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Letter from North America: Understanding and Minimizing Nocebo Effects in Childbearing Women Carol Sakala Nocebo (‘‘I shall harm’’) effects are the inadequately recognized inverse of placebo (‘‘I shall please’’) effects. Expectations of injury, pain, incapacity, affliction, and other physical or mental malfunction, and affective states that accompany these expectations, can contribute to actually experiencing these outcomes (1). The effects may be specific, such as an expectation of airway restriction or of allergic reaction leading to those experiences, or nonspecific, such as an expectation of worsening or vulnerability leading to some form of deterioration (1). Expectations of individuals themselves, of their caregivers and people in their social network, and of both combined through relationships can have powerful negative effects (2). Under certain rare conditions, negative beliefs appear to be powerful enough to bring about death (2). A search of the MEDLINE database with PubMed in August 2007 revealed that although nocebo phenomena have been examined in a wide range of medical fields, not a single article was available when searching on ‘‘nocebo’’ and the following terms and their derivatives: ‘‘pregnancy,’’ ‘‘fetus,’’ ‘‘maternal,’’ ‘‘labor,’’ ‘‘birth,’’ ‘‘childbirth,’’ ‘‘newborn,’’ and ‘‘obstetrics.’’ Researchers have especially studied mechanisms of nocebo effects in experiments of pain in nonpregnant volunteers, and have measured behavioral, neuroanatomical, and biochemical effects. Whereas positive expectations about pain control stimulate endogenous opioids, nocebo expectations generate hyperalgesic effects through anticipatory anxiety and hyperactivity of the hypothalmic-pituitary-adrenal axis (3). This

action is consistent with Lowe’s classic research, which found that a woman’s degree of confidence in her ability to handle labor was the most important predictor of her experience of labor pain, exceeding the impact of age, parity, childbirth preparation, state anxiety, concern about outcome of labor, fear of pain, cervical dilation, and frequency of uterine contractions (4).

Carol Sakala, PhD, MSPH, is Director of Programs at Childbirth Connection, New York, New York, USA.

Recognition that words, beliefs, and expectations can lead to demonstrable biologic benefit or harm that might, as Lowe found, be more powerful than numerous other plausible sources of influence, suggests understanding nocebo effects in childbearing women is a priority.

Address correspondence to Carol Sakala, Childbirth Connection, 281 Park Avenue South, New York, New York 10010, USA. Ó 2007, Copyright the Author Journal compilation Ó 2007, Blackwell Publishing, Inc.

Climate of Confidence versus Climate of Doubt The influential women’s health handbook Our Bodies, Ourselves (6), in both the current and earlier editions, described two very different environments for childbearing women—a ‘‘climate of confidence’’ and a ‘‘climate of doubt’’ (5, pp 420,421): You deserve to experience your pregnancy and birth with a climate of confidence that reinforces your strength and power and minimizes fear. Some of the factors that contribute to such a climate can be achieved only through collective efforts to create a just maternity care system; others are more likely to be within your personal control. As you enter your pregnancy, seek out friends and family who can provide support; choose caregivers who listen to you and respect the birthing process; and select a birthing environment in which you feel comfortable. . . Unfortunately, a climate of doubt prevails in thinking about pregnancy and childbirth in the U.S. today. Childbirth is seen as an unbearably painful, risky process to be ‘‘managed’’ in a hospital setting with a wide array of tests, drugs, and technologies. Routine medical practices regularly disregard and disrupt the natural rhythms of labor (‘‘physiologic’’ labor) and often fail to support a woman’s inherent capacity to give birth.

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The social environment for childbearing women in the United States includes multiple and often mutually reinforcing contexts for casting doubt. ‘‘Reality’’ television shows depict childbirth in sensational and frightening episodes (6). The national Listening to Mothers II survey of women who gave birth in United States hospitals in 2005 found that 68 percent of mothers had watched one or more of these television shows during pregnancy. Seventy-two percent of the primiparous viewers reported that the shows helped them understand what it would be like to give birth, and 32 percent reported that the shows caused them to worry about their upcoming birth (7). Books were the most important information source about pregnancy and childbirth for primiparas (7), yet in advice books for pregnant women, discussions of choice and women’s empowerment were commonly intertwined with contradictory messages of fear and vulnerability (8). For the declining number of women who attend childbirth education classes in the U.S. (25% of survey participants in their present pregnancy and 56% of primiparas), the predominant location of classes was in a hospital or other clinical setting (87%), which suggests that health professionals and facilities are likely to shape the content and values in classes. When asked to describe the impact of those classes, many participants reported having greater trust in their hospital (60%) and their caregivers (54%) and being less afraid of medical interventions (58%) (7). Compared with childbirth education classes in former years, the content of today’s classes socializes women about what to expect in their hospital rather than focusing on childbearing processes, coping skills, and making informed and individualized decisions (9). Stories and advice from female friends, relatives, and others may overwhelmingly convey doubt to pregnant women in an environment where 50 percent of mothers giving birth in hospitals experience attempts to induce labor, 76 percent experience epidural analgesia, 47 percent have labor augmentation, 65 percent have ruptured membranes, 56 percent experience bladder catheters, 76 percent do not walk after admission and having well-established contractions, and 32 percent give birth by cesarean section (7). Conventional maternity services often send a broad and continuing array of doubting messages to women (5). The threshold for use of cesarean section (10) and many other consequential interventions is declining, with more and more healthy women experiencing interventions that were developed for specific complications. In a cascade of intervention, women typically experience numerous co-interventions that are used to prevent, monitor, or treat side effects of other interventions. Numerous catheters, drips, monitors and other technologies are commonly applied on, or lead

into, a woman’s body. This technology immobilizes most women during the physically challenging process of giving birth (7). Although most interventions are applied to address risks of other interventions (e.g., vasopressor drugs to treat hypotension associated with epidural analgesia), mothers are unlikely to understand these interrelationships and more likely to view these as measures that their bodies need to carry out childbirth. Troubling proportions of Listening to Mothers II participants reported that while giving birth they had felt overwhelmed (44%), frightened (37%), weak (30%), agitated (28%), groggy (26%), and helpless (24%) (7). How Does a Climate of Doubt Affect Women and Maternity Outcomes? What is the impact on women of terminology that explicitly and repeatedly contributes to a climate of doubt? In addition to labeling healthy childbearing women as patients, practitioners communicate strong messages of doubt through terms such as ‘‘trial of labor,’’ ‘‘failure to progress,’’ ‘‘failed induction,’’ ‘‘incompetent cervix,’’ ‘‘inadequate pelvis,’’ and ‘‘macrosomic baby.’’ A casually applied label of ‘‘high risk’’ may be extremely alarming for the typical pregnant woman who deeply desires a normal birth and healthy baby. Labels of failure and inadequacy consistently refer to the woman and her body and baby, placing blame on personal shortcomings. Rarely acknowledged, however, is the failure of the health care system to provide appropriate support to mothers and their babies. This failure may result from a loss of, or disinterest in, using skills to facilitate physiologic birth (11), pressure from caregivers to be induced and have cesareans (7), and use of technology to shift births to convenient non-holiday weekday hours (12). Thus, many women may be unaware of the external pressures that shape their care and may experience their specific childbearing path as a necessary and inevitable consequence of the failure of their bodies. What effects do brief communications such as the following have on childbearing women? I’d like you to have another ultrasound. Looks like your fetus is getting very large. Despite your wish for unmedicated childbirth, I’m sure you’ll want an epidural when the time comes.

Available nocebo research suggests that a single negative suggestion from a person who is viewed as authoritative can have a harmful effect. What is the cumulative effect of negative conversation, surveillance, and technology that pushes and pulls birthing processes along on birthing women’s sense of

350 competence and effectiveness? How do these experiences affect short-term birth outcomes and women’s emotional and physical readiness to care for their newborns and balance new family roles? Can sensitive, encouraging, supportive health professionals and companions who provide continuous labor support effectively counter such negative influences? It is especially important to understand how the established nocebo mechanisms for shaping the experience of pain apply to childbirth. Do negative comments, labels and expectations commonly activate the hypothalmic-pituitary-adrenal stress axis and the ‘‘fight or flight’’ stress response, leading to high levels of adrenaline that inhibit endogenous oxytocin and slow or stop labor (13)?

How Does a Climate of Confidence Affect Women and Maternity Outcomes? Research that has looked systematically at care within a climate of confidence has documented highly desirable results. Two studies in North America, the largescale National Birth Center Study (14) and Certified Professional Midwife 2000 study (15), are compelling examples. The latter more recent study especially sets benchmarks for what most healthy, low-risk North American women might experience in childbirth. When compared with the national U.S. population of mothers who gave birth in the same year and met national Healthy People 2010 criteria for low-risk childbearing woman, women who planned to give birth with certified professional midwives experienced excellent outcomes with strikingly lower use of many interventions, including electronic fetal monitoring (10% vs 84%), labor augmentation (9% vs 19%), episiotomy (2% vs 33%), assisted delivery (2% vs 7%), and cesarean section (4% vs 19%). Do confident or doubtful words, beliefs, and expectations contribute to these differences? Can better maternal and newborn outcomes and more effective use of resource expenditures be obtained by making a climate of confidence the standard of care? Climate of confidence and climate of doubt are elegantly concise concepts that shed light on contrasting approaches to childbearing in North America. Knowledge about nocebo effects in other contexts suggests that a climate of doubt may contribute significantly to undesirable maternity outcomes. It is crucial to undertake research that enables maternity caregivers and policy makers to develop a solid understanding of nocebo effects in childbearing. Those who

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are in contact with pregnant and birthing women and new mothers—including individuals in their social networks, their caregivers, and authors of educational and media materials—should recognize that confidence and encouragement can contribute to favorable outcomes while negativity, doubt, and skepticism can be harmful. In their effort to make safe, effective maternity care available to women and families, health professionals may need to consider best evidence about the effects of our beliefs, expectations, and words in addition to best evidence about the effects of drugs, tests, and procedures.

References 1. Hahn RA. The nocebo phenomenon: Concept, evidence, and implications for public health. Prev Med 1997;26:607–611. 2. Benson H. The nocebo effect: History and physiology. Prev Med 1997;26:612–615. 3. Benedetti F, Lanotte M, Lopiano L, Colloca L. When words are painful: Unraveling the mechanisms of the nocebo effect. Neuroscience 2007;147:260–271. 4. Lowe NK. Explaining the pain of active labor: The importance of maternal confidence. Res Nurs Health 1989;12:237–245. 5. Boston Women’s Health Book Collective. Our Bodies, Ourselves: A New Edition for a New Era. New York: Simon & Schuster, 2005. 6. Lothian JA, Grauer A. ‘‘Reality’’ birth: Marketing fear to childbearing women. J Perinat Educ 2003;12:vi–viii. 7. Declercq ER, Sakala C, Corry MP, Applebaum S. Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection, October 2006. Available at: http://www.childbirthconnection. org/listeningtomothers/. Accessed August 31, 2007. 8. Pincus J. Critique of childbearing advice books. Our Bodies Ourselves, 1999. Available at: http://www.ourbodiesourselves. org/book/companion.asp?compID=45&id=21. Accessed August 26, 2007. 9. Chiaverini D, Baker VM. The perinatal education coordinator. In: Nichols FH, Humenick SS, eds. Childbirth Education: Practice, Research and Theory. 2nd ed. Philadelphia: W.B. Saunders, 2000:669–680. 10. Declercq E, Menacker F, Macdorman M. Maternal risk profiles and the primary cesarean rate in the United States, 1991– 2002. Am J Public Health 2006;96:867–872. 11. Gawande A. The score. The New Yorker October 9, 2006; 82(32):59ff. 12. Peltier J. Births by day of the year. Available at: http://peltiertech. com/Excel/Commentary/BirthsByDayOfYear.html. Accessed August 31, 2007. 13. Buckley SJ. Undisturbed birth: Nature’s hormonal blueprint for safety, ease and ecstasy. MIDIRS Midwifery Digest 2004;14: 203–209. 14. Rooks JP, Weatherby NL, Ernst EK, et al. Outcomes of care in birth centers: The National Birth Center Study. N Engl J Med 1989;321:1804–1811. 15. Johnson KC, Daviss B-A. Outcomes of planned home births with certified professional midwives: Large prospective study in North America. BMJ 2005;330:1416.