinical Psychology Review 31 (2011) 1022–1031
4.6. Hypnotic suggestibility
Hypnotic suggestibility is a trait-like individual difference variable
reflecting the general tendency to respond to hypnosis and hypnotic
suggestions (Gur, 1978/1979). Suggestibility can be measured with
standardized scales consisting of a hypnotic induction and a series of test
suggestions. Lynn and Shindler (2002) recommend assessing hypnotic
suggestibility whenever hypnosis is used as a treatment. A metaanalysis on the effectiveness of hypnotic analgesia by Montgomery,
DuHamel, and Redd (2000) suggests the value of doing so. This metaanalysis found that the average person treated with hypnosis
experienced more pain relief than 75% of individuals in no-treatment
and standard care control conditions. However, the analgesic effect of
hypnosis varied dramatically according to suggestibility level. The
average effect size was D = 1.16 for participants in the high range of
suggestibility, D = 0.64 for those in the medium range, and only D =
−0.01 for those in the low range. That is, hypnosis had virtually no
analgesic effect for individuals of low suggestibility.
Of the 13 studies reviewed herein, only three assessed hypnotic
suggestibility with a standardized scale. Of these three studies, only
one examined the statistical association between suggestibility and
treatment condition. Somewhat surprisingly, Harmon et al. (1990) did
not find a significant interaction between hypnotic suggestibility and
treatment condition. However, women scoring in the high range of
suggestibility reduced pain more than those falling in the low range.
More research is needed on the relationship between hypnotic
suggestibility and the effectiveness of hypnosis for reducing labor
pain. We would like to echo the recommendation of Lynn and
Shindler (2002). Future studies of the effectiveness of hypnosis for
managing labor pain should measure hypnotic suggestibility using a
standardized scale and perform appropriate moderator analyses (see
Baron & Kenny, 1986). Of course, this will only be meaningful if
researchers also randomly assign participants to treatment condition.
If participants are allowed to self-select into treatment condition,
those scoring in the high range of suggestibility may be overrepresented in hypnosis condition and those scoring in the low range
overrepresented in the comparison conditions.
4.7. Other methodological considerations
A word is in order regarding the nature of the dependent measures
of pain used in this literature. Self-report measures provide an index
of a patient's pain perception. A visual analog scale in which the patient
rates pain intensity along a 0–10 scale is an example. Observational
measures provide an index of a patient's pain behavior (e.g., moaning,
crying). The use of analgesic medication and epidural anesthesia
provides a biological indicator of pain. Self-report, observational and
biological indicators offer complimentary information. However, only
one of the 13 reviewed studies tapped all three channels of
measurement (Venn, 1987).
By far, utilization of analgesic medication and epidural anesthesia
was the most commonly employed measure of pain; only one study
failed to tap the biological channel of measurement (Guthrie et al.,
1984). Five studies used a self-report pain measure (Freeman et al.,
1986; Guthrie et al., 1984; Harmon et al., 1990; Mairs, 1995; Venn,
1987) and two studies used an observational measure (Rock et al.,
1969; Venn, 1987). However, of these investigations, only one study
employed a well-established self-report or observational measure of
pain. Specifically, Harmon et al. used the McGill Pain Questionnaire
(Melzack, 1975), a reliable and valid self-report measure of pain
perception.
In contrast, studies in which patients or observers (e.g., nurses,
attending physicians) made a single global rating of pain are likely to
have produced results that are unreliable. Similarly, if a long period of
time passed since the end of delivery, self-report measures may have
provided a distorted indicator of the effects of treatment. Research has
1029
shown that people have difficulty remembering the intensity of a pain
stimulus and that self-reports of the analgesic effects of treatment
tend to increase with the passage of time (Price et al., 1999). In the
future, researchers are encouraged to utilize reliable and valid
measures of pain that tap all three channels of measurement.
5. Discussion
Our comprehensive review of 13 controlled studies suggests that
hypnosis holds promise as an intervention for managing labor and
delivery pain. Hypnosis was shown to be more effective than standard
medical care (Cyna et al., 2006; Guthrie et al., 1984; Jenkins &
Pritchard, 1993; Rock et al., 1969; VandeVusse et al., 2007),
supportive counseling (Letts et al., 1993; Mehl-Madrona, 2004), and
traditional childbirth education classes (Davidson, 1962; Harmon
et al., 1990; Mairs, 1995). Just two studies comparing hypnosis with
supportive counseling (Martin et al., 2001) and childbirth education
classes (Freeman et al., 1986) failed to show a positive effect for
hypnosis on at least one indicator of pain. Our conclusions are
consistent with those of a recent general review of hypnotic analgesia
by Stoelb, Molton, Jensen, and Patterson (2009), who observed that
hypnosis tends to outperform standard medical care and interventions that are non-hypnotic in nature in relieving pain.
In addition to reducing reports of pain, as well as the use of
analgesic medications and epidural anesthesia, hypnosis was found to
have other benefits for expectant mothers and their infants. The
administration of hypnosis was associated with better infant Apgar
scores (Harmon et al., 1990; VandeVusse et al., 2007), as well as
shorter Stage 1 labor (Davidson, 1962; Harmon et al., 1990; Jenkins &
Pritchard, 1993). This latter finding is noteworthy because it is during
Stage 1 labor that women experience very painful uterine contractions and often request pain medication (Harms, 2004).
A clear pattern emerged when considering the nature of the
hypnotic interventions used in these studies. Hetero-hypnosis (Rock
et al., 1969), self-hypnosis (Davidson, 1962; Harmon et al., 1990;
Jenkins & Pritchard, 1993; Letts et al., 1993; Mairs, 1995; VandeVusse
et al., 2007), and a combination of hetero-hypnosis with self-hypnosis
(Guthrie et al., 1984) were consistently found to be more effective
than comparison conditions in alleviating pain. There were no studies
contradicting this pattern. However, only 2 of the 5 studies evaluating
hypnotic preparation were able to show that it was significantly more
effective than a comparison condition in reducing some indicator of
pain (Cyna et al., 2006; Mehl-Madrona, 2004). This pattern suggests
that hypnosis may be more effective if it is experienced during the
actual labor process, either in the form of self-hypnosis or heterohypnosis.
Although we contend that hypnosis holds promise as an
intervention for labor pain, it is not possible for us to reach a more
definitive conclusion regarding its efficacy. This is because only five of
the 13 reviewed studies utilized random assignment to condition. In
the other 8 studies, participants were allowed to self-select into
treatment condition, which likely produced findings overestimating
the effectiveness of hypnosis.
Considering only the five studies that used random assignment,
three yielded a positive effect for hypnosis on pain. Rock et al. (1969)
showed that hetero-hypnosis was more effective than standard
medical care in reducing pain and use of analgesic medication.
Harmon et al. (1990) found that self-hypnosis was more effective than
childbirth education classes in reducing analgesic medication use.
Mehl-Madrona (2004) reported that hypnotic preparation was more
effective than supportive counseling and standard medical care in
reducing the use of analgesic medication and epidurals. The two
studies using random assignment that failed to show a positive effect
for hypnosis on some indicator of pain both used hypnotic
preparation as the intervention (Freeman et al., 1986; Martin et al.,
2001).
1030
A.S. Landolt, L.S. Milling / Clinical Psychology Review 31 (2011) 1022–1031
Consequently, based primarily on the studies employing random
assignment, and using the other studies only as supportive evidence,
it seems reasonable to conclude that both hetero-hypnosis and selfhypnosis show considerable promise as interventions for managing
labor and delivery pain. The evidence regarding hypnotic preparation
was less encouraging. These observations may have important clinical
implications. Clinicians who provide hypnosis to expectant mothers
may wish to consider the benefits of designing their interventions in a
way which maximizes the likelihood that hypnosis will be used
during the actual labor and delivery process. This can be accomplished
by having the clinician administer hypnosis to expectant mothers
during labor or by explicitly teaching women how to do self-hypnosis
so that they can administer hypnosis to themselves during labor.
However, simply providing expectant mothers with hypnotic experiences during training sessions appears to be of limited value. Also, it
is unclear that adding posthypnotic suggestions to these training
experiences is likely to make hypnotic preparation effective.
The failure to use random assign to condition was a widespread
methodological limitation in this body of research. Other common
limitations included a failure to use a treatment manual and to specify
the demographic characteristics of samples. Future studies of the
efficacy of hypnosis for managing labor pain should strive to randomly
assign participants to condition, describe the age and race characteristics of samples, as well as clearly operationalize the hypnosis and
comparison interventions by incorporating them in a manual. A
growing emphasis on evidence-based practice (American Psychological
Association Presidential Task Force on Evidence-Based Practice, 2006)
and continuing interest in empirically supported therapies (Chambless
& Hollon, 1998; Task Force on Promotion and Dissemination of
Psychological Procedures, 1995) suggest the importance of doing so.
Random assignment, sample specification, and use of a treatment
manual are explicit criteria for evaluating studies with the goal of
identifying a psychological therapy as empirically supported for a
particular problem and population (Chambless & Hollon, 1998). In
turn, identifying an intervention as an empirically supported therapy
is one way of establishing evidence-based practice.
A previous review identified a failure to blind participants to
treatment condition as a limitation of this literature (see Cyna et al.,
2004). Blinding participants would be important in a drug study
where the researcher is interested in separating the chemical effects
of a medication from the effects of what participants think about the
drug. Accordingly, blinding participants is a key component of a
placebo-controlled drug study. However, blinding participants is
counterproductive in the study of a psychological therapy like
hypnosis, where a person's thoughts about the nature of the therapy
are integral to its psychological mechanism of action.
Along these lines, prominent social psychological theories of
hypnotic responding such as role theory (Sarbin, 1950), compliance
with demand characteristics (Wagstaff, 1991), and response expectancies (Kirsch, 1990) all share the premise that believing one is being
hypnotized is what leads to profound alterations in behavior. Indeed,
in a meta-analysis of 18 studies, Kirsch et al. (1995) showed that
cognitive-behavioral therapies for a variety of symptoms and
problems could be enhanced simply by relabeling and reframing
them as “hypnosis.” Thus, communicating to participants that they are
receiving hypnosis is a desirable feature in studies of the efficacy of
hypnosis for managing labor pain — not a limitation. Fortunately, 11 of
the 13 studies included in our review clearly established a hypnotic
context for participants and researchers are encouraged to continue
this practice.
6. Conclusions
Childbirth ranks among the most universal of human experiences.
However, the pain associated with labor and delivery can be very
distressing and many women describe it as severe or extremely
severe (Melzack, 1993). Although pharmacologic methods such as
analgesic medications and epidurals have proven to be effective for
reducing the discomfort of labor and delivery, there are risks
associated with their use (Anim-Somuah et al., 2005; Simpson &
Creehan, 2008; Thorp & Breedlove, 1996). Fearing these side effects,
many expectant mothers voice reservations about pharmacologic
analgesia (Van den Bussche, Crombez, Eccleston, & Sullivan, 2007).
Our review suggests that hypnosis shows considerable promise as
an adjunct to pharmacologic methods of managing labor pain. Heterohypnosis and self-hypnosis were consistently shown to be more
effective than standard medical care, supportive counseling, and
childbirth education classes. However, additional controlled trials,
emphasizing random assignment to condition, specification of study
samples, and the use of treatment manuals, are needed to establish
hetero-hypnosis and self-hypnosis as empirically supported therapies
for managing labor pain.
There is a substantial amount of scientifically sound research on the
effectiveness of hypnosis for treating a range of clinical pain problems,
such as burn pain and cancer-related pain (see Montgomery et al.,
2000; Patterson & Jensen, 2003; Stoelb et al., 2009). Unfortunately,
studies of the use of hypnosis for reducing labor and delivery pain have
lagged behind these other areas in terms of quality. There is no reason
for this to be so. In some ways, research on the effectiveness of
hypnosis for managing labor and delivery pain represents an underexplored area of inquiry. Consequently, we look forward to the
proliferation of methodologically sound research evaluating this
promising, but unproven intervention for labor and delivery pain.
References⁎
American Psychological Association Presidential Task Force on Evidence-Based Practice
(2006). Evidence-based practice in psychology. American Psychologist, 61, 271–285.
Anim-Somuah, M., Smyth, R. M. D., & Howell, C. J. (2005). Epidural versus non-epidural
or no analgesia in labour. Cochrane Database of Systematic Reviews, 4, 1–81.
Baron, R. M., & Kenny, D. A. (1986). The moderator–mediator variable distinction in
social psychological research: Conceptual, strategic, and statistical considerations.
Journal of Personality and Social Psychology, 51, 1173–1182.
Brann, L. R., & Guzvica, S. R. (1987). Comparison of hypnosis with conventional
relaxation for antenatal and intrapartum use: A feasibility study in general practice.
The Journal of the Royal College of General Practitioners, 37, 437–440.
Brown, D., & Hammond, D. (2007). Evidence-based clinical hypnosis for obstetrics,
labor and delivery, and preterm labor. International Journal of Clinical and
Experimental Hypnosis, 55, 355–371.
Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies.
Journal of Consulting and Clinical Psychology, 66, 7–18.
Creasy, R. K., Resnik, R., & Iams, J. D. (2004). Maternal–fetal medicine: Principles and
practice (5th edition). Philadelphia, PA: W.B. Saunders Co.
*Cyna, A. M., Andrew, M. I., & McAuliffe, G. L. (2006). Antenatal self-hypnosis for labor
and childbirth: A pilot study. Anesthesia Intensive Care, 34, 464–469.
Cyna, A. M., McAuliffe, G. L., & Andrew, M. I. (2004). Hypnosis for pain relief in labour
and childbirth: A systematic review. British Journal of Anaesthesia, 93, 505–511.
*Davidson, J. A. (1962). An assessment of the value of hypnosis in pregnancy and labour.
British Medical Journal, 2, 951–953.
Erickson, M. H. (1966). The interspersal hypnotic technique for symptom correction
and pain control. American Journal of Clinical Hypnosis, 8, 198–209.
*Freeman, R. M., Macaulay, A. J., Eve, L., & Chamberlain, G. V. P. (1986). Randomised trial
of self hypnosis for analgesia in labour. British Medical Journal, 292, 657–658.
Gur, R. C. (1978–1979). Measuring hypnotic susceptibility: A guest editorial. American
Journal of Clinical Hypnosis, 21, 64–66.
*Guthrie, K., Taylor, D. J., & Defriend, D. (1984). Maternal hypnosis induced by
husbands. Journal of Obststrics and Gynaecology, 5, 93–96.
*Harmon, T., Hynan, M., & Tyre, T. (1990). Improved obstetric outcomes using hypnotic
analgesia and skill mastery combined with childbirth education. Journal of
Consulting and Clinical Psychology, 58, 525–530.
Harms, R. W. (2004). Mayo clinic guide to a healthy pregnancy. New York, NY: Harper
Resource.
Hilgard, E. R. (1965). Hypnotic susceptibility. New York, NY: Harcourt, Brace & World.
*Jenkins, M. W., & Pritchard, M. H. (1993). Hypnosis: Practical applications and
theoretical considerations in normal labour. British Journal of Obstetrics and
Gynaecology, 100, 221–226.
Kirsch, I. (1990). Changing expectations: A key to effective psychotherapy. Belmont, CA:
Brooks/Cole.
Kirsch, I. (1994). Defining hypnosis for the public. Contemporary Hypnosis, 11, 142–143.
⁎
(References marked with an asterisk indicate studies included in review.).
A.S. Landolt, L.S. Milling / Clinical Psychology Review 31 (2011) 1022–1031
Kirsch, I., & Lynn, S. J. (1995). The altered state of hypnosis: Changes in the theoretical
landscape. American Psychologist, 50, 846–858.
Kirsch, I., Montgomery, G., & Sapirstein, G. (1995). Hypnosis as an adjunct to cognitivebehavioral psychotherapy: A meta-analysis. Journal of Consulting and Clinical
Psychology, 63, 214–220.
Leeman, L., Fontaine, P., King, V., Klein, M. C., & Ratcliffe, S. (2003). The nature and
management of labor pain: Part I. Nonpharmacologic pain relief. American Academy
of Family Physicians, 68, 1109–1112.
*Letts, P. J., Baker, P. R. A., Ruderman, J., & Kennedy, K. (1993). The use of hypnosis in
labor and delivery: A preliminary study. Journal of Women's Health, 2, 335–341.
Littleton, L. Y., & Engebretson, J. (2004). Maternity nursing care (1st ed.). Albany, NY: Delmar.
Lowe, R., & Frey, J. (1983). Predicting Lamaze childbirth intentions and outcomes: An
extension of the theory of reasoned action to a joint outcome. Basic and Applied
Social Psychology, 4, 353–372.
Lynn, S. J., & Shindler, K. (2002). The role of hypnotizability assessment in treatment.
American Journal of Clinical Hypnosis, 44, 185–197.
*Mairs, D. (1995). Hypnosis and pain in childbirth. Contemporary Hypnosis, 12, 111–118.
*Martin, A., Schauble, P., Rai, S., & Curry, R. (2001). The effects of hypnosis on the labor
processes and birth outcomes of pregnant adolescents. Journal of Family Practice,
50, 441–443.
*Mehl-Madrona, L. (2004). Hypnosis to facilitate uncomplicated birth. American Journal
of Clinical Hypnosis, 46, 299–312.
Melzack, R. (1975). The McGill Pain Questionnaire: Major properties and scoring
methods. Pain, 1, 277–299.
Melzack, R. (1993). Labour pain as a model of acute pain. Pain, 53, 117–120.
Montgomery, G. H., DuHamel, K. N., & Redd, W. H. (2000). A meta-analysis of
hypnotically induced analgesia: How effective is hypnosis? International Journal of
Clinical and Experimental Hypnosis, 48, 138–153.
Niven, C., & Murphy-Black, T. (2000). Memory for labor pain: A review of the literature.
Birth: Issues in Perinatal Care, 27, 244–253.
Oster, M. I., & Sauer, C. P. (2000). Hypnotic methods for preparing for childbirth. In L. M.
Hornyak & J. P. Green (Eds.), Healing from within: The use of hypnosis in women's
health care (pp. 161–190). Washington, DC: American Psychological Association.
Patterson, D., & Jensen, M. (2003). Hypnosis and clinical pain. Psychological Bulletin, 129,
495–521.
Pillitteri, A. (2009). Maternal and child health nursing: Care of the childbearing and
childrearing family (6th ed.). Baltimore, MD: Lippincott William & Wilkins.
Price, D. D., & Barber, J. (1987). An analysis of factors that contribute to the efficacy of
hypnotic analgesia. Journal of Abnormal Psychology, 96, 46–51.
Price, D. D., Milling, L. S., Kirsch, I., Duff, A., Montgomery, G. H., & Nicholls, S. S. (1999).
An analysis of factors that contribute to the magnitude of placebo analgesia in an
experimental paradigm. Pain, 83, 147–156.
1031
*Rock, N., Shipley, T., & Campbell, C. (1969). Hypnosis with untrained, nonvolunteer
patients in labor. International Journal of Clinical and Experimental Hypnosis, 17,
25–36.
Sarbin, T. R. (1950). Contributions to role taking theory: 1. Hypnotic behavior. Psychological
Review, 57, 225–270.
Schauble, P. G., Werer, W. E. F., Rai, S. H., & Martin, A. (1998). Childbirth preparation
through hypnosis: The hypnoreflexogenous reflex. American Journal of Clinical
Hypnosis, 40, 273–283.
Schoenberger, N. E., Kirsch, I., Gearan, P., Montgomery, G., & Pastyrnak, S. L. (1997).
Hypnotic enhancement of a cognitive behavioral treatment for public speaking
anxiety. Behavior Therapy, 28, 127–140.
Simkin, P. (2000). Commentary: The meaning of labor pain. Birth: Issues in Perinatal
Care, 27, 254–255.
Simpson, K. R., & Creehan, P. A. (2008). AWHONN's perinatal nursing (3rd ed.). Philadelphia,
PA: Lippincott Williams & Wilkins.
Spanos, N. P., Brett, P. J., Menary, E. P., & Cross, W. P. (1987). A measure of attitudes
toward hypnosis: Relationships with absorption and hypnotic susceptibility.
American Journal of Clinical Hypnosis, 30, 139–150.
Spiby, H., Slade, P., Escott, D., Henderson, B., & Fraser, R. (2003). Selected coping strategies
in labor: An investigation of women's experiences. Birth: Issues in Perinatal Care, 30,
189–194.
Stoelb, B., Molton, I., Jensen, M., & Patterson, D. (2009). The efficacy of hypnotic
analgesia in adults: A review of the literature. Contemporary Hypnosis, 26, 24–39.
Task Force on Promotion and Dissemination of Psychological Procedures (1995).
Training in and dissemination of empirically validated psychological treatments:
Reports and recommendations. Clinical Psychologist, 48, 3–23.
Thorp, J. A., & Breedlove, G. (1996). Epidural analgesia in labour: An evaluation of risks
and benefits. Birth, 23, 63–83.
Van den Bussche, E., Crombez, G., Eccleston, C., & Sullivan, M. J. L. (2007). Why women
prefer epidural analgesia during childbirth: The role of beliefs about epidural
analgesia and pain catastrophizing. European Journal of Pain, 11, 275–282.
*VandeVusse, L., Irland, J., Berner, M., Fuller, S., & Adams, D. (2007). Hypnosis for
childbirth: A retrospective comparative analysis of outcomes in one obstetrician's
practice. American Journal of Clinical Hypnosis, 50, 109–119.
*Venn, J. (1987). Hypnosis and Lamaze method — An exploratory study: A brief
communication. International Journal of Clinical and Experimental Hypnosis, 35,
79–82.
Wagstaff, G. F. (1991). Hypnosis, compliance, and belief. New York, NY: St. Martin's Press.
Waldenström, U., Bergman, V., & Vasell, G. (1996). The complexity of labor pain: Experiences
of 278 women. Journal of Psychosomatic Obstetrics and Gynecology, 17, 215–228.
Woodrow, K. M., Friedman, G. D., Siegelaub, A. B., & Collen, M. F. (1972). Pain tolerance:
Differences according to age, sex, and race. Psychosomatic Medicine, 34, 548–556.