This article describes the reactions and perceptions of 122 women who experienced nausea and vomiting of pregnancy (NVP) and who subsequently responded to a questionnaire distributed in the Boston, Massachusetts, metropolitan area between August 1, 1998, and October 1, 1998.
The questionnaire appeared in the Boston Parents’ Paper (BPP) and via the Internet on www.dietitian.com. The NVP economic impact study was approved by the Brigham and Women’s Hospital IRB committee in Boston (Legacy 98-09258/Assurance No. M-1049, Protocol # 1999-P-003137/1). Women evaluated therapies from acupuncture, acupressure, Chinese herbs, massage therapy, homeopathy, ginger, cinnamon, lemon aromatherapy, olfactory reduction, psychiatric intervention, relaxation, prescription medications, and intravenous hydration. We inquired for salary and sick time losses and zip code. Marital status, income, education and gestational age were omitted due to space restriction.
Table 6: Reported efficacy of agents used
NVP affects approximately 75 percent of all pregnancies (1), averaging 17.3 weeks (2). Some degree of NVP appears to protect the fetus. Brandes found a fetal loss of 86.0 per 1000 in women with no NVP, while fetal loss was 49.1 per 1000 in sick women.(3) Consistent negative results are difficult to demonstrate; however, smaller infants are reported.(4, 5, 6) Growth restriction can be mitigated by aggressive intravenous hydration, electrolyte correction, and anti-emetic therapy.(7) A correlation between weight loss, lost work and reduced birth weight exists.(8) In the United Kingdom, 8.6 million hours of paid employment and 5.8 million hours of housework lost due to NVP have been reported.(9) In Australia, 20 percent of women had NVP until delivery (10), while in a racially mixed group of South African women only 5 percent were ill until delivery (11). The latter statistic is similar to morbidity reported in the United States.(12) Gadsby evaluated work losses of 363 women in the United Kingdom and found 73 percent lost an average of 62 hours of work time.(13) Direct health care costs noted in a community hospital in Pennsylvania were $186,000, for an average $2,900 per woman per hospitalization.(14) Nationally, an estimated $130 million in direct financial loss is assigned to NVP.(15)
In our study, 106 women had singleton pregnancies, eight pregnancies were the result of IVF (in vitro fertilization), seven women were pregnant with twins and one with triplets. Data was analyzed via computer programs of Microsoft Access and Microsoft Excel. The rating scale to assess therapy efficacy was a convention of the study originator and is as follows:
0 = did not try
1 = adverse reaction
2 = effective 80% any time used
3 = effective 60% any time used
4 = effective 40% any time used
5 = effective 1–2 times only
6 = effective morning only
7 = effective afternoon only
8 = effective nighttime only
9 = seemed to be effective with other treatments
10 = ineffective
The total salary loss was $316,212, or an average of $2,591.90. Of the 122 women, 43 women (35.2 percent) reported significant disability, which resulted in $7,353.77 loss per sick woman (Tables 1 and 2). Of the women reporting salary loss, 16 percent (n=20) used disability, which could not be assigned a monetary value.
The number of women reporting nausea was 121/122, which computed to 11.8 hr/day of nausea. Forty-five women (36.8 percent) classified their nausea as “constant.” We arbitrarily assigned a value of 16 hours as the definition of “constant,” assuming eight hours of sleep per day. Ninety-nine women had an average of seven vomiting episodes per day. The number of retching episodes was 9.7 per day per respondent (retching is also referred to as “dry heaves”). A cumulative 12,892 hours of sick time was reported, which averaged 105.6 hours per respondent. The sicker women reported more time losses, or 204.63 hours per respondent. Whether women used benefit and vacation time is not known. Women aggressively pursued nausea relief, averaging 6.29 remedies each. In addition to economic losses, 38 percent of women stated family size was limited because of NVP. Eighteen women contemplated abortion, while two subjects (1.6 percent) actually terminated. Nine women were hospitalized for dehydration.
Termination due to NVP/HG (hyperemesis gravidarum) is not new. First employed in France in the 1850s, medically sanctioned abortion has declined as pharmacological interventions developed. Tylden noted in the 1920s and 1930s that HG was a condition of significant mortality, citing a termination rate of 35.6 percent for maternal rescue.(16) By 1938–1939, abortion in Scotland was 14 percent, dropping to 4 percent between 1940 to 1945.(17) A Swedish investigation of 948 pregnancies in 1983, producing 855 live-born infants, showed 56 cases of spontaneous fetal loss, and 25 (2.6 percent) legal terminations. In 12 percent of these cases, emesis was so pronounced and/or of such a long duration that it rendered ordinary work impossible.(18)
The reported client-initiated termination statistic in our study is similar to that reported by Mazzoto of 1.5 percent. (8) The women in the Mazzoto study who aborted vomited an average of 9.3 times a day vs. 6.5 times a day for women who considered abortion but did not follow through. The abortion group, 17 of 1,100 women, had fewer hospitalizations, experienced an average weight loss of 5.9 kilograms and an average of 20 days of work loss. Ten of 17 were offered dimenhydrinate (Dramamine), which was efficacious in only two of 10 cases. One woman found Compazine (prochlorperazine) effective. The two who opted for termination had vomiting episodes of 15 and 20 to 30 times per day and weight losses of 12 and 5–7 kilograms each, respectively, as well as disabilities affecting four months of graduate studies and one month of paid employment, respectively. One woman lost consciousness three times.
Two women aborting in our study reported different profiles. Woman A did not report salary sacrifice, while Woman B reported a $40,000 loss. Both women reported “constant nausea.” Woman A reported 160 hours of sick time and emetic events averaging four per day with five episodes of retching. Woman A used crackers, ginger root and tablets, seasickness bands, and smell reduction. Woman B reported 1080 hours of sick time, 20 episodes of emesis per day with 10 episodes of retching. Woman B employed Compazine, ondansetron, Reglan, Bendectin, droperidol, relaxation techniques, massage therapy, psychotherapy, chewable vitamins, cinnamon, Emetrol, smell reduction, sea sickness bands, acupuncture, acupressure, lemons, crackers, ginger root and tablets, potato chips, raspberry tea, home intravenous therapy and vitamin B6, as well as reporting hospital admissions and intravenous nutrition.
Tables 3–5 show therapies used: alternative and adjunctive, prescription, and over-the-counter or folkloric suggestions. Table 6 summarizes efficacy per client perception.
Our survey indicates a significant psychosocial and economic morbidity associated with NVP. We suggest a more comprehensive, multi-centered study to assess the total costs of this pregnancy problem.
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- Gross, S., Librach, C. & Cecutti, A. 1989. Maternal weight loss associated with hyperemesis gravidarum: a predictor of fetal outcome. Am J Obstet Gynecol 160: 906‑9.
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