To Partners, Employers, and the Media
Nausea and Vomiting of Pregnancy (NVP), or “morning sickness”, is the most common complication experienced by pregnant women, affecting up to 80% to 90% to some degree – a condition often underestimated and oversimplified.
While some women experience mild NVP or none at all, studies indicate the vast majority will suffer from moderate to severe NVP for varying amounts of time. However, current obstetric textbooks, student guidebooks, and mainstream pregnancy books only give the condition a few paragraphs.
Further, online articles on numerous different sites seem to share the same dozen tips. This leads pregnant women to believe the condition is easy, can be relieved relatively quickly with ginger and frequent small meals, and is therefore not worth much time or resources from anyone – women are on their own.
But women are begging for help – and they are not asking for much. Less judgment, more empathy, support, the ability to talk, and less worry and concern over childcare, employment, finances and housework, so they can focus on their physical symptoms. Most importantly, they just want to be believed.
Advocates of NVP education are fighting more than 200 years of misinformation.
The term “morning sickness” was reportedly used for the first time in 1803 and has therefore had more than two centuries years to stick. A study published in 1918 added weight to this term and indicated the majority of “morning sickness” cases occurred in the morning, disappeared during the day, and returned the next morning, perpetuating the misbelief that an empty stomach was the sole responsible factor.
Further, the “morning” part of NVP was still actively promoted as recently as 1980, with a popular pregnancy book telling women that NVP “rarely” occurred at other times of the day, and was most likely because a woman was tired and needed to “get away”.
Researchers now know that up to 80% of women experience all-day symptoms, while less than 2% report symptoms that occur only in the morning. In addition, eating usually does very little to relieve symptoms, especially when severe. Eating, may however, work in women in whom an empty stomach is a contributing factor.
NVP is Not a Stomach Bug
First – NVP is not a stomach bug or a case of food poisoning; it’s “food poisoning” for weeks; all day misery that is not cured by food or sleep; a type of nausea that comes and goes, peaks and wanes, and causes a kind of vomiting that does not provide instant relief.
NVP is also not solely in the stomach. Different aspects of the central nervous system are involved, and simply eating or not eating will not always relieve NVP symptoms. Women simply eat to get through another day.
Although stomach viruses and NVP produce similar symptoms, the mechanisms are very different, therefore the management is different. “Anti-nausea” techniques such as ginger, ice water, broth, toast, and crackers are based on the treatment of gastrointestinal illnesses that result from foodborne illnesses or viruses. These tips are useful for recovery in these cases; but they are not always very useful, nor do they eliminate nausea in NVP.
These tips may help for NVP in that women still need to eat and drink, and when women are actively nauseous or are vomiting, these foods can help nausea from getting worse so they can eat least eat something. However, partners and family members should not assume crackers or ginger will fix the condition all together.
For example, if the cause of one woman’s NVP is a sensitivity to an increase in hormones which is acting on her central nervous system, whether she eats ginger or crackers will not make a difference. Those items just hopefully will not make her nausea any worse.
NVP is difficult to mentally cope with and can last a long time. For example, when non-pregnant individuals get a stomach virus, everyone knows the physical symptoms are awful – but mentally coping is easier because there is always a fast light at the end of the tunnel. Most people can think, "I will feel better by morning".
This does not occur with NVP. Women have no idea when it will end. It can go away tomorrow, or it can last for months. They have no choice but to take one day at a time, and partners, family members, and employers need to help them do this.
It is estimated that only about 50% of NVP cases resolve by 14 weeks, and 90% by 22 weeks. Up to 10% of women will experience symptoms beyond 22 weeks, to include up until delivery. Symptoms that continue up to 16 to 18 weeks before completely improving is considered normal. Further, NVP symptoms are estimated to last an average of five to eight weeks (35 to 56 days).
The effects of NVP are compounding and progressive. The longer a woman experiences NVP without adequate support from family/HCPs, the higher the risk for complications (read more).
Causes and Contributing Factors
The development of NVP is currently assessed to be multifactorial, and different women will experience different combinations of these factors, which is why symptom severity is so variable among women. To date, this is likely the main explanation no "optimal" treatment method has been found for all women (i.e. some women find B6 or ginger helpful, while others find no relief with these methods).
The assessed potential causes, contributing factors, symptoms, and complications of NVP are similar and overlap because what causes NVP vs. what does NVP cause has not been clearly determined or defined.
Many symptoms of pregnancy can make NVP worse, and NVP can make common pregnancy-related symptoms worse. The effective management of one or more may provide significant relief of others. This is going to be different per each individual woman (read Causes and Contributing Factors).
Symptoms and Complications
NVP is also more encompassing than nausea and vomiting; these two symptoms can lead to additional symptoms and complications such as extreme fatigue, dehydration, acid reflux, headaches, dental issues, trouble sleeping, weight loss, malnutrition, electrolyte imbalances, and hospitalization, as well as anxiety and depression.
Management of NVP needs to consider all these symptoms, as NVP occurs simultaneously with other uncomfortable early pregnancy symptoms, and NVP can also cause many others. This is also why unmanaged NVP can sometimes spiral quickly, leaving women feeling that no matter what they do, nothing works.
Further, women (and their HCPs) tend to only focus on the nausea and vomiting, even though some of these methods and medications can make pregnancy-related symptoms worse, which in turn, makes women feel worse.
For example, ginger should not be advised for women with acid reflux or severe vomiting, and some medications should not be used for NVP if a woman is experiencing severe constipation due to pregnancy (read Symptoms and Complications).
Clinical significance is very different from personal significance, which is also known as quality of life. A woman does not have to be severely dehydrated or experience dramatic weight loss to require medical help. Further, some women can have severe NVP and can gain weight if eating is the only thing that keeps nausea away. However, to an HCP this is not viewed as a significant situation physically, therefore the woman may not receive proper care (i.e. weight loss gets more attention).
While dehydration and weight loss are very important, they are not the only factors to consider regarding severity. Stress, anxiety, depression, fatigue, and a lack of sleep are strongly associated with NVP and can all lead to adverse pregnancy outcomes (and so can weight gain) (read Severity).
Hyperemesis Gravidarum (HG) is considered the most severe form of NVP, affecting almost every aspect of a woman’s life (and her family’s) for weeks – usually months. In women with HG, nausea and vomiting is unrelenting, constant, and debilitating.
No amount or method of eating, drinking, sleeping, or distraction can completely ease symptoms – if at all – and in most cases, medications work only mildly or all too temporarily.
HG is a condition that needs to be managed hour-by-hour; it can result in repeat emergency department visits as well as hospitalizations.
Physical, emotional, and mental health support, as well as recognition of the condition by family, friends, and HCPs is critical in the prevention of serious complications, some of which can be life-threatening.
Note: Because there is no hard-line between severe NVP and HG, many women likely fall through this system, are not diagnosed with HG, and therefore do not get more of the supportive/medical care they require (read Hyperemesis Gravidarum).
No Quick Fix
Because of the perception that “morning sickness” is quick and easy to manage, friends and family can become frustrated when a pregnant woman does not suddenly get better or have the energy for normal family functions and responsibilities after a few days.
While plenty of movies reference and show characters with NVP, the character usually vomits once (or is used for a quick laugh) and moves on with her life – this is not the case for most women.
Even in cases where a woman experiences NVP only several hours a day and can feel completely normal other parts of the day, it only takes a week or two for this pattern to become wearisome, taking a physical and mental toll.
It is progressively tiring to manage days and weeks in which nausea is always present, and nothing the woman tries to do appears to be making any difference.
Further, although anti-nausea medication is available during pregnancy, it is complicated:
Research regarding medication safety during pregnancy is fraught with its own complications, therefore women have very few options, and the options that are available come with guilt as a major side effect.
When options that are available for non-pregnant individuals get taken away from pregnant women, the condition becomes that much harder to handle. Family members and (some) HCPs tend to throw up their hands and say “good luck” – there isn’t much more they can do.
Women are then left to figure it out on their own, hour-by-hour, day-to-day until it goes away. It does not have to be this way. Researchers know enough about the condition now to help women relieve some of their symptoms until better treatments become available (read Management Overview).
Patience and understanding are the two most important traits partners/support can show to a pregnant woman with NVP.
Symptoms can be sudden and constant at the same time, changing minute-to-minute, hour-to-hour. NVP takes women by surprise, especially those who expected they could handle it. Managing unrelenting nausea is very difficult, especially as mental and physical coping skills wane over time.
The best support a partner can offer right away is to learn about the condition. Even if they cannot help her in any other way, taking the time to read about what she is going through can ease a tremendous amount off her shoulders.
Fighting nausea on a near constant basis is exhausting and extreme fatigue is inevitable. However, one long nap and one good night sleep is not going to fix it either – it is a long-term management technique, and a necessary one. This requires more childcare, household responsibilities, and patience on the part of the partner/family, but her suffering would be a lot worse without it.
Partners/family members should also recognize that pregnant women with NVP cannot “just do this” or “just eat that”; it is much more complicated. NVP is not caused by the same factors that contribute to other well-known stomach illnesses. Therefore, certain management techniques such as small meals, crackers, water, broth, or ginger do not work for NVP – they are completely different mechanisms.
The only reason they continue to be recommended is women need to eat and drink without making their symptoms worse; but these tips cannot and should not be expected to cure their symptoms (although they may – in a lucky few).
The goal of eating/drinking is to alleviate symptoms enough to try to continue on with the day, avoid dehydration, remain nourished, and maintain enough energy for when symptoms return.
Researchers know a lot more about this condition and its management than even just a generation ago. NVP must be managed early and actively, with everyone in the family playing a role. NVP may completely change a family for months, but not always, and there are many things partners/support can do to make this process easier on not only the pregnant woman, but the entire family.
Every page within this category has a “Partners/Support” section; it is our recommendation that all loved ones who actively support a pregnant woman experiencing NVP – no matter the severity – read through these pages. NVP can by much easier when it is managed as a team/family effort and a close relationship with a supportive HCP.
It is estimated that 206 work hours are lost for each employed woman with NVP, and about a quarter of women may experience impaired job efficiency. Further, NVP accounts for about 28% of all sick leave during pregnancy before week 28, and before maternity leave. Some women with severe NVP/HG can be absent from work their entire pregnancy.
Employers should understand and recognize that NVP symptoms can begin as early as 4 weeks of pregnancy, which is much earlier than most women want to inform other individuals of their pregnancy. Therefore, some women may feel forced to take leave instead of telling anyone else they are pregnant, or instead of requesting accommodations for the same reason.
Having to tell someone at their place of employment of their pregnancy may make some women very uncomfortable, especially if they do not know their supervisor/boss that well. Due to this, some women may also continue to work their job through their symptoms, which can eventually take a physical and mental toll, leading to possible loss of productivity.
In either situation, women are forced to make a decision that may have negative consequences. If she takes leave too often, her job could be in jeopardy. However, if she stays and works through symptoms, and her performance suffers as a result, she could also be in fear for her job.
Places of employment should have systems in place where women can comfortably inform a superior they are pregnant. This method should be private, supportive, and respectful of her wishes regarding informing other coworkers.
Employers should also consider reasonable accommodations that can help a woman feel more comfortable and be more productive without her feeling like she may be forced to take the day off or have her work performance suffer.
Teleworking is the primary and likely best option for many women with NVP. However, if this is not possible, additional accommodations can include (women may only need one of these or several):
The ability to stand or sit when she needs to
Periodic walks/fresh air
Looking away from a screen occasionally to do a different task
Desk/workstation near a bathroom, or a desk with a bit more privacy
Frequent bathroom trips without questioning/monitoring
Breaks during long conferences or meetings
The ability to eat and drink a little when necessary (NVP can create nausea cycles that can only be kept at bay with constant small snacks/fluids)
Accommodations to avoid potential nausea triggers (away from trash cans, break rooms, fumes, bright lights, foods, odors, etc.)
Potential flexibility in the morning or evening, depending on the type of nausea experienced (includes possible temporary shift change)
Reasonable, comfortable temperature at workstation/location
Employers should allow women to suggest reasonable accommodations that are more unique to her that are not mentioned above.
Employers should also understand that even with these changes, a woman could still need to take leave occasionally.
These accommodations are more critical to women than employers realize; it can be embarrassing to feel the need to vomit or throw up in public or in front of coworkers. Additionally, because this type of behavior is very strongly associated with pregnancy, it is a woman’s right not to advertise her pregnancy before she is comfortable.
NVP symptoms are highly variable; a woman can work just fine one week, but need to be out the next. Symptoms can last anywhere from several days to an entire pregnancy (but 5 to 8 weeks on average).
It is time the general public was better educated on the facts of NVP. If all individuals understood the condition better, than every pregnant woman in the future would have a better support system – leading to more positive pregnancy outcomes, for both mother and baby.
Well-publicized, accurate, and detailed information on NVP will:
Create more HCPs sympathetic toward the condition
Potentially ease the burden of emergency departments and health care facilities by giving women, their partners, and their families more tools to manage symptoms and prevent serious complications
Provide the general public with the understanding that this is a real and debilitation condition that affects and burdens many aspects of society (but doesn't have to)
Provide more awareness of the condition in general, and get individuals to stop calling it "morning sickness"
Increase research opportunities as the general public becomes more engaged
Create employer awareness so women can take the time they need to focus on their health (or receive accommodations) without feeling guilty, stressed, or anxious
Provide women more opportunities to improve their emotional and mental health
Nausea and Vomiting of Pregnancy: Committee Opinion 189; January 2018 (American College of Obstetricians and Gynecologists)
Morning Sickness: Nausea and Vomiting of Pregnancy (American College of Obstetricians and Gynecologists)
Pregnancy sickness (nausea and vomiting of pregnancy and hyperemesis gravidarum) (Royal College of Obstetricians and Gynecologists)