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Medical and Non-Medical Programs for Birth - A Feminist Perspective by Liana Voia

Posted Feb 19 2012 1:19pm
 1. IntroductionHypnosis is an ancient therapeutic modality that has been used under various forms and known under different names in many cultures for thousands of years. Hypnotic or trance-like techniques/rituals had been used in the past by the village midwives, shamans, healers, spiritual figures. Today, it is mainly practised by certified/lay hypnotists and licensed hypnotherapists. Therapeutic hypnosis consists of a series of cognitive sequences based on carefully chosen words and word order, phrases, verbal/sensorial cues, rhythm, voice inflection,   sensorial stimulants (i.e., a spiral, an image, music, etc.) that aim to facilitate particular body, emotional and mental states and hypnotic phenomena such as   progressive muscle relaxation, numbness, amnesia, anesthesia, dissociation, dream inducement, hallucination, higher consciousness, intense focusing, alertness, gradual desensitization, etc..Before the medical models of childbirth were established, women used herbs and hypnotic-like techniques as natural anesthetics for childbirth administered by a village midwife/”night woman”, shaman, healer, or sorceress ( Storl, 2003:65) . Storl describes how the village midwife (or the “old woman”, or the “wise woman”) “gave the birthing advice with comforting words, and she also knew magical words used to call the disir, Frau Holle, or the Salige Frau for assistance” (Storl, 2003:66). During the birth, the midwife was in an “ecstatic state”, acting as “a soul-guide to the baby, which found itself on the threshold of the earthly world” (Storl, 2003:66). Storl believes that birth has become a potentially traumatic experience as “a manipulation by an elaborate medical apparatus” that “causes stress and fear” (Storl, 2003:66). In the ‘primitive’ societies, birth was “an experience of the greatest ecstasy”, in which the labouring woman “does not fight against pain but rather – under the guidance of a wise woman – gives in to labor and transcends her mortal ego” (Storl, 2006:66).As allopathic medicine became the norm, more women chose (or were offered) drugs to alleviate/eliminate labour pains, marginalizing the potent effect of hypnosis as a natural anesthetic. In the 1960s, some hospitals re-introduced hypnosis in obstetrics and Dr. William Kroger even filmed a natural birth using hypnosis, becoming the first obstetrician in North America to have captured on film a natural childbirth using hypnosis.The susceptibility to hypnosis varies from person to person. Chiasson (1990) states that natural childbirth with hypnosis is possible in 25-30% of the pregnant women, while Kroger (2008) contends that only 20% of the “selected patients” used hypnoanesthesia successfully. According to Kroger, approximately 50% of the women are able to give birth with hypnosis and drugs (in lower dosages) (Kroger, 2008). Both Kroger and Chiasson indicate that hypnosis proved successful in performing surgical interventions such as episiotomy, forceps delivery, and repair (Chiasson, 1998; Kroger, 2008).

During pregnancy, the susceptibility to hypnosis increases (mostly, in primiparas), sometimes reaching the highest level as the woman gets closer to birth (Alexander, Turnbull & Cyna, 2009). Brann and Guzvica (1987) used the eyeroll score as a guide of hypnotizability. In their study, the self-selected group of hypnosis had a mean score of 2.6 compared with 2.1 for the psychoprophylaxis group. Based on their reviews, Cyna, Andrew, Robinson, Crowther, Baghurst, Turnbull, Wicks & Whittle (2006) state that “in the laboratory, 14% of people are refractory or uncooperative towards hypnosis, about 36% enter a light hypnotic state, over 25% perform in the moderate range and just under 25% score as highly responsive” (Cyna et al, 2006:10). They also indicate that the level of hypnotizability is predictive of analgesia requirements during labor and birth (Cyna et al, 2006). While some researchers use standardized scales (Brann & Guzvica, 1986; Barabasz & Watkins, 2005; Alexander et al., 2009) to assess hypnotizability, other researchers do not use any scales (Letts & al., 1993).

A study dedicated to the effect of pregnancy on hypnotizability found that the pregnant women were more hypnotizable than the non-pregnant ones; primigravidas were more hypnotizable than parous women (Alexander et al., 2009). They indicated that the hypnotizability increased from the second trimester to the third trimester (Alexander et al., 2009). The authors attributed the increased hypnotizability in women to hormonal shifts in pregnancy and childbirth, which may be related to changes that occur in the central nervous system (Alexander et al., 2009). Also, it could be explained by the fact that physiological changes in the brain occur in late pregnancy and for up to three days after childbirth (Alexander et al., 2009).

Some of the advantages of using hypnosis during the pregnancy and in childbirth are well documented (Brown & Hammond, 2007; Kroger, 2008; Hilgard and Hilgard, 1994; Mehl-Madrona, 2004; Smith, 1985): prevention of miscarriage; reduction or elimination of nausea and vomiting in early and mid- pregnancy; reduction or elimination of fear, pain and anxiety; reduction or elimination of chemoanalgesia and anesthesia; increased control of uterine contractions; reduced incidence of intervention (cesarean, forceps, episiotomy) (Smith, 1985); reduction/lack of post-birth side effect (nausea, vomiting) (Simon & Schwartz, 1999); speedier recovery and better bodily functions (eating, digesting, emptying bladder and bowels); shorter labor; increased mental alertness during the labor and birth;to cope with more difficult, but rare, situations (i.e., turning the baby; resuming a stalled labour; coping with unforeseen surgical procedures) (Sauer, 2000); to prevent post-partum depression;higher Apgar score (Harmon, Hynan & Tyre, 1990) ; better lactation (LeCron & Cheek, 1968). Importantly, hypnosis can be induced and maintained with minimal cues from partner (Guthrie, Taylor & Defriend, 1984) or hospital staff.2. Feminist perspectives of pregnancy, labour and birth

2.1. Pregnancy. Feminists such as Oakley (1984, 1993), Rabuzzi (1988) and Raphael-Leff (1991, 1993) present pregnancy as a state in which the woman loses her identity. She is depersonalized by her pregnancy, and the fetus/baby is "a thing" moving inside her making her body feel "alien". The woman becomes separated from herself as she grows bigger and heavier, and pregnancy feels unnatural. The baby is perceived as an intruder, who invades her body, takes it for granted, and dwells in it for nine months. The woman often feels "threatened" by the fetus in that s/he will keep her captive for nine months, taking her life away, leaving her no control over her existence.

In their work, Oakley (1984, 1993), Rabuzzi (1988) and Raphael-Leff (1991, 1993) acknowledge the infantilization of pregnant women, the pathologization of pregnancy, and the depersonalizing effect of standard medical examination. The dependence on technology and chemicals (IVF, ultrasounds, dopplers, anesthetics, etc.) turned natural human processes (pregnancy, labour and birth) into some of the most complex   and sophisticated medical interventions in the human history that require highly advanced science, a hierarchized establishment and close supervision of experts. Man-made machines/instruments are in charge with the uterine contractions, labour inducement/termination, administration and supervision of anesthesia, etc., while women are “passive objects of clinical attention” (Oakley, 1993: 20) and the baby is an obstetrical product. As Oakley (1984) put it: “Obstetricians must deliver to paediatricians good quality obstetrical products” (p. 234). In a society where pregnancy and childbirth continue to be presented and treated as a "medical events” (Oakley, 1993:22), the women’s need to regain control over their bodies is at the forefront.

2.2. Birth. As they get closer to birth, fears intensify in most pregnant women. Many of them have recurrent images/dreams of deformed or dead babies or monstrous births that might be interpreted as signs of depravity or sins or deep-seated fears/trauma (Rabuzzi, 1988; Raphael-Leff, 1991, 1993). In the medical setting, the mystery of birth was "known" only to men in the past; women learned about their bodies from men, which fueled and perpetuated women’s fears and perceptions of pain (Rabuzzi, 1988; Raphael-Leff, 1991, 1993).

3. Feminine perspectives of pregnancy, labour and birth

3.1. Pregnancy. Historically, women have been taught that pregnancy is a joyful experience filled with anticipation. The woman is the "lucky one" to carry life in her. Pregnancy occurs in those women who are happy in their relationship and pleased with their sexuality; it is a sign of the husband’s love and evidence of healthy sexual relationship. Pregnancy is a rite of passage from girlhood to motherhood, reflecting fertility and “the primary purpose of sexuality" (Rabuzzi, 1988: 110). In some cultures, the pregnant woman is the image of Mother-Goddess that protects the earth, soil, agriculture.

Labour pains are part of the labour of love, and inherent to bringing new life into this world. A woman who has experienced labour pains is a woman who reached a climactic point of her womanhood, and her pains have sometimes orgasmic connotations.

3.2. Birth. Birth brings joy and renewal. It is "sacred mystery" (Rabuzzi, 1988:200), and in those cultures that value reincarnation, birth is the beginning of a new cycle of an old entity. Metaphorically, birth is perceived as spiralling through a tunnel (birth canal) into this world, similar to death (where a tunnel takes us to the other side). Through the body's movement of outward expansion and inward contraction, the birth touches two infinites: the infinitely large and the infinitely small (Rabuzzi, 1988: 208).

4. Fears and childbirth in the context of the medical setting

Fear is a central primary emotion during labour and birth in most women. Some of the identified "fears" in pregnant women (Smith, 1985) are: dying at childbirth; giving birth to a stillborn or the baby suffers asphyxia at birth (or gets strangled with the umbilical cord); giving birth prematurely; hemorrhaging; dropping her baby; unforeseen surgical procedures; long labor; being unable to void after birth; having to be catheterized, and others.

Women's anxieties/fears of birth contribute to the increasing number of cesareans in North America and other developed countries. In the USA, women who had a cesarean with her first child would be recommended the same procedure for future pregnancies. Vaginal Birth after Cesarean is now considered a (high) risk (Medscape, Dr. P.K. Spry, Lamaze International). The women who choose/are recommended cesarean early in the pregnancy have fewer incentives to enroll in childbirth programs (i.e., Lamaze, yoga for pregnancy and birth, hypnosis for birth, etc.). Highly educated women are more likely to opt for a cesarean intervention mostly because it is perceived as safer (yet, more expensive), shorter in labour (or no labour), and less painful. Overweight women are also more likely to give birth by cesarean.

The epidemic of cesarean births distorted the purpose and the meaning of the labour and birth stages as the vagina is reduced to being merely an entrance for the sperm, and no longer an exit for the baby. The uterus also loses its function of a muscular chamber that opens when the child is ready to be born. The body no longer decides when to give birth; the analytical/critical brain does (this author recently talked to a woman who disclosed that her having a cesarean birth on a specific date depended on how fast she could find a parking spot near the hospital, which seemed more difficult to tackle than the C-section). Finally, the social context is also a factor; a woman who gives birth by cesarean section is spared the embarrassment of exposing her vagina for hours to a number of strangers, while she is moaning, panting and sweating.

5. Hypnosis for Birth – Brief Description and Literature Review

Natural birth using hypnosis is one way of gaining control over birth, without depending on medical assistance (drugs, dopplers). The current hypnosis for birth models/programs are designed for women with normal labour. They focus on pain and symptom management; use hypnosis as a substitute for chemical analgesia or anesthesia (medical programs are generally more open to chemical anesthesia than the non-medical models/programs); acknowledge fear, anxiety and feelings of loss of control.

Hypnosis for birth uses vivid imagery and permissive and non-directive hypnotic techniques (You could be...; imagine if you will; take a moment...); it often contains a "safe place" (this could be a remote place such as an island or the pregnant woman's womb). Most times, the imagery used in hypnosis is not consistent with medical or scientific surgery (Sauer, 2000); the images are deliberately exaggerated or idealized to effect positive thinking, feelings and attitudes, and for dissociation purposes. Hypnosis and guided imagery (as part of visualization) aim to evoke physiological change (Simon & Schwartz, 1999), helping the future mothers see themselves giving birth, holding and breastfeeding the baby, feeling coolness (for numbness and increased body heat), feeling soothing waves of relaxation washing their bodies; releasing tension, etc.

A comparison between hypnosis babies and newborn infants from mothers who received varying amounts of analgesics or local anesthetics showed that hypnosis babies had a significantly greater ability to recover from the asphyxia of birth in their first hour of life (Moya and James, 1960)

An Australian study of the obstetricians' and midwives' perceptions of complementary therapies in pregnancy found that 78% of the obstetricians believed both hypnosis and meditation to be safe modalities for pregnancy. At the same time, 68% of the midwives found hypnosis useful and safe while 88% midwives found meditation safe for pregnancy (Gaffney & Smith, 2004).

Omer, Friedlander and Palti (1986) looked at the benefits of using hypnosis to prevent premature labour. Hypnotic relaxation was an adjunct to pharmacologic treatment for 39 women hospitalized with premature contractions. The control group (n = 70) received drug therapy alone. At the time of hospitalization, the experiment group received three hours of hypnotic relaxation treatment. They were also given cassettes with a hypnotic relaxation exercise for daily practice. The rate of pregnancy prolongation was significantly higher for the hypnotic relaxation group than for the drugs-only group. Birth weight was also greater in the hypnosis group. The authors also noted the importance of social support, cooperation and motivation to prolong the pregnancy as important variables in their study (Omer, Friedlander & Palti, 1986)

In a study of 96 pregnant women, 51 of them chose hypnosis and 45 opted for psychoprophylaxis for antenatal and intrapartum use. The women in the hypnosis group received weekly hypnosis classes (beginning the 28 th week of pregnancy) accompanied by tapes that were being used at home for practice. The women in the second group received four psychoprofilaxis classes when they were about 28 weeks pregnant. During labour, 40% women in the hypnosis group required no analgesia or Etonox alone compared to 35% in the psychoprophylaxis group. In the hypnosis group, the first stage of labor was significantly shortened by 98 minutes for primiparas and 40 minutes for multiparas. These women were more satisfied with labor and reported other benefits of hypnosis such as reduced anxiety and help with getting to sleep. The second stage of labour was five minutes longer in the hypnosis group, a finding that the authors explained as “due to hypnotic relaxation as a disincentive to push” (Brann & Guzvica, 1987).

A study of 60 nulliparas evaluated the combined effects of hypnotic analgesia and skill mastery with childbirth education (Harmon, Hynan & Tyre, 1990). The women received six sessions of childbirth education and skill mastery (stress inoculation) using an ischemic pain task (repeated exposure to a mild form of pain until subjects developed a psychological immunity through skillful coping). The women were divided into high and low hypnotic-susceptibility groups. Half of each group was randomly assigned to receive hypnotic induction at the beginning of each session. The other half was the control group and they received relaxation and breathing exercises typically taught in childbirth education. The women in the hypnosis groups experienced shorter Stage 1 labours, less medication, more spontaneous births, and higher Apgar scores (Harmon et al., 1990: 528). The women who were highly susceptible to hypnosis experienced lower scores of post-natal depression than the women in the other groups. Hypnosis had no effect on stage 2 of labor. The authors concluded that the positive outcomes in the hypnosis groups resulted primarily from reduced perceptions of pain. (Harmon et al., 1990)

In a Canadian study, Letts, Baker, Ruderman and Kennedy (1993) wanted to determine if teaching self-hypnosis to 87 pregnant women decreased the obstetric intervention (particularly, with respect to epidurals). This group was compared to a control group of 56 women who did not use hypnosis, and to 352 low-risk women delivered by other family physicians at the same hospital (Women’s College Hospital in Toronto). The latter group was dubbed as the WCH group. Audiotapes were produced during the individual sessions and given to women to use at home. No hypnotizability tests have been used prior to the training. The authors reported that all women were able to achieve at least “a light trance” (Letts & al., 1993:336). The hypnosis and control groups were subdivided by risk (low and high risk) and parity (primiparas and multiparas). The length of pregnancy was significantly longer in the hypnosis group producing babies that weighed 198 g more than the babies born in the control group. The epidural rates were 17.0% lower in the hypnosis group compared to the 352-women group, and 11.4% lower than the control group. The use of intravenous use was 18.5% lower in the hypnosis group than both other groups, combined obstetrical interventions (epidural-forceps-episiotomy) was 15.8% lower than the control group, and 10.2% lower than the WCH group. The second stage of labour was 10-minutes shorter in the hypnosis group, compared to the control group.

6. Hypnosis for childbirth in a medical context

Rabuzzi considers the medical model of birth "the worst excesses of patriarchal and technological domination" (Rabuzzi, 1994: 72). In this context, pain killers are readily available to women. The narcotics reinforce the doctor’s authority since only a doctor can approve them and (supposedly) they know their chemical composition, effects and side effects on the women and their children. These drugs numb the pain, but also slow down the dilation process and create a disconnection between the woman's psyche and her body, and between the mother and the child. Since these drugs cross the placenta, they might contribute to a lower Apgar score in the baby and, possibly, cause sluggish vital signs and brain activity. One study indicated that the babies of mothers who had been heavily medicated during the labour were more prone to develop drug addictions later in life (Beech, 1999).

The following sections present the most relevant and significant medical and non-medical programs or models of hypnosis for childbirth in developed English-speaking countries.

7. Medical Models of Hypnosis for Birth

Most medical models and programs presented here have been by male doctors. Male (and some female) medical doctors who use hypnosis for labour and birth present the women as “patients” (implicitly, asking for patience, acquiescence and compliance). They take ownership of life and death, in a God-like manner. One male doctor writes about his practice of using hypnosis with pregnant women in an Ego-centric manner, completely disconnected from the subjective experience of the mothers: “my fetal mortality rate from prematurity was about the same as that of my colleagues in the same practice”, “my incidence of preterm birth dropped”, “all my premature babies weighed more than 4 lbs. and all survived” (Brown & Hammond, 2007: 362, 363). One can barely get a glimpse of the mother and her baby.

7.1. The Kroger Method (USA)

William S. Kroger was an avant-garde doctor who promoted and used hypnosis for childbirth as early as the 1950s. He created the Glove Anesthesia hypnotic technique labor and birth, now widely used by many lay and clinical hypnosis practitioners. Dr. Kroger recommended that the women begin hypnosis training for childbirth in their 3 rd or 4 th month of pregnancy; also, he promoted group training and encouraged women to form a supportive network.

7.2. The LeCron & Cheek Model (USA)

LeCron and Cheek (1968) treated pregnant women as "patients" and divided them in: good risk patients (those couples who planned pregnancy, have happy a marriage, uncomplicated pregnancy history, etc.); and poor risk patients (serious illness or death of a parent before the woman was 10 years old; divorce separation before the woman was 5 years old; history of infertility, abortion, still birth, illness during the patient's mother's pregnancy or delivery).

They believed that hypnosis was "a use of familiar experiences", and stated that the woman "should not feel like a failure if her doctor decides that she needs some help with analgesic drugs or local anesthetics” (LeCron & Cheek, 1968:126). Their program used postural suggestions, ideomotor signals, future projections about the pregnancy, labour and birth and recommended watching the facial expression of the woman to see if they were accepted. They also addressed the importance of frightening dreams and made an association between them and nausea and vomiting, severe headaches, urinary tract infection, repeated cold or sinusitis, asthma, pregnancy toxemia, hemorrhage or premature uterine contractions.

7.3. Hilgard & Hilgard Model (USA)Hilgard & Hilgard (1994) are well-known for their work in the area of hypnosis for pain (not just childbirth-related pains). They suggested that the women begin their hypnosis training in the last two months of the pregnancy. Their model consisted of eight characteristics of hypnotic techniques: rehearsals of a pseudo-future (mothers imagine the first cry of their babies); relaxation; substitute a minor symptom for the pain; displace the symptom to another part of the body; direct suggestions of symptom relief ("feel numb from the waist down"); indirect suggestions (glove anesthesia); imaginative separation from the present scene (a trip to the seashore, etc.); posthypnotic suggestions ("intended to reduce postoperative pain and discomfort"). The found that the women who used hypnosis during episiotomy recovered faster. Also, the mothers using hypnosis were more relaxed and lactated better.

7.4. Oster's Model (USA)

Marc Oster (2000) works primarily with groups but also acknowledges the advantage of working with the expectant mother individually. Dr. Oster treats the expectant women as "patients" and encourages them to attend Lamaze classes or study day-by-day pregnancy description materials. The Oster’s 6-session program includes a thorough assessment, the initial hypnotic experience (eye fixation, Special Place, Deepening, Hypnotic-state Ratification, the Working Part - analgesia inducement); visualization/rehearsal of the woman’s labour and birth and her Special Place; age regression to locate positive memories and use them to create dissociation. The last 2 sessions involve the husband’s increased participation. The program had good results with women difficult labour and those who required vacuum extraction (Oster, 2000).

7.5. Sauer's Brief Model (USA)

Carolyn P. Sauer developed a brief 2-session program that helps the women manage pain and fear of childbirth. Session 1 begins with an assessment and continues with guided imagery (the women are also tested for depth of hypnosis), followed by pain management intervention and post-hypnotic suggestions. Session 2: the woman is trained in self-hypnosis (and offered to make a tape to use at home/office). In this session, she rehearses the labour and delivery. The model has been used with good results to turn a breech baby into position; to restart labor (the dilation stalled at 6 cm for 7 hours); and it proved useful in a case of unexpected cesarean (Sauer, 2000).

7.6. Barabasz’s and Watkins’ Model (USA)

Barabasz and Watkins (2005) used a Freudian and psychoanalytical approach. They looked at the possible traumatic effects of birth both on the child and the mother. They addressed the issue of childbirth-related PTSD (CB-PTSD) as stemming from extreme pain or loss of control, and made the link between CB-PTSD and post-partum depression, neglect or physical abuse of the child. They cautioned about using suggestions such as "your child will be a joy for you" (especially where the pregnancy was not expected or welcome).  They used inductions tailored to the patient (as opposed to scripted protocols). They contended that nausea and vomiting deserved psychodynamic consideration (i.e. might indicate rejection of the child). They stated that urinary and bowel control could be helped with a combination of hypnosis and behaviour therapy; also, they recommended "psychological treatment" for alterations in self-concept, the attitude toward the unborn child, and the relationship with the child's father.The first session was dedicated to prepare the woman psychologically for the birth experience; also, they believed that the woman needed to be aware of the availability of chemoanesthesia (not just the hypnoanesthesia). The woman was suggested that she would "feel" no pain rather than she would "have" none. They used a dissociative technique (the woman leaves her body and watches herself giving birth). They specified that they did not use glove anesthesia because of the potential for paralysis of functions (the glove anesthesia aims to reduce/eliminate pain, not the muscular ability to induce contractions, this author’s note).

7.7. Hypno-Beginning (Canada)

Created by Nathalie Fiset, M.D., a family doctor in Quebec, Canada, the Hypno-Beginning program is a four 2-hour session hypnosis program. Dr. Fiset believes that breathing exercises are not crucial to labour and birthing, nor do they help significantly with these final stages. She uses medical terms (i.e., Braxton-Hicks, delivery) and she presents the labour and the birth as medical conditions that should be attended to in the hospital. Her demo video shows a woman birthing quietly and almost painlessly in a hospital bed. In her manual, Dr. Fiset taps into fears and pain, and, in her anesthesia induction, she asks the women to visualize an electric panel and switch the power off and on, to create numbness.7.8. The McCarthy Method (New Zealand)The New Zealand-based Dr. Patrick McCarthy, developed a childbirth training program consisting of five, 30-minute sessions conducted in the final weeks of pregnancy. His program is described in details in Barabasz’ and Watkins’ work (2005). To facilitate self-hypnosis, the sessions were conducted one-on-one, audio-recorded and given to the women. The training program was based on the Standard   Hypnotic Susceptibility Scale and the Standard Hypnotic Clinical Scale in order to obtain specific hypnotic responses such as muscle relaxation, catalepsy, age progression, amnesia, anesthesia, dissociation, hallucination, and posthypnotic suggestion (Barabasz & Watkins, 2005). Dr. McCarthy paid attention to the language of women, particularly those with unpleasant experiences of labor and considered them key to possible pathology such as PTSD. He stated that childbirth could produce an indelible memory that could weigh the woman down for the rest of her life (Barabasz & Watkins, 2005). He stressed the importance of using hypnotic responses for uses in birthing that were tailored from the special abilities and talents of each woman. Also, he pointed out that the women should never be promised pain-free labors/births.

7.9. An Ericksonian Approach (USA)

Noelle Poncelet, PhD (1983, 1990) developed a childbirth training protocol that used Ericksonian principles and techniques and offered to “patients receiving traditional obstetrical care” (Poncelet, 1983: 267). In her protocol, Poncelet (1983, 1990) used eye fixation, anchoring, dissociation, relaxation, trance deepening, amnesia or partial amnesia (with women who gave birth before), pseudo-orientation in time, analgesia, reframing pain, anxiety and hospital language, time distortion, bleeding control and posthypnotic suggestions.

8. Non-Medical Models/Programs

8.1 The Mongan Method (USA)The Mongan Method or HypnoBirthing is the first North-American hypnosis childbirth education program designed by Marie Mongan, a former college counsellor. The program is one of the best marketed and best known hypno-childbirthing programs in Canada and the USA. The Method draws heavily from the Dick Read’s Childbirth without Fear method and the Lamaze method, and adds the hypnosis component. Similar to her predecessors, Mongan focuses on alleviating and re-defining pain (“pressure”), tension and fear. In an effort to minimize the medicalization of birth and being inspired by Ina May Gaskin’s midwifery work, Mongan used softer terminology to replace the medical language (i.e., Birth Show, instead of Bloody Show; Pre-Labor Warm-ups, instead of Braxton-Hicks, Surge, instead of Contraction) (Mongan, 2005, p. 71).               Mongan’s constant efforts to explain the origins of Fear, Tension and Pain, while offering several techniques (Breathing Exercises, Glove Relaxation, NLP for Releasing Fears, Emotions and Limiting Thoughts, Depthometer) reinforce, in fact, the women’s assumptions that birth is preceded by pain.In addition to hypnosis, Mongan recommends daily perineal massage, to soften the perineal tissues and to avoid episiotomy although there is no medical evidence that such practice would reduce the likelihood of this intervention. Probably, the highest accomplishment of the Mongan Method resides in encouraging the women to have more control over the labour and birth by asserting their birth preferences, doing their breathing and hypnosis exercises, and by using non-medical terms.8.2. Hypnobabies (USA)Kerry Tuschheff, a doula and a former HypnoBirthing Method user, is the creator of Hypnobabies, “a complete childbirth education program” (six 3-hour sessions). The program aims to help women “eliminate pain” “by using real step-by-step hypno-anesthesia that works so well women use it for internal exams, IV/hep-lock insertion if needed” (Hypnobabies, 2009); to bond with the baby in utero; and to achieve a solid childbirth education. The program also “fully trains the birth-partners” (who receive their own hypnosis CDs and guide), whereas in the Mongan Method the birth partner’s role was that of a companion and support. The program builds around pain elimination and promises powerful hypno-anesthesia comparable to the one used during surgical interventions and by doing birthing rehearsals in the last session with both women and birth-partners.While providing substantial information, the program also reinforces the idea of (intense) pain and advertises powerful inductions that will help mothers to give birth painlessly. Presently, there is no data showing how much the Tuschheff method fares compared to the Mongan method, and how much both of them “release” (Mongan) or “eliminate” (Tuschheff) fears and pain compared to other existing methods (medical or non-medical).

8.3. Chaplain Paul G. Durbin Childbirth Protocol (USA)

The former director of the Clinical Hypnotherapy Department at the Methodist Hospital in New Orleans, Chaplain Durbin designed the program to fit in a medical model of birth. He used a Christian approach (Psalms, Bible's quotes). To obtain his services, the expectant mother needed a referral from her physician for "hypnosis for childbirth preparation."

Chaplain Durbin used similar steps and scripts as Mongan (six sessions) and credited Mongan and her collaborators for some of the techniques he used.

He advised the mother to b egin using hypnosis as soon as the labour started, and also go to the hospital as instructed by her physician. "When in the hospital, re-induce hypnosis and deepen but responsive to physician and nurses" (as found on his website).

8.4. Gayle Peterson’s Body-Centered Hypnosis for Childbirth (USA)

Gayle Peterson is a family therapist specializing in prenatal and family development. She developed the Body-Centered hypnosis, a technique used for resolving past childbirth and birth trauma, facilitating normal delivery, decreasing the risk of pre-mature birth and increasing maternal-infant bonding. It is b ased on her Body-Centered hypnosis modality for decreasing anxiety and then applied to fear of childbirth and post traumatic stress syndrome resulting from physical and/or emotional trauma. It consists of using a body-centered or associative hypnosis (associating to the body’s sensations and working with pain and the individual woman’s psychological profile).

Body-Centered hypnosis focuses on changing the sensation of labour pain due to the individual nature of anxiety related issues in the pregnant woman. Although not a medical program, it is designed to be used only by psychotherapists, psychologists, family therapists, etc., and treats pregnancy, labor and birth from a clinical perspective, with focus on anxiety. The method uses a birth inventory (a detailed assessment and questionnaire); then, continues with guided imagery visualization, relaxation techniques and journal writing, techniques used to decrease anxiety.

8.5. HypnoPregnancy and Birth (Canada)

The 5-session program was created by Liana Voia, an Ottawa-based hypnotherapist (Canada). The HypnoPregnancy and Birth (HPB) program uses guided visualization, breathing, self-hypnosis training to assist the expectant mothers with the pregnancy, labour and birth, as well as provide them with post-natal strengths. The women are also encouraged to take prenatal yoga classes during the pregnancy.HPB focuses more on reframing the perception of pain rather than on anesthesia. Also, it focuses on preventing/reducing any suffering that might come with the pain. HPB dedicates equal attention to both pregnancy and birth and the women begin their training earlier in the pregnancy. The program uses progressive relaxation, hyperempiria, double induction, Gestalt-based visualization, dream inducement, mindfulness, meditation, Meridian Tapping Techniques (MTT), Positive Psychology-based principles, and Neuro-linguistic programming. The women have the option of attending a sixth session, after giving birth to address post-birth issues (i.e., lactation, weight loss, fatigue, etc.). 9. The Partner’s RoleMost current medical and non-medical programs recognize the importance of the baby’s father’s involvement and even train the father to cue the woman during labour and birth, by using affirmations or specific pre-arranged cues (verbal, kinesthetic, etc.). The fathers are encouraged to also attend childbirth education and prenatal classes. Guthrie et al. (1984) conducted a study of eight pregnant women whose husbands induced hypnosis during labour to help them control pain. Both the women and the husbands received basic training in self-hypnosis, which consisted of suggestions for relaxation and positive affirmations. The mothers reported less pain than the women in the comparative group (n = 9) who did not receive hypnosis. Also, four women in the hypnosis group gave birth without drug analgesia, while only two women in the comparative group had drug-free births (Guthrie et al., 1984).All programs do not explicitly discuss how they accommodate same-sex couples, single mothers, or surrogate mothers, partly because most women who approach these programs are heterosexual and married/in a relationship.Also, there is no research looking at how the medical models fare compared to the non-medical ones.
 
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