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By Yoetzet Halacha Avital Gastwirth
This article reflects the individual experience of the author, beginning with harsh descriptions of her experience with Hyperemesis Gravidarum (HG) that may be difficult for some readers. Each woman’s experience with HG varies, with a range of intensity of symptoms and emotions. Please see below for various medical, emotional, and spiritual resources for women with HG.
Slam
Slam. My pregnancy hits me like a punch in the face. Slam. I’m on the floor. I try to get up. Slam. I can’t. I’m being punched down, over and over, please, please make it stop. There is no respite. I vomit. I am slammed again, thrown into a black hole of first trimester pregnancy, some of the darkest depths I’ve been through. Goodbye, I think. Goodbye, family and friends, pursuits and pleasures, getting dressed and eating food. Here in this dark hole, it’s just me and Hashem.
But is this even really me? I feel like I’ve left myself behind, beyond this black hole of misery where I wake up every morning to wish I hadn’t, where I wonder lamah zeh anochi and count the endless minutes, where I weep into my pillow because how will I survive another few months of this? I cannot survive another few months of this. I cry to Hashem to make it stop, take it away, I can’t do it anymore. Someone is shaking me violently and the world won’t stop spinning. My only rest is sleep, but I dread going to sleep because I only wake up feeling more horrible than before.
My husband comes to sit next to me. “I’ve come to visit the Shechina,” he says, referring to the idea that the Shechina (the Divine Presence) rests above the head of the sick. “The Shechina is crying,” I say. There is nothing left to vomit but I vomit anyway. I am crawling down an endless black tunnel, with no light in sight.
Symptoms and Treatment
Many women experience morning sickness during pregnancy, but for 2-5% of women, the nausea can be so severe it is debilitating. Women with this condition, known as hyperemesis gravidarum (HG), may vomit incessantly, lose a significant amount of weight, or become dehydrated. They may find it impossible to eat, despite being literally starving, leading to nutritional deficiencies. HG cases can range from mild to severe. For some women, symptoms ease up after the first trimester; for others, they last the entire pregnancy.
In many cases, standard methods of dealing with morning sickness (small meals, dry/bland foods, lemon/ginger, acupressure points) are ineffective for HG. Knowledge is power. Women with HG should be aware that it is essential for their health and that of the fetus to seek medical treatment for the condition, and that there are multiple treatment options. For example, there are various drugs that can, in many cases, be helpful for easing nausea.
It’s also important to note that one of the main problems affecting women with HG is dehydration. A woman who finds it impossible to keep down fluids may become dehydrated, which worsens nausea and leads to more dehydration. Receiving intravenous fluids in such a case is critical. Without proper treatment, HG can sometimes be a life-threatening condition.
Perhaps most importantly, women should try to find a sympathetic and understanding doctor from whom to seek advice regarding medical care.
Emotional and Psychological Aspects
The effects of HG are not only physical. In one study,* 78% of women hospitalized with HG exhibited symptoms of depression, as opposed to 5% of the control group of women who were hospitalized during pregnancy for other reasons – a staggering difference. Besides feeling physically miserable all day, every day, these women may question their self-image when they go from being a high-functioning mother or professional to being a dysfunctional vomit fountain. A woman with HG may wonder what is wrong with her; she may feel guilty for not being a good mother or wife. She may even wonder whether she wants this pregnancy, or come to resent the clump of cells growing inside her that has done this to her, and then feel guilty for that. She may feel she’s lost the desire to even live – as Rivka Imeinu, suffering so greatly from her own pregnancy, said: Im ken, lamah zeh anochi? If so, why should I live? For a woman who is normally healthy in body and mind, these thoughts can be scary.
A woman with HG should never feel guilty for her emotions and should know that much of what she may be feeling is normal for someone suffering from HG. Nonetheless, she should seek professional counseling if she or those around her feel that she is severely depressed or shows symptoms of anxiety or OCD. Women who experience depression during pregnancy are more likely to suffer postpartum depression as well – a serious, sometimes life-threatening condition. Seeking professional help for one’s mental health is not something to be embarrassed about; on the contrary, it is a brave step toward self-help and prevention.
HG can have long-lasting psychological effects as well. For example, 18% of women who have suffered from HG during pregnancy later exhibit post-traumatic stress symptoms.**
Community, Family, and Marriage
Unfortunately, many women with HG feel alone. This may either be because they have decided not to divulge the pregnancy at this stage, or because others simply don’t understand them. Many women with HG have been brushed off by family, friends, a boss, or even insensitive medical professionals as exaggerating. They’re told that all women get nauseous during pregnancy, I did it/so-and-so did it and was ok, you just need to “man up.” They may be told it’s just “psychological” or all in their head, and be offered solutions by well-meaning neighbors that work for morning sickness, but not for HG.
Families of women suffering from HG may suffer in silence, too. Husbands may feel overwhelmed or helpless seeing their wives suffer. One father wrote:
She’s falling, and I can’t catch everything at once. The kids, the house, my job, her, myself. I’m father and mother together now, and things are falling apart. I wish I could make her feel better, do something to ease her pain. I feel helpless to see her this way, lying on the couch, vomiting again.
HG can take a toll on shalom bayit. For some women, the thought of even touching their spouse makes them sick. This can become a real source of tension, especially for a new couple at the beginning of their journey of connection and exploration in physical intimacy, and a natural frustration for the confused husband. An innocently ignorant husband may unintentionally make hurtful statements such as, “you’re not incapacitated,” “you just have to stop thinking about being nauseous,” or, “if you get out of pajamas and start doing things you’ll feel better.”
HG also affects children in the family. Children may have a difficult time seeing their mother so sick or understanding why Ima can’t tuck them into bed at night. Parents can validate children’s emotions and explain that Ima’s illness is temporary and she will get better, explaining the situation and timeframe in terms the child can understand. The father, or anyone assisting with childcare, can help children feel empowered and important by enlisting their help in bringing Ima a cup of water or helping with younger siblings, then praise them for being so helpful.
For couples, it can be beneficial to look at this challenging time as an opportunity to strengthen their relationship. One couple told me they felt their marriage was stronger because of their early challenges with HG. Even now, years later, the woman’s memories of her husband’s care and dedication during those times bring back feelings of love and connection which help overcome current strife. Life doesn’t always happen in the order we expect, and if a couple feels they have missed a stage in early marriage they can go back and embrace it once the HG passes.
Recognizing that the woman suffering from HG did not choose this and acknowledging that both sides are hurt by the situation can help put feelings in perspective. Rebbetzin Ruthie Halberstadt, author of the book Hyperemesis: A Spiritual Perspective, recommends the couple both consider the wife’s situation a “stranger” – which neither side invited into the marriage. As a friend described, she sees herself as two people – “real me and HG me. When I’m pregnant, it feels like my husband and I are both married to a woman we don’t recognize.” By understanding that these new HG characteristics are not the “real” woman, it can be easier to separate feelings and take things less personally. Couples therapy is also an important resource if needed.
Offering Support
How can we help women and their families suffering from HG?
First, it’s important to note that although there is indeed a minhag in some communities not to reveal a pregnancy in the first trimester because of ayin hara (evil eye), this is not a halachic psak. A woman suffering from HG can and should reveal her pregnancy if it means getting help or a more understanding employer. (As a side point, some couples prefer not to share their pregnancy in its early stages lest they miscarry. However, normalizing earlier sharing can help break the taboo on speaking about miscarriage, so that women who miscarry can more easily share their experience and receive the support they need).
Practical support, such as volunteering to watch kids, fold laundry, or make meals, can be a huge help. Stress can make already existing nausea even worse, and women with HG should not be embarrassed to ask for or receive help; they should be encouraged to focus on caring for themselves as much as possible. They should not feel guilty if, for a few months, their house is a mess and their kids are cared for by babysitters or eat more junk food than they’d like.
Practical help for a couple dealing with HG can also free up the father to spend time with the children; his presence alone can be calming to them.
Specific offers of help, such as, “I’m going to town later today, can I pick anything up for you?” or, “Would it help for me to pick up your daughter from preschool today?” may be easier to accept than general questions such as “What can I help you with?” (although that’s good, too!).
Emotional support is also critical. A listening ear and sympathy can go a long way. Support groups, including those online, can help women suffering with HG feel less alone and receive advice from others with similar experiences.
Sensitivity is key. Examples of inappropriate questions or comments are: “do you think you’ll have another kid after this?”, “maybe you should wait a few years after this one,” or, “next time plan it so you don’t get pregnant during summer vacation when the kids are off school.” If a woman suffering from HG states that she doesn’t want to have kids ever again, the listener’s job is to be accepting and supporting in her time of need, not to have a logical debate with her.
Some women may be distraught because they always imagined a large family and are now torn between conflicting emotions of still wanting to fulfill that dream and feeling they will be unable to cope. A good response to such a situation may be: “Don’t worry about that right now. Right now, you need to just focus on yourself and getting through this. You don’t need to decide how many children you’re going to have at this moment; there’s a reason Hashem gives us children one at a time.”
When offering support, it’s important to be sensitive to the woman’s personal needs. For some women, being reminded that this is all for a good cause will help them through the difficult process. For others, it will not. Although it’s easy for an onlooker to think, “This, too, shall pass,” saying that to a person who has months of severe nausea, fatigue, and vomiting ahead of her may be torture. Perhaps it would be more helpful to try something more along the lines of, “One day at a time, one hour at a time, and I’m here to help any way I can.”
Finding Meaning
After my own experiences during pregnancy, I found myself grappling for meaning behind my suffering. Finding meaning in suffering is a personal and subjective journey, and I encourage each individual to make that journey for herself. For myself, I found the following idea powerful and potent:
When Hashem punishes Chava for eating from the forbidden Tree of Knowledge, He states: Harbah arbeh itzvonech v’heronech, “I will increase your suffering and pregnancy,” B’etzev teldi banim, “through suffering shall you birth children.” (Bereishit 3:16). Rav Yitzchak Hutner (Ma’amarei Pachad Yitzchak, Pesach, 24) points out that the first part of the verse, dealing with pregnancy, describes suffering which is uniquely yours – “your suffering.” The suffering in the second part of the verse, that of childbirth, is a general suffering – “through suffering shall you birth.” That’s because the suffering of childbirth includes an imminent sense of our redemption, while the suffering of pregnancy is uniquely the woman’s, a burden she carries alone. In a certain sense the pain of pregnancy is more personal and thus more difficult; there is no imminent geulah, or redemption, to it.
But why this unbearable pain and suffering? Rav Hutner explains: Before the first sin, humanity was brought into the world simply and naturally – to do good, to do God’s will, to bring God’s light into the world. Once Adam and Chava sinned, the question of whether mankind should be created was reopened.
I think of this as almost like a break in confidence, like someone who’s been cheated on. If you cheat me in business or stab me in the back, I’m going to think long and hard before investing in a relationship with you again. The suffering of pregnancy reflects that fundamental difficulty of bringing another life into a world of sin. Because of Adam and Chava’s sin, each drawing down of a neshama into the world is a painful process. It’s a process which demands of us to solidify our belief that each child born brings us closer to redemption, to recognize that each descent brings an even greater ascent, and to stand up and say, “Yes! It is worth it!”
To be honest, for a woman who suffers from HG, it is easier to say that after the fact. And she may legitimately question why her suffering is so much worse than other women’s pregnancies. I certainly don’t have an answer to that question. But I do know there are medications and other ways for friends, family, and medical professionals to help. Awareness is the first step. Action is the next.
* Hizli, D., Kamalak, Z., Kosus, A., Kosus, N., & Kurt, G. (2012). Hyperemesis gravidarum and depression in pregnancy: is there an association? Journal of Psychosomatic Obstetrics & Gynecology, 33(4), 171-175. https://www.tandfonline.com/doi/abs/10.3109/0167482X.2012.717129
** Christodoulou-Smith, J., Gold, J. I., Romero, R., Goodwin, T. M., Macgibbon, K. W., Mullin, P. M., & Fejzo, M. S. (2011) Posttraumatic stress symptoms following pregnancy complicated by hyperemesis gravidarum. The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Societey of Perinatal Obstetricians, 24 (11), 1307-1311
https://www.tandfonline.com/doi/full/10.3109/14767058.2011.582904
Helpful Resources
Online medical information
Support and Insight
HG help – support for Jewish women
Rebbetzin Ruthie Halberstadt, Hyperemesis: A Spiritual Perspective, (Targum Press, 2023)
Chavi Eve Karkowsky, MD, High Risk: Stories of Pregnancy, Birth, and the Unexpected (Liveright Publishing, 2020), chapter 1 “Nausea and Vomiting of Pregnancy: Did We Save Enough of Your Life” pp. 3-23
Ashli McCall, Mama Has Hyperemesis Gravidarum (But Only for a While), picture book for children, available here
Facebook support group for women in Israel
Facebook support group for partners of women with HG in Israel
Mental Health Resources
Avital Gastwirth, a resident of Alon Shvut, became a Yoetzet Halacha through Nishmat’s Keren Ariel Program in Jerusalem in 2023 and is an active kallah teacher. A graduate of Herzog College, with an education degree in Tanach and Israel studies, Avital teaches high school and post-high school students. She is the author of the forthcoming book “The Secret of Rachel and Leah.”
