Social Support Interventions as a Means to Alleviate Social Stress Caused By Nausea and Vomiting of Pregnancy (NVP)
“Morning sickness,” or nausea and vomiting of pregnancy (NVP), are terms used to describe the symptoms of nausea, vomiting, and retching during the first trimester of pregnancy. It is a common misconception that if the mother becomes “sick,” this would cause the baby to transitively become ill. However, mothers who have NVP are more likely to have healthy births, indicating that there is an evolutionary protective mechanism behind NVP (Flaxman & Sherman, 2000). The embryo protection hypothesis indicates that during this sensitive time of fetal organogenesis, or organ development, the mother develops taste-aversions to food and other related stimuli in order to protect the fetus from potential microbial or chemical threats (Bayley, 2002; Flaxman & Sherman, 2008). Although NVP is seen as a protective mechanism, there is overwhelming physical and psychological strain on mothers experiencing NVP, and therefore, they will seek antiemetic remedies (Parker, 1997). Halting the mechanism of NVP conflicts with the embryo protection hypothesis, as NVP is in place to protect the embryo from potential teratogenic substances. Working to reduce the intense, isolating psychological experiences associated with NVP will help preserve the physiological protective mechanisms that protect the embryo. Social support, or feelings of being cared for and valued, is a known psychological protective factor against stress and overwhelming, adverse experiences that are a part of NVP. This paper proposes that implementing increased feelings of social support will mediate the negative psychopathology that could potentially lead to more negative birth outcomes. Specifically, providing group therapy to patients with NVP, as well as working toward improving health care professionals’ bedside manner, will increase feelings of social support and help alleviate and prevent adverse psychosocial experiences. These interventions would minimize the psychological distress experienced by the mothers while maximizing the baby’s possible health outcome.
Physical Symptomatology
“Morning sickness” is a common feat of the first trimester of pregnancy that occurs in upwards of 90% of women around the world (Broussard & Richter, 1998; Flaxman & Sherman, 2000). A more representative term, nausea and vomiting of pregnancy (NVP), is more commonly accepted than “morning sickness”, as “morning sickness” implies that symptomology occurs only in the morning, and that the mother is ill, so the baby will not be healthy – which is not necessarily true (Broussard & Richter, 1998). In fact, women are significantly less likely to miscarry if they experience symptoms of NVP when compared to women who do not experience symptoms of NVP (Flaxman & Sherman, 2000).
The characterizing symptoms of NVP include vomiting, nausea, and retching, or dry-heaving, but there may also be an increased general sensitivity to smell and taste, dizziness, thirst, and fatigue (Gadsby, Barnie-Adshead, & Jagger, 1993). The manifestation of these symptoms are subjective and have a spectrum of severity and occurrence (Gadsby, Barnie-Adshead, & Jagger, 1993). Most of the symptomology abruptly cease after 18 weeks, or after fetal organogenesis, or organ development (Flaxman & Sherman, 2000). Hyperemesis gravidarum (HG) is a severe symptomatic manifestation of NVP that occurs in roughly 1.5% of pregnancies (Verburg et al., 2005). Severe nausea and vomiting are present, leading to an imbalance of electrolytes, loss of fluid, decreases in the mother’s weight, and decreased overall nutrition, which lead to hospitalization (Verburg et al., 2005).
Current Treatments
Current treatments mainly focus on symptomatic alleviation by using both pharmacological or natural agents. Health care professionals typically advise patients with NVP to avoid food stimuli that they find nauseating, and to eat small meals of dry, bland food (Davis, 2004; Matthews et al., 2014). These behavioral changes can also be coupled with pharmaceutical and non-pharmaceutical remedies. Pharmaceutical medications include combinations of anticholinergics, dopamine antagonists, antihistamines, vitamins B6 and B12, and H3 antagonists (Koren, 2002; Matthews et al., 2014). Taking and prescribing pharmaceuticals during the first trimester of pregnancy is approached with caution due to possibility that the medications have teratogenic effects, or the ability to disturb the development of the embryo (Mazzotta & Magee, 2000). In response to this risk, there is now a general decrease in the use of drugs, even those that were found safe and effective (Koren, 2002).
The concern of a pharmaceutical treatment approach for NVP led to an increase in the use of alternative therapies as they are perceived to be natural, and therefore, safe. Some examples of these remedies include ginger, acupressure, acupuncture, relaxation techniques, and others(Aikins Murphy, 1998; Matthews et al., 2014; Niebyl, 2002; Wilkinson, 2000). Because of the overall increase in popularity and claims of effectiveness, even healthcare professionals are recommending non-pharmaceutical treatments more often than pharmaceutical treatments (Matthews, 2014; Tiran, 2002). However, there are concerns regarding the efficacy and safety of natural remedies as they are not regulated as thoroughly as pharmaceuticals, and therefore, patients and professionals may underestimate risks (Tiran, 2002). The treatments outlined above mainly target the physical manifestations of NVP, however, there may be contradictory teratogenic risks if one treats the symptoms of NVP. Specifically, if the symptomatic mechanism of NVP is actually in place to protect the baby, then using treatments would increase the risk of negative birth outcomes.
The Embryo Protection Hypothesis
The mechanisms and significance of NVP are explained in both proximate and ultimate evolutionary analyses through the Embryo Protection Hypothesis. Physiologically speaking, the neuroendocrine system plays a significant role in the symptoms of nausea and vomiting. The nuclei in the brain stem orchestrate these symptoms by receiving inputs from the area postrema and the gastrointestinal afferent projections, which both respond to possible toxin ingestion with chemoreceptors. These responses may result in psychological conditioned taste aversions that prevents future intake of similar, potentially toxic food. Hormonal fluctuation of estrogen, progestins, androgens, cortisol, or human chorionic gonadotropin during the first trimester bring about NVP, however, hormonal levels do not play a role in predicting who experiences NVP and symptom severity– they merely play an responsive role by activating the neural pathways (Andrews & Whitehead, 1990; Walsh et al., 1996).
These symptoms clearly have a functional role, as there is a lower frequency of miscarriages in women who experience NVP than women who do not experience NVP (Flaxman & Sherman, 2000). The correlation of positive pregnancy outcomes with NVP indicate an adaptive role of NVP, as opposed to a pathological role. Profet (1992) suggests that these taste-aversions, nausea, and vomiting in response to food are an adaptive mechanism that was evolved to protect the embryo against teratogens that exist in food. An example of NVP being protective is women who ingest more alcohol or tobacco, substances known to have teratogenic effects on the embryo, are more likely to experience symptoms of NVP (Hook, 1978; Hook, 1980). Mothers become increasingly sensitive to toxins to protect the extremely vulnerable embryo during organogenesis. These taste aversions were thought to be evolved from times of human foraging, and mothers learned be careful with specific plant species (Sherman & Flaxman, 2001). This is because specific plants have protective phytochemicals that induce sickness in herbivores that are attempting to eat it (Beier & Nigg, 1994; Sherman & Flaxman, 2001). These phytochemicals have minor effects on humans, as safe concentrations of phytochemicals are present in common vegetables and spices – food that is regularly ingested in a modern human diet (Flaxman and Sherman, 2008; Sherman & Flaxman, 2001). Some spices and plants even have antimicrobial phytochemical properties that may prevent any foodborne illnesses (Beier & Nigg, 1994). However, ingestion of phytochemicals in high concentrations still lead to possible allergenic, mutagenic, teratogenic, and abortifacient (toxins that can induce abortions) effects on a vulnerable, growing fetus (Beier & Nigg, 1994; Shepard, 1992). Caffeine is an example of something that is not harmful in small concentrations, but if too much is ingested during pregnancy, could lead spontaneous abortion (Klebanoff et al., 1999). Flaxman and Sherman (2000) found that foods that are historically high in toxins and pathogens have the most robust, specific triggering of NVP, but do not have any taste-aversive associations on the general population. Specifically, women develop taste aversions, or responses of illness to specific food stimuli, to prevent the mother from ingesting harmful foods in the future (Bayley et al., 2002). The embryo protection hypothesis posits that the symptoms of taste aversion, nausea, and vomiting in response to potentially harmful foodstuffs are in place in order to protect the embryo and the mother from these potentially harmful toxins in a semi-selective manner. Meaning that if certain food stimuli resemble potentially teratogenic food, then these aversions will generalize to the similar stimuli to be safe (Bayley et al., 2002; Flaxman & Sherman, 2008).
Other theories suggest that NVP is not used to protect the embryo directly. For example, the main conflicting theory, the byproduct hypothesis, states that there is competition between the mother and child for resources and overall evolutionary fitness (Forbes, 2002). The increased physiological stress on the body is theorized to produce the external representations of nausea and vomiting. However, there is no evidence to date that supports the byproduct hypothesis, and therefore, the most supported evolutionary reasoning behind NVP is the embryo protection hypothesis (Flaxman & Sherman, 2008).
Using the lens of the embryo protection hypothesis, it would be impractical to alleviate the symptoms of normal NVP as these mechanisms are in place to maximize pregnancy outcomes. Inhibiting this mechanism could lead to an increased likelihood of negative pregnancy outcomes as there would be no preventative and eliminatory response to possible dangerous food. Additionally, the potential teratogenic risks in taking either natural or pharmaceutical remedies are unclear, and they should be avoided in order to prevent any negative birth outcomes. If symptomatic manifestations are too severe, however, pharmaceutical or natural intervention is needed to prevent compromise of the mother's’ physical and mental health. For example, hyperemesis gravidarum is an exception, as maternal and fetal health are jeopardized by the severe dehydration, decreased nutrition, and other symptoms, and should be medically treated with anti-emetics as organogenesis in the fetus cannot occur without sufficient nutrients and energy. In less physiologically severe cases, the embryo protection hypothesis specifies that NVP is a biological adaptation in place to protect the fetus and symptoms should not be treated. However, the symptoms still may have severe physical and secondary psychological strain on the mother that could also potentially harm fetal and maternal health, clashing with the embryo protection hypothesis.
Psychological Symptomatology
The somatic symptoms of NVP often affect one’s psychological well-being and quality of life (Attard et al., 2002; Balik, Tekin, & Kagitci, 2015). Attard and colleagues (2002) found that the mother’s social life, work life, and family life can be negatively affected by symptoms of nausea and vomiting. Job efficiency is reported to be greatly reduced, as women experiencing NVP find that it is difficult to focus on work during symptomatic episodes, and therefore, feel less autonomous (O’Brien & Naber, 1992). Mothers are also more likely to experience feelings of guilt, loss of control, isolation, helplessness, depression, anxiety, and a perception of not feeling supported in response to NVP (Munch, 2002; O’Brian, Evans, & White-McDonald, 2002). The stressful experience of pregnancy misaligns with generally positive idea of having a baby, leading to many of these psychopathological experiences (Parker, 1993). Indeed,
many women report that NVP was an overall traumatic experience (Ericson et al., 2013).
The psychological stress experienced by women with NVP or HG are thought to not only be a result of relentless and debilitating symptoms, but also from their invalidating experiences with others in their support network (Munch & Schmitz, 2006; Parker, 1997). One of the primary frustrations for patients with NVP is that they often feel invalidated and isolated by their caretakers in the healthcare industry (Parker, 1997). Patients want their overwhelming symptoms to be acknowledged, however, they feel as if health care professionals treat them as if their symptoms are not indicative of an illness, which invalidates their experiences with NVP (Locock, 2008; Munch & Schmitz, 2006; Parker, 1997). Indeed, healthcare professionals often advise patients that NVP is not an illness and that their symptoms will protect baby (Munch & Schmitz, 2006; Parker, 1997). In response, patients with NVP report feeling confused about how their negative experiences could lead to a more positive birth outcome, and feel guilty for having an opposing perspective on their symptomatic experiences (Parker, 1997). Mothers with NVP also feel less support from their families due to the mothers’ psychological and physical symptoms (Parker, 1997). Often times, the mother’s families also experience feelings of stress, depression, and fatigue in response to the mother’s illness, which leads them to be less emotionally available and unlikely to be emotionally supportive to the mother (Parker, 1997). The lack of feelings of support, humanism, and trust in their caretakers and support network lead to harmful psychological manifestations with NVP. The mothers’ experiences and perceptions are incongruent with the embryo protection hypothesis that states NVP is a protective and healthy mechanism that maximizes the health of the baby.
Having mental disturbances during pregnancy can not only affect the mothers’ overall health, but also the embryos’ (Berle et al., 2005). If the mother experiences psychopathology and minimal feelings of psychosocial support, then there is a higher risk of negative birth outcomes, contradicting the embryo protection hypothesis (Berle et al., 2005; Collins et al., 1993). Collins and colleagues (1993) examined the correlation between social support and pregnancy outcomes, and concluded that maximizing social support (quantity of support, quality of support, and network resources) is positively correlated with better pregnancy outcomes, as measured by higher Apgar scores, higher birth weight, and lower rates of postpartum depression. Conversely, mothers who experience more psychosocial stress in combination with physical, symptomatic stress are more likely to have higher rates of birth termination, as well as increased desire for any alleviation possible, including dangerous medications and remedies (Attard et al, 2002; Mazzotta, Magee, & Koren, 1997). These psychological manifestations that often arise from NVP are maladaptive, as they are associated with negative birth outcomes. Therefore, having psychopathology during pregnancy conflicts with the embryo protection hypothesis, as evolutionarily, NVP is in place to maximize reproductive success and gene transmission. In order for the protective mechanism of NVP to be preserved, the mothers’ evolutionarily dysfunctional psychological experiences should be therapeutically targeted to help reduce psychosocial stress felt during NVP. Specifically, working to reduce the negative psychological experiences with a psychosocial protective mechanism, such as social support, may provide resilience against the secondary stresses of NVP. This increased resilience to psychosocial stress will decrease negative mental health symptoms in mothers with NVP, which will lead to maximized birth outcomes for the baby, thus allowing the psyche to augment instead of conflict the embryo protection hypothesis.
Targeting Social Support to Reduce Psychological Symptoms
Social support is the perception that one is generally cared for and valued by others (Gottlieb & Bergen, 2010). Social support embodies feelings of affiliation, belongingness, and expectation of empathy and help from others if needed. These feelings are dependant on interactions within relationships, which lead to a perceived mutual relationship where one is able to exchange both physical resources and emotional support, such as love, trust, and empathy (Gottlieb & Bergen, 2010).
Social support as a concept arose from the observation that those who have stronger relationships or bonds with other people have a higher tolerance for stress, or resilience, and have better health outcomes. For example, increased social support is correlated with increased birth outcomes (Hoffman & Hatch, 1996), is able to attenuate the impact of intense social stress, such as bereavement (Krause, 1986), and can decrease the perception of somatic pain (Brown et al., 2003). Mothers who experience NVP often feel socially unsupported, especially from healthcare workers, which significantly affects their mental health and compromises their fetuses’ health (Parker, 1997). Mothers’ with NVP indicate that the sense of feeling emotionally supported, listened to, and validated is one of the most important things to them (Ericson et al., 2013; Parker, 1997). In other words, they desire feelings of social support, which includes feelings of confirmation and emotional support within their relationships. In order to maximize feelings of social support in mothers, another source of social support could be added in the form of group therapy. Additionally, feelings of social support could be increased within their established social network by educating health care professionals on the experiences of patients with NVP.
Group therapy is an effective way to implement feelings of social support for people who experience a variety of stresses (Mallinckrodt, 1989). Patients with similar experiences greatly benefit from group therapy through increased feelings of social support (Mallinckrodt, 1989). Group therapy strengthens feelings of emotional bonding and reliable alliance (or that others can be counted on for help), which leads to improvement in self-esteem, reduction in depression, affirmation of competency, and feelings of reassurance (Mallinckrodt, 1989). Group therapy also helps patients feel as if their group members understand their anxieties, and that their group members can help them cope with the stresses they all similarly experience. Additionally, patients in group therapy are given an opportunity to nurture and provide support for others, which gives the same social support benefits to the provider as the receiver of support (Mallinckrodt & Fretz, 1988). These positive outcomes associated with group therapy fit with the negative emotional byproducts of NVP, which indicates that an NVP themed group therapy could decrease the feelings of isolation, depression, invalidation, and other psychosocial symptoms resulting from their stressful symptomatic experiences (Munch, 2002; O’Brian, Evans, & White-McDonald, 2002). Participants within theme group therapies show increased perceived availability of guidance support, or available advice and confidants, showing that direct advice, even if it may not be useful, is more welcomed from people who have experienced similar trauma (Gottlieb, 1983; Lehman, Ellard, & Wortman, 1986). This creates a stronger emotional, trustworthy bond between group members, which could help women with NVP because they are often unable to trust medical professionals’ advice as they feel their traumatic experiences are disregarded (Parker, 1997).
Although group therapy offers many benefits for women with NVP, group therapy is a implemented in response to a lack of social support within their support network. On the other hand, social support from a more direct part of patients’ social network, or outside of therapy, seems to be the most beneficial intervention in decreasing negative psychological symptoms (Mallinckrodt, 1989). Teaching healthcare professionals to be more humanistic and supportive could be the most valuable mediation in decreasing the maladaptive psychosocial symptoms of NVP. Therefore, I propose that treatment of NVP should not only include a group therapy component, but also an increased awareness in the medical field about these reactionary psychological symptoms, and how to better communicate with patients to prevent it altogether.
Proposed Treatments
I propose that conjunction with group therapy, health care professionals must have an opportunity to learn about the psychological stress experienced by their patients with NVP and validate their experiences. Group therapy is an important reactionary fix to the psychological stress induced by the experience of NVP, however, in order to prevent much of the loneliness, depression, and guilt experienced by patients with NVP, health care professionals must learn to communicate to their patients in a humanistic, empathetic way (Munch, 2002; O’Brian, Evans, & White-McDonald, 2002; Parker, 1997).
Group therapy should include small groups of mothers experiencing NVP. All patients should have similar psychological and physical experiences with NVP, in order to promote the most nurturing and collaborative community (Gottlieb, 1983). The facilitator of the group should be a psychiatrist that is well-educated in the physical and psychological symptoms of NVP, as well as have knowledge of how NVP is commonly viewed and treated within the medical field. This previous knowledge would enable the psychiatrist to intentionally facilitate discussion to stimulate feelings of of social support, as discussed in the previous section. Long term therapy attendance should be controlled individually, giving the patients as much control as possible, as patients often feel a lack of control due to the symptoms (Ericson et al., 2013). It should be a continuous session, allowing the addition and subtraction of members based on patient choice. The addition of new members gives more opportunities to increase social support within the group (Mallinckrodt, 1989). Group therapy is meant to help alleviate any psychological symptoms and stress to assure the embryo protective mechanism of NVP remains intact. Specifically, the reduction of possible negative birth outcomes derived from stress leads to less interference between the stress mechanism and the embryo protection mechanism of NVP, amplifying birth outcomes.
An important preventative intervention for the progression of psychological symptoms of patients with NVP is to educate healthcare professionals on how to properly communicate with their patients. Health care professionals who have a positive bedside manner, or provide general support and reassurance, have significant positive impacts on patient health outcomes (Blasi, et al., 2001). Having humanistic approaches, such as actively listening, having respect, and being empathetic, is very important to patients’ experience with disease, and is something that many patients with NVP could benefit from (Locock et al., 2008; Parker, 1997). Indeed, many women with NVP would appreciate increased acknowledgement of their distress, as opposed to the common downplaying or trivialization of NVP (Locock et al., 2008). As previously described, the invalidation of NVP from health care practitioners contributes to psychopathology, however these negative experiences could potentially be improved from having a humanistic and empathetic bedside manner (Parker, 1997). Additionally, educating medical professionals who frequently work with patients with NVP on the physical and psychological experiences of NVP would lead to increased empathy and improved bedside manner. I propose that because NVP is a relatively common experience during pregnancy, there should be increased quality and quantity of the conversation about the psychological and physical effects of NVP with health care professionals, specifically when they initially learn about NVP. The initial conversation about NVP should include the negative psychosocial effects of NVP and how it may cause more harm to the baby (Flaxman & Sherman, 2000). Building a holistic representation of NVP during initial learning will influence how patients are treated in the future, as original experiences with concepts greatly bias future experiences with the same or similar concepts (Baxter, 2000). In addition to changing the perception of NVP during primary stages of professional learning, medical professional schools should work to improve bedside manner through increased humanistic role modeling (Weissman et al., 2006). Successful teaching of bedside manner includes teachers using intentional and conscious modeling behaviors, ultimately leading to longitudinal impacts on how future health care professionals treat their patients (Weissman et al., 2006). Specifically, during primary learning of bedside manner, increasing the presence of behaviors within the categories of positive nonverbal communication, overt demonstrations of respect, building a personal connection with the patients, eliciting and addressing patients’ affective response to illness, and caretakers’ self-awareness gives rise to more empathetic and humanistic patient experiences, and therefore, better health outcomes (Blasi, et al., 2001; Locock et al., 2008; Weissman et al., 2006). Improved bedside manner and empathy will help progress the clinical experience with patients with NVP, as these positive psychological experiences of increased feelings of social support could lessen the maladaptive psychopathology, and therefore, lessen the counter interaction with the embryo-protective mechanism of NVP.
Conclusion
Through the lens of the widely accepted embryo protection hypothesis, I propose to eliminate medications and other somatic symptomatic alleviations in order to allow for the protective mechanism of NVP to take place. However, the psychological consequences of the overall stressful social and physical experience of NVP conflicts with the embryo protection hypothesis as psychosocial stress leads to negative birth outcomes (Attard et al, 2002; Flaxman & Sherman, 2008; Mazzotta, Magee, & Koren, 1997). In order to truly maximize the evolutionarily protective processes of NVP, the conflicting psychological effects must be reduced and prevented by implementing social support. Social support is shown to decrease psychopathology and social stress (Collins et al., 1993). By providing NVP-based group therapy as a means to increase feelings of social support outside of patients’ caretaker network, as well as preventing invalidating and isolating communications between primary healthcare workers and patients through improved beside manner teaching techniques, feelings of social support can be increased and will consequently boost the success of the embryo protective mechanism. These proposed solutions support the embryo protection hypothesis, and allow for evolutionarily selected mechanisms to protect the mother and embryo naturally and successfully.