Ginger is ineffective for hyperemesis gravidarum, and causes harm: an internet based survey of sufferers.

Abstract

Abstract:

Objective

Ginger is commonly suggested to women experiencing Nausea and Vomiting of Pregnancy (NVP). Evidence for the efficacy of ginger for HG is lacking despite its well-known status. The aim of this study was to assess the efficacy of ginger for controlling symptoms of Hyperemesis Gravidarum (HG) and to investigate possible negative side-effects.

Design

A self selected internet based survey.

Setting:
Participants were recruited principally through social media and were predominantly UK based.

Sample

512 women who had been hospitalised for HG within the past five years.

Methods

Internet survey platform Survey Monkey

Main Outcome Measures

Questions were mostly asked using Likert-type scales with the option for additional free text responses.

Results

Women reported that ginger is often suggested for HG and 87% of respondents have tried it. 88% of those report that it is completely ineffective. 51% of respondents who tried ginger reported that it actually exacerbated symptoms. 82% of women reported that suggestions of ginger caused a worsening of their mood inducing feelings of lack of anger, isolation, guilt and exacerbating the feeling that they are misunderstood. 79% of women who had ginger suggested by an HCP reported that it eroded their trust and confidence in the HCPs.

Conclusions

HCPs should stop suggesting ginger to women with hyperemesis. Not only is it ineffective, but it can cause harm to the sufferer and damages the patient-HCP relationship.

Full text

Pregnancy
ORIGINAL
Objective: Ginger is commonly suggested to women experiencing nausea and vomiting
of pregnancy (NVP). Evidence for the ecacy of ginger for hyperemesis gravidarum (HG)
is lacking despite its well-known status. The aim of this study was to assess the ecacy of
ginger for controlling symptoms of HG and to investigate possible negative side eects.
Design: A self-selected internet-based survey.
Setting: Participants were recruited principally through social media and were
predominantly UK-based.
Sample: 512 women who had been hospitalised for HG within the past ve years.
Methods: Internet survey platform Survey Monkey.
Main outcome measures: Questions were mostly asked using Likert-Type scales with the
option for additional free text responses.
Results: Women reported that ginger is often suggested for HG and 87% of respondents
have tried it. Eighty-eight per cent of those report that it is completely ineective. Fifty-one
per cent of respondents who tried ginger reported that it actually exacerbated symptoms.
Eighty-two per cent of women reported that suggestions of ginger caused a worsening of
their mood, inducing feelings of anger, lack of validation, isolation, guilt and exacerbating
the feeling that they are misunderstood. Seventy-nine per cent of women who had ginger
suggested by a health care professional (HCP) reported that it eroded their trust and
condence in the HCP.
Conclusions: HCPs should stop suggesting ginger to women with hyperemesis. Not only is it
ineective, but it can cause harm to the suerer and damages the patient-HCP relationship.
Keywords: Ginger, hyperemesis gravidarum, nausea, vomiting, pregnancy, health care professional.
Introduction
HG is a severe form of pregnancy sickness.
Although no agreed denition of the condition exists,
clinical manifestations include weight loss of 5% or
more of pre-pregnancy weight, ketosis and/or a urine
output of <500ml in 24 hours. Electrolyte imbalance
and further complications can occur without
adequate treatment (Dean 2014). Its prevalence
varies depending on how HG is dened, but a
recent meta-analysis of international studies
gives a prevalence of 1.1% (Einarson et al 2013).
HCPs can be reluctant to prescribe pharmaceuticals
for HG (Gadsby 2004, Gadsby et al 2011) and both
HCPs and women over estimate the teratogenicity of
medication (Koren & Levichek 2002). The only drug
licensed worldwide for NVP is doxylamine succinate
and pyridoxine hydrochloride 10mg/10mg, known as
Diclectin in Canada and Diclegis in the USA.
Ginger is often recommended to women as a ‘natural’
remedy for NVP, regardless of severity of symptoms.
In our experience running a helpline for the charity
Pregnancy Sickness Support (PSS), we nd that most
Ginger is ineffective for hyperemesis
gravidarum, and causes harm: an internet
based survey of sufferers
Caitlin R Dean, Margaret E O’Hara
MIDIRS Midwifery Digest 25:4 2015 449

women have tried ginger in desperation for something
that can ease their symptoms, generally before seeing
a doctor or seeking pharmaceutical treatments.
They report that ginger is ineffective at controlling
symptoms and can cause side effects, as reported by a
previous online survey (O’Hara 2013).
Women have also informed us that suggestions to try
ginger make them feel that their condition is being
trivialised and even that they no longer trust their
HCP. This is important as poor physician-patient
relationships are a risk factor for therapeutic abortion
in women with HG. Women with HG who had had
terminations were three times more likely to report
that their health care providers were uncaring or did
not realise how sick they were. Most of these women
expressed that one reason for the termination was
that they had no hope of relief (Poursharif et al 2007).
Women with HG often feel isolated and
misunderstood by family, friends and HCPs
(Swallow 2010, O’Hara 2013, Sykes et al 2013)
and suggestions to try ginger may exacerbate these
feelings. In this context, advice from an HCP to take
ginger may not be helpful.
We wished to examine how useful women nd ginger
for controlling symptoms of HG, prevalence of side
effects and the effect it has on morale and their
relationship with HCPs. No previous studies have
investigated the effectiveness of ginger as used in the
community for HG, a suggestion to try ginger for a
woman’s experience of HG, or her relationship with
her HCP.
Method and materials
The online survey service Survey Monkey was used to
gather data and surveys were promoted via
Wseveral social media platforms reaching several
thousand individuals. Respondents were not asked
to supply any personal or identiable information so
all data are fully anonymous. The posts promoting
the survey were worded in a neutral way so as not to
imply any particular outcome.
For example:
‘I want to assess the impact of people suggesting
“Have you tried ginger?” to women with hyperemesis
gravidarum. Please take this survey if you were
admitted to hospital in the last 10 years for HG’.
Respondents were not limited to the UK but, due
to the routes of promotion, respondents were
predominantly UK sufferers. In order to avoid
problems with the lack of a denition for HG,
only women who had been hospitalised for HG
during their pregnancy were eligible to participate.
The survey was open for four consecutive days, from
Monday to Thursday of one week, and all responses
were collected in that period.
Questions were predominantly quantitative although
some questions had an option to add a comment if
the answer they wanted to give was not an option.
The questions were worded so as not to indicate bias
and there was equal opportunity to report positive
outcomes from trying or suggesting ginger as there
were negative.
There were two qualitative questions. The rst
was for people who answered that taking ginger to
help symptoms had experienced a negative effect.
They were asked to specify the impact. The second was
an opportunity at the end of the survey for women to
add further comment regarding their experience.
Results
A total of 514 eligible women responded. Between
them they had experienced 965 HG pregnancies.
Not all women answered all questions and so the
number per answer will be specied in each case.
All respondents had been pregnant within the previous
ten years. Four hundred and fty-seven (89%)
respondents had been pregnant in the last ve years.
Knowledge of ginger and experience of trying it
Most women were already well aware of ginger as
an antiemetic; only 59 women said that they had
not known about it prior to pregnancy. Those who
already knew about it were asked how they knew
and 410 respondents gave 640 responses. The most
common response (275) was through word-of-mouth
with a number of women specifying it had been
a remedy used in childhood for travel sickness or
tummy bugs. One hundred and forty-eight said it was
general knowledge, and media, books, internet and
other made up the remaining 247 responses.
During pregnancy, respondents reported that they
frequently heard suggestions to try ginger, with 60%
MIDIRS Midwifery Digest 25:4 2015450
Pregnancy
© pololia, Fotolia.com

saying that they had heard the suggestion more than
20 times. Only three women said that they had never
encountered a suggestion to try ginger. When asked
who had recommended ginger, 487 respondents gave
a total of 2770 responses, making an average of 5.7
per woman. The largest category was friends with
447 responses. The next highest were close relatives
(385), work colleagues (336) and strangers (304).
HCP categories were doctors (295), nurses (258),
midwives (289), sonographers (78) and pharmacists
(131). The remaining categories were distant relatives
(225) and other (22), in which women specied online
social media forums, dieticians, alternative health
practitioners and health food store staff.
Women were asked if they had tried taking ginger
to help with their symptoms during pregnancy, with
88% (439 of 501) answering yes. Many different
forms of ginger had been tried, such as ginger biscuits
(360), ginger beer (173), dried ginger tea (169), ginger
sweets (157), fresh ginger tea (144), raw ginger (115),
crystalised ginger (111) and ginger root capsules
(1000mg) (79). On average 3.5 different types of
ginger had been tried per woman.
Those who tried ginger for their symptoms were
asked to rate how helpful it was on a scale of 0–10.
Results are illustrated in Figure 1. Four hundred and
twenty-nine women responded of whom 376 (88%)
rated it not helpful at all. Of those who gave it a
rating greater than zero, some noted that ginger only
helped in the early stages. Others noted that it may
not have been the actual ginger which helped but the
substrate in which they took it eg biscuit, ice lolly, tea.
400
350
300
250
200
150
100
50
0
376
24 18 3 3 1
4
0 1 2 3 4 5 6 7 8 9 10
Number of responses
Rating
How eective is ginger? N = 429
Figure 1. How helpful was ginger? Rated on a scale of 0–10.
0 = not at all helpful, 10 = helped signicantly.
When asked about side effects from ginger or other
negative impacts, 225 (54%) said that they had
experienced negative effects. Two hundred and
thirty-eight women left a comment on the impact
that taking ginger had had on them. Exacerbation
of nausea and/or vomiting symptoms were the most
common impact reported by 127 (56%) women.
‘Dramatic increase in nausea vomiting and heartburn.
I was very surprised because when I am not pregnant
ginger is helpful.’
The next most common category was pain and/or
burning during vomiting with 76 (32%) of those
who responded:
‘It burns the throat then you throw it up. It was so painful.’
‘Gingery sick stings more than any other!’
Acid reux or heartburn caused by ginger products
was reported by 24 (10%) women:
‘It gave me painful heartburn and burnt my throat
coming back up!’
Emotional distress caused by the loss of hope or
increased isolation was reported by 29 (12%) of those
who offered responses:
‘Every time a new remedy is tried, a lot of hope is attached
to it, so it is hugely disheartening when it doesn’t work.’
‘Feeling of utter despair that it didn’t work.’
Eect on mood of suggestion to try ginger
Respondents were asked if people suggesting ginger
had an effect on their mood in either a positive or
negative way. Four hundred and eighty-nine women
responded with 403 (82%) reporting a solely negative
effect on their mood. Four (0.8%) reported a positive
impact and 44 (9%) reported both positive and
negative effects. Twenty-eight (6%) reported no impact
on their mood and ten (2%) couldn’t remember.
The women who experienced a positive or negative
impact were asked to rate the impact on a scale of 1–10.
The results are illustrated in Figure 2. Only 42 women
rated the impact as positive, with the majority
giving a low score: none rated it as more than seven.
Four hundred and forty women indicated a negative
impact and the ratings distribution is almost the inverse
of the positive one; 216 (49%) indicated that it made
their mood a great deal worse with a rating of 8–10.
Number of responses
100
80
60
40
20
0
1 2 3 4 5 6 7 8 9 10
Rating
Positive impact N = 42
Negative impact N = 440
Figure 2. Ratings of both positive and negative eect on
mood of suggestions to try ginger. 1 = improved my mood
a little; 10 = improved my mood a lot (positive impact).
1 = made my mood a little worse; 10 = made my mood a
lot worse (negative impact).
MIDIRS Midwifery Digest 25:4 2015 451
Pregnancy

Respondents were asked about reasons for the
positive and negative impacts. The results are
shown in Table 1 (positive) and Table 2 (negative).
Forty-eight women gave a total of 104 responses for
the positive impact. For the negative impact, 448
women gave a total of 2601 responses, an average
of 5.8 responses per woman.
Eect on relationship with HCP
We asked women who had experienced a suggestion
of ginger from an HCP to rate the impact it had on
their feelings towards the HCP. Results are shown in
Figure 3.
Number of responses
250
200
150
100
50
0
0 1 2 3 4 5 6 7 8 9 10
Rating
Trust N = 384
Understanding N = 393
Condence N = 390
Figure 3. Eect of suggestion of ginger on feelings towards
HCPs. 0 = reduced trust/condence completely/made me
feel less understood; 10 = increased trust signicantly/
increased trust a lot/yes I felt very understood.
When asked to rate how understood it made them
feel by their HCP, 393 women responded with 239
(61%) giving a score of zero. A further 131 (34%)
rated their feeling of being understood between 1–4
and only six (1.5%) scored it from 7–10.
A large majority indicated that it had reduced trust in
the HCP with 305 (79%) giving a rating of between
zero and four. One hundred and twenty (31%) gave a
rating of zero indicating that the suggestion of ginger
eroded their trust in their HCP completely. Only 28
(7%) of those who answered the question reported an
increased feeling of trust with ratings from 6–10.
When asked about effect on condence in the HCP’s
professional ability, 390 women answered the
question with 305 (78%) scoring 1–4, indicating
that condence had been reduced. One hundred and
forty-eight (38%) answered zero: that it reduced
their condence completely. Only two women (0.4%)
reported any increase of trust in their HCP by giving
a score greater than ve on the scale.
Emergent themes
Respondents were offered the opportunity to relate
additional information with the question and 182
responses were given.
‘Is there anything else you would like to add about
your experience of people suggesting ginger while
you were suffering hyperemesis gravidarum or since
your pregnancy?’
Several themes emerged which have been
characterised as anger, lack of validation, wish for
greater understanding and feelings of isolation.
Sixty out of the 182 respondents expressed feelings
ranging from some degree of frustration to outright rage.
‘It upset me everytime as do people honestly think
that I wouldn’t have tried something that simple to
cure my constant vomiting! I felt people thought I
was being dramatic and exaggerating it!! Felt like
shoving ginger down their throats!’
Table 1. Reason given for improvement of mood following
suggestions to try ginger
Answer options Response % of
48 respondents
Response
count
It let me know people cared 69% 33
I liked that people were trying
to help me
27% 13
Made me feel hopeful that I
could help myself
4% 2
It made me feel loved and
cared for
13% 6
Reduced feelings of isolation 15% 7
Made me feel like others
appreciated what I was
experiencing
0% 0
It made me feel happier 54% 26
Made me feel understood 21% 10
It made me trust their
advice more
6% 3
Other (please specify) 8% 4
Total 104
Table 2. Reason given for worsening of mood following
suggestions to try ginger
Answer options Response % of
48 respondents
Response
count
It made me feel like no
one understood
93% 415
It made me feel like they
thought I shouldn’t
take medication
52% 233
It made me feel like they
thought I could cure myself
76% 340
It undermined my experience 73% 329
It increased my isolation 51% 230
It reduced my trust in
their advice
44% 199
It made me feel helpless 48% 213
It made me feel guilty for not
having a ‘natural pregnancy’
46% 204
It made me feel irritated and/
or angry
84% 378
Other (please specify) 13% 60
Total 2601
MIDIRS Midwifery Digest 25:4 2015452
Pregnancy

Women are dismayed to be told to try ginger
by HCPs. They feel that the HCP actually knows no
more about HG than anyone else they’ve spoken to
and this leads to a loss of trust and condence.
‘I can understand when family and strangers and
people who don’t know any better suggest ginger but
for it to be suggested by every healthcare professional
every single time it gets really frustrating that they
don’t seem to know any better.’
‘When it came from a HCP it infuriated me because
when you are in hospital not able to keep even
water down being told to try ginger is just ridiculous.
It lowered my trust in the HCP and I didn’t want to
to [sic] listen to anything else they said as I thought
they just didn’t understand.’
‘I now have no trust in my midwife, nor do I feel I
can conde in her or discuss any issues or fears
I have with her. If she couldn’t show compassion
& knowledge about HG, what else doesn’t she
know about!?’
A commonly expressed sentiment is that of isolation;
women supported by the PSS report isolation as
one of the most difcult aspects of the condition.
Suggestions to try ginger can intensify this feeling.
‘I think the ginger issue highlights that people feel
like HG could be “cured” by natural methods.
When every HG woman has real anxiety over the
need to take prescribed medicines [will it harm my
baby? being a signicant worry], it adds to our
isolating experience when someone suggests ginger.
I recognised that people were trying to be helpful but
it was so upsetting that people didn’t appreciate how
ill I was.’
‘I can understand non medical professionals’ suggestions
of ginger products even if it’s incredibly frustrating.
But when the senior consultant, head midwife and
nurses suggest ginger it just made me want to give up.
I was alone. No one would be able to help me.
I considered termination a hundred times or more.’
Many women expressed the feeling that suggestions
to try ginger are tantamount to saying that they
are exaggerating their symptoms and nd that it
undermines their experience.
‘It’s like saying have you tried smiling to someone
with depression. It completely undermines what that
person is going through and makes you feel like they
think you are making it up.’
One woman expressed that the manner in which the
suggestion is made is important to how it is received:
‘...whilst preparing for another pregnancy a doctor
brought up again “would I try ginger?”! However she
did so very sensitively and was talking about using
pure ginger capsules 3000mg a day and alongside
other treatment. This was the rst time I didn’t get
very cross, as I felt she understood that for it to
possibly help, the amount of ginger and its level of
purity are paramount and she was acknowledging
that it was only one small thing to try, but that the
condition requires proper treatment.’
Discussion
The results reported here reect a picture which
accords with anecdotal evidence related regularly
to PSS. Knowledge of ginger as an antiemetic is
widespread in the community and people in women’s
lives are keen to tell them about it. Women were
told repeatedly by family and friends, but also
acquaintances and HCPs and even strangers in
the street. Most women had tried ginger, mostly in the
form of food and drinks. The overwhelming verdict
from this study on the efcacy of ginger is that it is
not at all helpful for controlling symptoms and causes
unpleasant physical side effects in around half of
those who tried it.
Ten times as many women said that suggestions of
ginger worsened their mood than those who said it
improved their mood. Even those who said it had
a positive effect, largely rated that effect as minor.
Conversely, of those who said that it made their
mood worse, the majority rated the worsening of the
mood as severe. The main reason for this was that
it underlined to women that the person making the
suggestion did not understand what they were
going through. Rather than experiencing suggestions
to try ginger as helpful and welcome, women nd
them irritating and enraging. This partly stems
from the fact that the suggestions are repeated by
numerous people, but also that women perceive it to
be undermining of their experience.
Suggestions of ginger from an HCP had a marked
negative impact on the feelings of women towards
their HCP. The majority of respondents reported that
it reduced their condence in the HCP, made them feel
that their HCP understood their symptoms less and
severely eroded their trust in the HCP. The reaction of
women to suggestions of ginger must be set in context
to understand why it is not regarded positively.
Women rarely approach an HCP for help at the rst
sign of NVP symptoms, rather, they are usually severe
before women will visit their GP for what is, in the
public consciousness, regarded as a minor side effect
of pregnancy. A lot of hope is invested in HCPs, so
the realisation that they can offer nothing better than
a folkloric remedy which has already been suggested
by friends and family engenders despair. HCPs should
be aware that the woman has almost certainly been
advised to try ginger repeatedly by friends and family
and is likely to have already tried it to no avail.
Even if she doesn’t already know about ginger,
women with HG are desperate for relief of their
suffering and will invest a great deal of hope into
any new suggestions. Offering this hope when there
is so little evidence of efcacy is highly questionable.
MIDIRS Midwifery Digest 25:4 2015 453
Pregnancy

The themes raised by this study are in accordance
with previous studies where women have been asked
to describe their experiences of HG; they report
being disbelieved by HCPs, having their symptoms
dismissed or trivialised, feeling misunderstood and
being isolated (Mazzota et al 1997, Munch 2002,
O’Brien et al 2002, Chandra et al 2003, Meighan &
Wood 2005, Locock et al 2008, Poursharif et al 2008,
Swallow 2009, Power et al 2010, O’Hara 2013, Sykes
et al 2013, Dean 2014).
This study is the rst to examine both the
effectiveness of ginger as used by women with HG
in the community, and to address the unintended
negative outcomes of its use. A limitation of the data
presented here is that they are retrospective and
self-reported. By denition, the women who replied
to this survey were those who were actively seeking
information online about HG. Nevertheless, these
ndings are a useful addition to a very small body
of evidence. There is a need for high-quality
prospective research into all treatments for HG,
pharmaceutical or not. A Cochrane review of
interventions for NVP noted the difculty of
comparing studies due to variations in denitions of
what constitutes mild, moderate and severe illness and
concluded that there was some inconsistent evidence
of benets of ginger for NVP (excluding HG)
(Matthews et al 2015). The only study to examine
the efcacy of ginger specically for HG compared
four daily doses of a 250mg capsule of ginger with
a placebo in 27 women admitted to hospital for
HG (Fischer-Rasmussen et al 1991). It found that
a carefully prepared, high-dose ginger capsule may
be effective at reducing symptoms in women with
HG. However, a drawback of any placebo-controlled
study relating to ginger is that it has a strong avour.
Although it may not be tasted while swallowing a
capsule, ginger avour is unavoidable during both
vomiting and belching so placebo effect cannot be
reliably discounted.
There is, therefore, a paucity of evidence that ginger
is effective for HG and no evidence whatsoever for
ginger avoured food and drink. Moreover, ginger is
unregulated and the strength of the active ingredient
may differ from batch to batch (Schwertner &
Rios 2007). Some reviews and management strategies
for HG advise that ginger may be recommended
as there is evidence of benet for NVP and no
evidence of harm (Goodwin et al 2008, Bottomley &
Bourne 2009, Sonkusare 2011), while others do not
recommend it, or recommend it only when symptoms
are mild (Einarson et al 2007, King & Murphy 2009,
Jarvis & Nelson-Piercy 2011). Not only does ginger
not help, but the use of ginger as a rst line treatment,
once symptoms have already become severe, may
delay effective treatment. Early intervention has been
shown to limit both the duration and severity of HG
(Maltepe & Koren 2012). By requiring a woman
to try an ineffective remedy, the HCP risks missing
a crucial window for commencement of effective
treatment, and may condemn women to a longer,
more severe illness.
Conclusion
If ginger is to be used as an antiemetic, then proper
dosages and methods of administration must be
determined, as well as more research into its efcacy
compared with conventional antiemetics. The risks
and side effects of ginger for HG require further
research to be understood and balanced against
potential benet. When an HCP recommends an
ingested treatment, the patient is entitled to ask: What
dose should I take? How effective is it? Are there any
side effects? At the present time, no HCP can answer
these questions for ginger as a treatment for HG.
Since evidence is presented here of harm caused by
the taking of, or the suggestion to take, ginger, we
would call for HCPs to stop recommending ginger
to women with HG until more evidence is available.
This would constitute a meaningful improvement in
the care of women with HG and can be implemented
immediately at no cost.
Acknowledgements
The authors wish to thank the women who
undertook the survey for their participation and
Roger Gadsby and Tony Barnie-Adshead for
suggestions to the manuscript. The authors have done
this work on a voluntary basis and have personally
covered any costs.
Disclosure
Caitlin Dean and Margaret E O’Hara are trustees of
the charity Pregnancy Sickness Support. Their work
for PSS is entirely voluntary and they receive no
payment for any work carried out for the charity.
Contributions
CD initiated and devised the survey with assistance
from MOH. CD promoted the survey. CD and MOH
jointly analysed the data and co-wrote
the manuscript.
Caitlin R Dean, Margaret E O’Hara, Pregnancy Sickness
Support, Dunmore Farm, Treesmill, Par, Cornwall, PL24
2TU. Correspondence to: Margaret O’Hara, Pregnancy
Sickness Support, Dunmore Farm, Treesmill, Par, Cornwall,
PL24 2TU.
MIDIRS Midwifery Digest 25:4 2015454
Pregnancy

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