The practice of toning in pregnancy and labour: participant experiences Beverly Pierce

Women, primarily from the author's childbirth education classes, were taught the practice of toning, i.e. voicing the exhalation of breath on a single pitch, using a vowel sound or a hum. Women were encouraged to explore toning during pregnancy and use it as a resource for labour. Postpartum, 22 women described their experiences with tone, pointing to a variety of effects such as increased ability to cope with pain, useful forms of focus, feelings of connection with nature, bodily vibration, relaxation, emotional release, diminished anxiety and a greater sense of power. Holistic aspects of breath and tone are described, as are specific applications of toning for pregnancy and labour. Carers who wish to use tone with clients are encouraged to develop a personal toning practice.

Even today, some

pregant women

admit that one of

their fears about labour is the way

they will sound.

Beverly Pierce BA, MLS, MHD, Childbirth Educator, 206 Winona Street, Northfield, Minnesota 55057, USA Tel: (507) 645-5422; Fax: (507) 646-3734; E-mail: pierceb@stolaf.edu

B R E A T H A N D V O I C E IN L A B O U R

The subject of breath has been a staple of childbirth education since the work of Fernand Lamaze in France in the middle of this century (1956). According to the Lamaze method, the labouring woman consciously alters the rate and depth of her breath according to the intensity of labour, and may count her breaths, interspersing short 'blows' at intervals (Bing 1994). Some programmes developed after Lamaze do not employ controlled breathing, but rather emphasize the benefits of relaxed dia- phragmatic, or abdominal, breath (e.g. Bradley 1974, Daub 1986). Nevertheless, beginning with Lamaze, a central tenet of childbirth education has been that breath not only supplies oxygen, but also supports a woman's mental and emotional well- being through labour.

It is noteworthy that though we hear much in birth classes about breath, we hear little about voice. A goal of Lamaze-inspired education was to equip the pregnant woman with mental tools such that, even in the most intense labour, she could stay 'in control' (Noble 1983). Breathing techniques were demon- strated soundlessly in class, to be practised at home the same way. An implicit message was conveyed that giving voice to emotion or effort in labour was not done, was perhaps a sign of being 'out of con- trol'. Even today, some pregant women admit that one of their fears about labour is the way they will sound. Some birth attendants, perhaps sensitive to the hospital setting, actively discourage vocalization.

A few educators and practitioners (e.g. Balaskas 1992, Noble 1983, 1988, 1993, Peterson 1984, Lowe 1996) have identified beneficial effects associated with making sound in labour. The author' s introduc- tion occurred during 12 years as a birthing mother, practitioner of vocal toning and childbirth educator

(see Box).

S T U D Y M E T H O D

To 'tone' is to voice the length of the exhalation of a breath on a single pitch, using a vowel sound or a hum (tone differs from chant in that it has neither melody nor words). To study the value of toning in pregnancy and labour, the author introduced the sub- ject in her childbirth classes. Presentation included cognitive, experiential and audiovisual components. Some physiological and psychological aspects of toning were described; toning was demonstrated and tried out in class; and a videotape was shown and discussed, depicting a labour and birth in which the mother vocalizes consistently through contractions (Noble 1988). Toning homework ( 'humwork') was assigned over a series of weeks, and feedback elicited during class.

Responses varied. Of 18 women in classes, five did not report doing any 'humwork'. Three tried and found it uncongenial. Another toned sporadically. Of those who toned every week, three toned twice, two 3-4 times, one 5-6 times, and three 7-8 times per week. A few spouses toned with their partners.

Complementary Therapies in Nursing & Midwifery (I 998) 4, 4146 �9 1998 Harcourt Brace & Co. Ltd

42 Complementary Therapies in Nursing & Midwifery

. . . 'Toning

a lways shi f ted my

energy pa t t e rns

to a more

harmon ious

w h o l e ' . . .

While labouring with my daughter, I found myself spontaneously moaning long, low sounds that carried me through each contraction until her birth. My nurse- midwife and doctor did not object to my way of coping, though a nurse who was present told me to 'keep it inside' (an ambiguous thing to say to a woman birthing a baby). Afterwards I forgot how I had felt while making these sounds. Voice and body had worked together so naturally, I didn't reflect why.

Seven years later, I took a course called 'Curative Aspects of Breath and Tone', developed by Don Campbell o f the Institute for Music, Health and Education (IMHE). I learned to 'tone', to voice the exhalation of breath on a single pitch, using a vowel sound or a hum. The course involved toning 15 minutes twice a day, five days a week, for 12 weeks, and journalling the experience. Towards the end, the assignment was to experiment with tone to find what vowel and pitch would best resonate a particular area of the body. On the day that was to focus on the lower abdomen, I wrote:

I realized, as I was Ah-ing for so long, that I sounded pretty much the way I did in labour. . . I know that Ah loosens the jaw, which loosens the pelvis. But this time I began thinking about the effect of the resonance itself on the pelvis, musculature, and process of labour. If resonance focuses energy on a specific part of the body, this is clearly positive in labour. Also, IowAh feels to me like a way to stay grounded - important in labour. It's also nurturing to an area of stress and moves energy, not letting it get stuck.

I continued to tone, completing three levels of the IMHE work and becoming a mentor in the programme. I also became a childbirth educator, certified by the holistic Birth Works programme, and began to teach toning to women and couples in small classes, with useful results.

Postpartum, informal feedback regarding toning in labour was positive, even from some who had toned little or not at all during pregnancy.

To gather systematic data, a survey was devised, reviewed by a psychologist experienced in survey methods, and mailed to all 23 women who had attended these classes to date. Surveys were returned by 17 (74%). One woman who did not return a survey had, nevertheless, journalled extensively. Data from her journal are included below. Further, two women responded to the survey postpartum who had not been in class but were pregnant while in the IMHE Therapeutic Sound School (see box). A fourth woman, referred to the author for telephone consulta- tion, also completed the survey, and a fifth (who learned about toning from another source) telephoned later and discussed her birth experience. Therefore, this paper is drawn from the toning experience of 22 women and couples. Their responses are summarized and quoted, with pseudonyms.

TONING EXPERIENCES IN PREGNANCY

Of the 22 women, 17 (77%) toned at least once out- side of class during pregnancy. In describing the

experience, four of the 17 (24%) mentioned physical relaxation. Anne, a psychologist with a high-stress job, observed 'after about a minute of toning, I can feel my wrists and neck and shoulders all start to relax'. Beth, a chiropractor, wrote 'It seemed to be relaxing, especially facial and temporomandibular joint ' . In addition, three women (18%) described an emotional calming or allaying of anxiety. Carrie said 'I toned to calm my uneasy feeling'.

Three other women (18%) described experiences related to physical relaxation or emotional calm, yet verging on the mental or spiritual. Dana said 'The toning would always help me align and focus inter- nally. I could block out any unwanted noise or distraction.' Emma commented that 'Toning always shifted my energy patterns to a more harmonious whole' and Frances felt that 'Toning brought an "other-worldly" feeling'.

Frances added 'I like the vibrations toning sent through my body'. This observation is interesting in light of her comment that, in the past, she had been 'negatively focused on body image'. Four other women also noted that toning stimulated physical vibration. Gall worked actively with the sensation:

[I would] visualize or feel where [the vowel tone] resonated in my body. I would usually try to find sounds that resonated in the pelvis, exploring moving it down the birth canal.

Of 17 women who toned in pregnancy, five (29%) experienced bodily vibration, which they identified as positive, and one developed this awareness into an extended exploration.

This is a recurring theme among respondents. Women (and some men) played with toning, made personal discoveries and then intentionally used what they had found to foster well-being and prepare for labour. Frances realized that her favourite sound, 'oh' , suggested a visual image: 'I imagined my cervix like an " O " gradually opening up'. Dana 'practised toning, trying to find sounds that fit, while driving in my car alone. As the pregnancy pro- gressed, I 'd tone "ahh" and open "ohh" during Braxton-Hicks contractions, sometimes in combina- tion with squatting.' Helen wrote:

My husband [Ira] would give me a nightly mas- sage and if I had a muscle tightening I would tone through the massage as it was painful . . . At first, I would scream or pull away . . . I learned to work through the pain by toning 'oh' , 'ah'.

Finding voice

The concept of 'voice' is often used as a metaphor for self-knowing and authentic expression. One speaks of a good writer as having found his or her 'voice'. Carol Gilligan (1982) called her landmark study of women's moral development In a Different

Voice. Belenky et al (1986), studying women's cog- nitive styles, found that women used a great variety

Toning in pregnancy and labour 43

'It he lped m e to

f o c u s and release

into the p a i n ' . . .

of voice-related metaphors when describing their self-understanding and personal development.

Music therapist Laurie Rugenstein (1992) has described helping women to rediscover inner resources through the sounding of their voices.

In this study, two women's experiences suggest that a practice of toning may support integration of self and voice through the stress and growth-time of pregnancy. During an unsettled first half of preg- nancy, Anne repeatedly doubted and reconsidered

decisions she had made about her obstetrical care. Ten days after beginning toning, she wrote: '[Toning is] helping me feel calmer about myself,

my choices, and my autonomy. I 'm feeling more confident after each session' and 'Hate my wavery voice!'One week later, she wrote 'I sound less tenta- tive' and in the last week of her journal: 'I do now

look forward to toning sessions' and 'I feel focused'. Another woman, Jane, toned and improvised

songs during her pregnancy. She reflected:

I guess I believe that women have need to prac- tise their voice, giving voice, for generations. We

are often too timid in what we say. In pregnancy and birthing, I was connecting with some

rhythms and sounds that made me feel a powerful connection to earth energies. I found that vocaliz- ing ... promoted my sense of well-being and my groundedness during pregnancy.

Toning experiences in labour

Of 21 women who laboured, 18 (86%) used tone. One woman did not labour but had a scheduled caesarean section because of diagnosed fetal anoma- lies. Fortunately, the baby was found to be normal

when she was delivered. The two most common themes these women expressed were that toning helped them to cope with pain and that toning pro- vided 'focus' in labour.

Pain was explicitly mentioned by 11 (61%) of

those who toned in labour. Two women specified that toning helped them to avoid pain medications. Frances felt that toning 'helped lessen the pain',

though Kate spoke for the majority when she wrote that 'it didn't ease the pain . . . but it made the pain

more bearable'. Comparing this labour with a previ- ous, Kate added 'I didn't feel as much of a need to escape my body and the pain. Maybe this was

because I was working with the pain (toning during the contractions while the contractions did their work)'. Different women described their use of tone differently. Gall wrote 'It helped me to focus and release into the pain' while Helen said 'the vowel sound had to last the duration of the contraction for me to deal with the overwhelming pain sensations'. Lucy added 'The more it hurt, the lower I 'd bring the sound'. Jane had 'unproductive' back labour and

'lots of pain'. She stated 'I grunted, groaned, prayed, used the word "open" a lot, [but toning] did not feel as effective as I had hoped during labour'.

Tonal focus

The frequency of references to 'focus' is interesting (9 out of 18, or 50%) as this was not a word used in class to describe toning. However, its occurrence in

the surveys may reflect the well-known Lamaze practice of using a visual focal point during contrac- tions. Women who perceived tone as 'focus' described the tonal focus as variously, a way into themselves or into their labour, a way through emo- tional-physical work, or a way out of overwhelming sensation. These several perceptions suggest that

(unlike a visual focus, which is external and static) tone, internal to the woman herself, is a flexible, moving energy, able to support one or more pre-

ferred metaphors for coping with labour. Four women described their tonal focus as a way

in. Marina, who had found toning 'silly' in preg- nancy, said 'It made me focus on my inside self'. Dana believed 'The sounds were essential to my ability to focus . . . Toning brought me inside'. Frances said '[Toning] gave me an inner focus. It provided catharsis'.

Frances' perception of catharsis (release or pur- gation) was echoed by two women who seemed to experience the tonal focus as a way through. Naomi,

who earlier had 'felt like a complete weirdo' while toning, wrote: '[It] gave me focus, freedom to emote, and the emoting helped cope with, as well as allow the contraction to do its work, and open'.

Three other women found the tonal focus a way out, a distraction from pain. Olivia said 'The toning

helped me focus on something else than the pain' and Kate added:

It helped not just because it gave me something to do (because the breathing techniques do that and yet didn't work as well), but also because it seemed to keep me grounded and it also gave my

body and mind another 'sensation' to focus on, notice.

Nature, power, energy

Of these 18 women, 6 (33%) described toning in labour as 'natural', 'primitive' or 'ancient' (not terms used in class). Frances said 'There is some- thing animal about it. Helps me feel connected to nature and how things really are'.

Five women (28%) addressed the theme of power. Carrie, after a hard, 2-hour labour with her first baby, wrote: 'I toned rather intensely ... It made me feel better and I gained some amount of control out of such a speedy, chaotic labour'. Gall mentioned that 'It gave me a better sense of my personal power' and Frances said 'Loud, high intensity toning definitely

helped me feel stronger and helped me release'. Five (28%) experienced toning as an energy

movement collaborating with the energy of labour. Dana said 'Toning was like releasing the excess energy of each contraction out of my mouth', and

Naomi, quoted above, wrote that toning gave her

44 Complementary Therapies in Nursing & Midwifery

... one can use

breath or tone to

slow heart rate . . .

promoting

physical

relaxation and

(especially in

labour)

conserving

energy.

'freedom to emote, and the emoting helped ... allow the contraction to do its work, and open'.

Five (28%) reported that pitching their tone low helped them to stay relaxed, or to guide or conserve their energy. Three had others help them with this: two did it on their own. Helen wrote '[Ira] would

remind me to keep my tonation at a lower register so that I was sending vibrations to the lower pelvic region'. Polly, who had found toning 'awkward' in

pregnancy, wrote: 'While I was pushing, once the tone got high and frantic. I could tell that I was tens- ing and not relaxing. Bringing the tone down low, and slowing it down helped me feel relaxed and open again.'

'Permission'

Three women (one who toned in labour and two of the three who reported not toning in labour) alluded to the question of 'permission'. Gail said 'Having [a toning companion] gave me permission to use what-

ever toning or sound felt right. I felt supported.' Emma, who had considerable past toning experi- ence, wrote:

Even though I was aware that toning would assist the birthing process and even though my mate and

midwife were aware of my toning practice, they never brought the subject up and I did not give myself permission to sound out loud. I needed ... someone to help me know that toning, vocalizing,

would be 'okay' ... Because I was 'separated' from my voice during the birth, it was a good experience but not a whole experience. There was tension within me that needed to be taken care of and the sounds would have been the key.

Anne's ambivalence regarding her voice was described earlier. Near the end of her journal, she mentioned twice that she 'hate[d] the thought of toning in front of other people'. She did not tone in labour, commenting afterwards 'I should have ... I think the toning would have helped'.

Toning to allay anxiety in labour was mentioned in three responses (17%). Naomi lowered her pitch when 'freaked out and losing grip'. Dana believed 'If I stopped toning, I 'd feel scared and lose my con- fidence'. Jane wrote:

I was experiencing panic attacks part way through my labour . . . . When I needed to be calmed down, my husband could hold me in a spoon position, my back tucked into his belly and chest, and he would do deep bass tones of ohmm

or humm ... and those vibrations served to help calm me down and reduce the fear and anxiety. It brought me back into my body.

Toning together

Four couples (22%) reported toning together in labour. Rachel and Sean had toned together several

times in pregnancy: 'I found the lower resonance

of his voice very pleasant and relaxing . . . I liked . . . being front to front with the baby between us, and the resonance it must have felt from both of us'. They toned also in labour (in 'spoon position') and appreciated her doctor's comment of 'I don't know what they're doing, but whatever it is, it 's

working'. Helen and Ira toned in hospital as well. Helen said 'My spouse toned with me occasionally to help me lower my register and also to help me harmonize and create a stronger vibration in the

room'. Ira said 'When she and l toned together in harmony, it was as if we three (baby included) were encapsulated in a sphere of pure light, energy

and vibration'.

HOLISTIC ASPECTS OF BREATH AND TONE

Because toning voices breath so simply, it is similar

to natural abdominal breathing. Both toning and slow, deep breathing stimulate the phenomenon of 'entrainment', by which natural body rhythms of respiration, heart rate and brain waves automatically coordinate (Goldman 1991). Slowing one of the

rhythms slows the others, and accelerating one accelerates the others. As respiration is both a volun- tary and an involuntary function, one can use breath or tone to slow heart rate and brain waves intention-

ally, promoting physical relaxation and (especially in labour) conserving energy.

Brain wave frequencies correlate not only with body rhythms but also with states of consciousness.

Higher frequencies (beta waves) correlate with alertness and outer-directed activity, while lower frequencies (alpha, theta, delta) relate to inward and meditative states (Goldman 1991). Obstetrician Michel Odent (1984) has described what many birth attendants observe - 'As a woman moves more deeply into labour, her awareness shifts from the outer world to an inner world of her own. If active labour is associated with lower brain wave frequen- cies, then by slowing and lengthening the breath or by toning, a woman may be able to alter her con- sciousness and facilitate labour.'

Body rhythms are also associated with emotions. The following small experiment proves this. Breathe

deeply and slowly (in through the nose, out through the mouth) for 90 seconds, and then assess emotional state. Next, breathe rapidly and shallowly for 90 sec-

onds, and reassess. To the extent that rapid respira- tions relate to sympathetic arousal and heightened

anxiety, it would seem that relaxed abdominal breath, or toning, is more conducive to emotional comfort in labour than is fast, shallow breath.

Lastly, it is worthwhile to notice ancient, cross- cultural associations between the concept of 'breath' and that of 'spirit'. Latin spiritus, Greek pneuma and Hebrew ruach mean both 'spirit' and 'breath' simul- taneously. However one may understand 'spirit', it

Toning in pregnancy and labour 45

would seem that breath and tone support its free flow through the pregnant woman and her fetus.

TONING, PREGNANCY AND BIRTH

While abdominal breathing and toning have some effects in common, tone has further qualities that make it useful for pregnancy and birth.

�9 Tone is vibratory. It stimulates physical vibration in the body, which some experience as internal massage. A pregnant woman can work with this sensation - locate it, visualize it, associate it with imagery, and move or alter it as part of her labour preparation and labour coping (Gall, Frances). Toning in hospital, especially with a partner, can create a vibratory 'room of one's own', pro- moting feelings of safety and protection (Helen and Ira). Labouring in an unfamiliar or unpleasant environment has been shown to increase pain perception (Lowe 1996).

�9 Tone is resonated in the body. As breath 'embodied' , tone may feel more 'grounding' to labouring women than does breath by itself (Kate, Jane). Toning does not lead to the dizziness or hyperventilation that can accompany some breathing patterns.

�9 Tone is audible. Toning the full length of an exhal- ation, especially in labour, can give a woman and her carets sensitive auditory feedback about level of relaxation and mental-emotional state. Self- listening can help a woman to tune in to her body and her needs (Anne, Polly). Carets who listen can develop pregnancy and labour interventions relating to length of tone, pitch, volume, placement or direction of vibration, imagery, and so on.

�9 Tone moves. When receiving therapeutic massage, a woman can tone in response to physical movement, collaborating vocally with sensation, as a way to prepare for labour (Helen). Tone moves emotions also. In pregnancy, tone can express confused feelings; and in labour, when being wordy is not helpful, it can release unnecessary tension. Women and carers may fear vocal release in labour as being 'out of control', but tone in labour is usually long, relatively low- pitched, intense and centred. Nurse-midwife Nancy K. Lowe (1996) points out that when labour vocalization is understood and supported, it is not a terrified scream. Movement of sound can help a woman to navigate extremely difficult passages (Naomi, Carrie).

�9 Tone is pre-verbal and pre-melodic. Tone is a function of primitive mammalian centres relating to instincts, emotional states and 'fight or flight' responses (Campbell 1989), not a higher, neocortical function (which may explain why some experience it as 'silly' or 'weird'). In an individual under stress, the hypothalamus activates arousal responses such as increased

heart rate, blood pressure, mental activity and physical tension; rapid, shallow respirations; and shunting of blood away from abdominal organs, including the uterus. Tone, audible language of the mammalian brain, can alleviate arousal responses that may be counter-productive in pregnancy and labour, and may help a woman to access instinctual birthing and mothering behaviours. Women who described toning in labour as 'natural', 'primitive', 'ancient' or 'animal' seem to have felt this.

�9 Due to these qualities of tone, a woman in labour has a variety of ways to cope with pain, such as using vibration to support physical and emotional release, allowing a partner to support her with his vibration, using an auditory focus (perceived and used variously) and allowing herself to collaborate with and/or guide intense energies.

�9 Due to as yet unidentified factors, toning may enable some people to reduce pain sensation itself (Frances). Anecdotal evidence from individuals with advanced toning experience supports this possibility (Campbell 1997). A survey of 54 toning practitioners (Adams 1994) found that those with less than 3 months' toning experience described tone as changing their 'physical or emotional' pain 'slightly', while those with more than 5 months' experience stated that tone changed their pain 'moderately' to 'quite a bit ' . With research, pain-reducing mechanisms of tone may be identified. Toning may stimulate endorphin release. It may also alter time perception. Dossey (1982) has suggested that the effectiveness of conventional analgesia is related in part to its altering the patient' s sense of time. Campbell (1997) has described toning as participating in 'non-ordinary time', and some practitioners state they lose track of time while toning.

�9 Tone, breath embodied, is understood by some as interrelating spirit and matter. Traditional Indian vocalist Sri Karunamayee has stated:

[W]hen you hum . . . the breath is going deep from where it came . . . [W]hen you take the breath with music it sustains you. The sus- tained sound naturally sustains. And [when] you add . . . the simplest mantra, 'Aum, Auuuum', with your breath you go into sound . . . And this is being one with the ' S p a n d a ' -

the basic thing that sustains the whole cosmos, creation, which is always passing through us.

(Maslan & Allekote 1996)

Sounded breath is 'sustaining', a quality needed by labouring women. Sri Karunamayee has stated that by sounding a combination of toned vowels and a hum - 'Auuuum', one participates in the energy of creation itself, a view that may be especially meaningful in childbearing,

�9 Toning is a discipline. Like jogging and other disciplines, it can become an addictive

46 Complementary Therapies in Nursing & Midwifery

. . . tone is a

suppor t i ve a n d

adap tab le

m e d i u m . . .

behaviour , though this is rare. Toning 15 to 30

minutes a day in one or two sessions, 5 days a

week, is ample for a woman to develop

relaxation, self- l istening and labour coping skills.

CONCLUSION

This paper documents the subject ive exper iences of

22 women who used tone in pregnancy and/or

labour and suggests theoretical foundat ion for

reported effects. The women described a range of

experiences, including an increased ability to cope

with pain, personally useful forms of focus, connect-

edness with nature, bodily vibration, relaxation,

emot ional release, d iminished anxiety, greater self-

confidence, awareness of power, a capacity for play-

ing with and guiding energy, and the use of sound to

facilitate imagery.

Practices of toning and relaxed abdominal

breathing share benefi ts in common. Toning appears

to have further usefulness in pregnancy and labour,

relat ing to factors such as vibration, sound, physical

movement , emot ional expression, s t imulat ion of

subcortical brain centres, endorphin release, alter-

ation of t ime sense, and connect ion with a larger

creative, sustaining dimension.

As tone is a support ive and adaptable medium,

each w o m a n ' s exper ience is individual and valid. As

it is literally a monotonous practice, it is not accept-

able to everyone. Caters can be very open to the

nature of each w o m a n ' s use, or non-use, of tone.

Nonetheless , when it is introduced, even some who

tone little in pregnancy may use it effectively when

needed. Polly had toned twice, but when in active

labour she found hersel f spontaneously combin ing

tone with an altered state of consciousness and a

strong self-image:

Near transit ion I began to tone without a lot of

conscious t h o u g h t . . . It really helped me to cope

with the extreme intensity of those powerful con-

tractions. I went deep inside myself, with my

eyes closed, and let the sound radiate f rom my

whole body.

Carers who wish to integrate toning into their

research and practice are encouraged to develop per-

sonal experience. Don Campbe l l ' s The Roar of Silence (1989) contains useful introduct ion and

exercises. Joy Gardner -Gordon ' s The Healing Voice (1993) covers the subject more generally. As initiat-

ing a toning practice can be a challenge, the support

and feedback of a mentor may be very helpful.

Avenues for research, in addit ion to labour applica-

tions, might include toning effects on hyper tension

in pregnancy; on ca techolamine and cortisol levels

in pregnancy and labour; on the emot ions and

adjustment of pregnant women with a history of

physical abuse; or on the ability of babies to organ-

ize and quiet themselves postpartum.

ACKNOWLEDGEMENTS

The author is grateful to her students for their rich and varied perspectives on toning; to Don Campbell for his enthusiasm regarding this project; and to Kathleen M. Galotti PhD and Bill Poehlmann PhD for indispensable advice.

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