The brain does not always distinguish between real and imagined. It is on this neuroscientific principle that the natural metaverse of birth is founded: a mental simulation tool that, through a narrating voice, immerses midwives and obstetricians in the experience of childbirth without exposing patients to risk. Accessible, scalable, at zero cost. A simple yet powerful tool for obstetric training, presented at the SIMMED 2025 Congress.
Imagine being a midwife. Your hands are guiding a head that is about to come into the world. You feel the pressure, the warmth, the tension of the moment. Then you open your eyes: you are sitting in a training room, with ten colleagues around you. No patient. No risk. Yet your brain has just lived that experience as if it were real.
It is not magic. It is neuroscience. And it is the principle on which mental simulation applied to birth is based.
The brain does not always distinguish between real and imagined
To understand why mental simulation works, we need to look inside the brain. Emotions originate in the palencephalon, the most ancient part of the central nervous system, which includes structures such as the amygdala, hippocampus, insula and anterior cingulate cortex. This region reacts rapidly and automatically to stimuli: even before the cerebral cortex consciously processes what is happening, the palencephalon has already responded.
The key point is that the palencephalon does not precisely distinguish between a real sensory stimulus and one evoked through narration, memory or fantasy. When we imagine performing a gesture, the same motor areas are activated as would be if we were actually performing it. Evoking an emotion mentally makes it physiologically real, at least in part.
Perception, after all, is never neutral: the emotional condition, previous experiences and the perspective of the observer constantly change the content of what we perceive (Nardone, 2019). And since most interactions between perception and emotion occur below the level of consciousness (Koch, 2012), cognitive processes do not drive emotions: they come afterwards (Searle, 1990).
This is the neuroscientific foundation of mental simulation. Not a psychological trick: a structural characteristic of the human nervous system.
Five zones for learning without making mistakes on patients
In 2017, Roussin and Weinstock of Boston Children’s Hospital rationalised the concept of simulation in healthcare with a model that has become a reference: the five simulation zones.
It starts from Zone 0, the most intimate: self-assessment, mentalisation, individual reflection. This is where mental simulation is located. In Zone 1, a group of practitioners deepens a technical procedure with the guidance of an instructor. Zone 2 introduces multidisciplinary simulated clinical scenarios, with the possibility of role-playing. Zone 3 takes the team no longer into a simulation laboratory but directly into real clinical environments, with high or low technological fidelity. Finally, Zone 4 is reality: the moment when everything that has been learned is truly put into practice, while continuing to reflect and learn.
The logic is precise: it starts from within, from the mind of the individual practitioner, to progressively reach the complexity of the real world, without ever exposing patients to the risks of the learning process.
Does mental simulation really work?
Scientific evidence exists, but with important distinctions. For technical skills, such as epidural anaesthesia administration and laparoscopic procedures, the literature confirms the effectiveness of mental simulation (Lim et al., 2016; Paige et al., 2015; Hayter et al., 2013). For social and relational skills, also known as non-technical skills, such as teamwork and Crisis Resource Management (CRM) principles, research is still ongoing: the evidence is not yet solid.
An interesting evolution is Visually Enhanced Mental Simulation (VEMS): it enriches classical mental simulation with “thinking aloud” and simple visual supports, such as a simple patient poster, to make visible the actions imagined by participants during a scenario (Burbach et al., 2015; Dogan et al., 2021). A hybrid approach, low in technological cost but high in cognitive impact.
It is worth noting that visualisation is already used in salutogenesis to help women immersively experience the birth (Garelli, 2022): a field that confirms how thin the line between mental preparation and physiological response really is.
Illustrations by Fiammetta Ciavurro
The natural metaverse is born
Here we come to the most original concept presented at the SIMMED 2025 Congress the natural metaverse of birth. The name is deliberately provocative. The technological metaverse uses three-dimensional digital headsets to immerse you in an artificial virtual reality. The natural metaverse uses something more powerful and more ancient: a voice.
The tool is a video guided by a narrating voice that accompanies the listener through the immersive experience of a midwife in the delivery room. No sophisticated hardware, no headsets or equipped rooms. Eyes close, the voice describes, the brain builds.
The mechanism exploits four perceptual channels in a targeted way:
- Internal visual channel: eyes closed, the voice describes a scene to be mentally reconstructed.
- External visual channel: a real image used metaphorically to evoke a moment of birth.
- Auditory channel: sounds that reconstruct a clinical situation.
- Kinaesthetic channel: the voice asks you to focus on a part of the body and imagine performing a gesture, as if it were reality.
This tool sits exactly in Zone 0 of simulation: individual, interior, accessible to anyone, anywhere.
Why this changes things
Birth care is one of those fields where art and science meet in an extraordinary way. For a woman, it is a unique and unrepeatable event. For those who assist her, the midwife, the obstetrician, it is a human experience that renews itself every time, with enormous responsibility.
Training these professionals requires adequate tools. High-fidelity simulation, robotic mannequins, simulated operating theatres, is valuable but expensive and not always accessible. Mental simulation, and in particular the natural metaverse, opens a different space: democratic, scalable, neuroscientifically grounded.
The message is simple: a technological simulator is not always needed to learn. Sometimes it is enough to close your eyes and listen.
Special thanks to Giulia Greco, actress, the narrating voice in the video, to Ilaria Perilli, midwife, and to Stefania Onorati, professional nurse
References
Burbach B, Barnason S, Thompson SA. Using “Think Aloud” to capture clinical reasoning during patient simulation. Int J Nurs Educ Scholarsh [Internet]. 2015;12(1):1–7.
Capogna G, Ingrassia PL, et al. Debriefing strategico per la simulazione avanzata Springer 2022
Dogan B PN, Alinier G. A form of mental simulation with significant enhancements enabling teamwork training. International Journal of Healthcare Simulation. 2021;1(1):56–60
Garelli S La visualizzazione in salutogenesi Gli Elementali 2022
Hayter MA, Bould MD, Afsari M, Riem N, Chiu M, Boet S. Does warm-up using mental practice improve crisis resource management performance? A simulation study. Br J Anaesth [Internet]. 2013;110(2):299–304
Koch C. (2012). Consciousness: Confessions of a Romantic Reductionist. Boston: The MIT Press.
Lim G, Krohner RG, Metro DG, Rosario BL, Jeong JH, Sakai T. Low-Fidelity Haptic Simulation Versus Mental Imagery Training for Epidural Anesthesia Technical Achievement in Novice Anesthesiology Residents: A Randomized Comparative Study. Anesth Analg. 2016;122(5):1516–23
Nardone G. (2019) Emozioni: istruzioni per l’uso, Adriano Salani Editore
Paige JT, Yu Q, Hunt JP, Marr AB, Stuke LE. Thinking it through: Mental rehearsal and performance on 2 types of laparoscopic cholecystectomy simulators. J Surg Educ [Internet]. 2015;72(4):740–8.
Roussin CJ, Weinstock P. SimZones: An Organizational Innovation for Simulation Programs and Centers. Acad Med. 2017 Aug;92(8):1114-1120. doi: 10.1097/ACM.0000000000001746. PMID: 28562455.
Searle JR. (1990). The Mystery of Consciousness. London: Granta Books.
READ ALSO
The brain does not always distinguish between real and imagined. It is on this neuroscientific principle that the natural metaverse of birth is founded: a mental simulation tool that, through a narrating voice, immerses midwives and obstetricians in the experience of childbirth without exposing patients to risk. Accessible, scalable, at zero cost. A simple yet powerful tool for obstetric training, presented at the SIMMED 2025 Congress.
Imagine being a midwife. Your hands are guiding a head that is about to come into the world. You feel the pressure, the warmth, the tension of the moment. Then you open your eyes: you are sitting in a training room, with ten colleagues around you. No patient. No risk. Yet your brain has just lived that experience as if it were real.
It is not magic. It is neuroscience. And it is the principle on which mental simulation applied to birth is based.
The brain does not always distinguish between real and imagined
To understand why mental simulation works, we need to look inside the brain. Emotions originate in the palencephalon, the most ancient part of the central nervous system, which includes structures such as the amygdala, hippocampus, insula and anterior cingulate cortex. This region reacts rapidly and automatically to stimuli: even before the cerebral cortex consciously processes what is happening, the palencephalon has already responded.
The key point is that the palencephalon does not precisely distinguish between a real sensory stimulus and one evoked through narration, memory or fantasy. When we imagine performing a gesture, the same motor areas are activated as would be if we were actually performing it. Evoking an emotion mentally makes it physiologically real, at least in part.
Perception, after all, is never neutral: the emotional condition, previous experiences and the perspective of the observer constantly change the content of what we perceive (Nardone, 2019). And since most interactions between perception and emotion occur below the level of consciousness (Koch, 2012), cognitive processes do not drive emotions: they come afterwards (Searle, 1990).
This is the neuroscientific foundation of mental simulation. Not a psychological trick: a structural characteristic of the human nervous system.
Five zones for learning without making mistakes on patients
In 2017, Roussin and Weinstock of Boston Children’s Hospital rationalised the concept of simulation in healthcare with a model that has become a reference: the five simulation zones.
It starts from Zone 0, the most intimate: self-assessment, mentalisation, individual reflection. This is where mental simulation is located. In Zone 1, a group of practitioners deepens a technical procedure with the guidance of an instructor. Zone 2 introduces multidisciplinary simulated clinical scenarios, with the possibility of role-playing. Zone 3 takes the team no longer into a simulation laboratory but directly into real clinical environments, with high or low technological fidelity. Finally, Zone 4 is reality: the moment when everything that has been learned is truly put into practice, while continuing to reflect and learn.
The logic is precise: it starts from within, from the mind of the individual practitioner, to progressively reach the complexity of the real world, without ever exposing patients to the risks of the learning process.
Does mental simulation really work?
Scientific evidence exists, but with important distinctions. For technical skills, such as epidural anaesthesia administration and laparoscopic procedures, the literature confirms the effectiveness of mental simulation (Lim et al., 2016; Paige et al., 2015; Hayter et al., 2013). For social and relational skills, also known as non-technical skills, such as teamwork and Crisis Resource Management (CRM) principles, research is still ongoing: the evidence is not yet solid.
An interesting evolution is Visually Enhanced Mental Simulation (VEMS): it enriches classical mental simulation with “thinking aloud” and simple visual supports, such as a simple patient poster, to make visible the actions imagined by participants during a scenario (Burbach et al., 2015; Dogan et al., 2021). A hybrid approach, low in technological cost but high in cognitive impact.
It is worth noting that visualisation is already used in salutogenesis to help women immersively experience the birth (Garelli, 2022): a field that confirms how thin the line between mental preparation and physiological response really is.
Illustrations by Fiammetta Ciavurro
The natural metaverse is born
Here we come to the most original concept presented at the SIMMED 2025 Congress: the natural metaverse of birth. The name is deliberately provocative. The technological metaverse uses three-dimensional digital headsets to immerse you in an artificial virtual reality. The natural metaverse uses something more powerful and more ancient: a voice.
The tool is a video guided by a narrating voice that accompanies the listener through the immersive experience of a midwife in the delivery room. No sophisticated hardware, no headsets or equipped rooms. Eyes close, the voice describes, the brain builds.
The mechanism exploits four perceptual channels in a targeted way:
- Internal visual channel: eyes closed, the voice describes a scene to be mentally reconstructed.
- External visual channel: a real image used metaphorically to evoke a moment of birth.
- Auditory channel: sounds that reconstruct a clinical situation.
- Kinaesthetic channel: the voice asks you to focus on a part of the body and imagine performing a gesture, as if it were reality.
This tool sits exactly in Zone 0 of simulation: individual, interior, accessible to anyone, anywhere.
Why this changes things
Birth care is one of those fields where art and science meet in an extraordinary way. For a woman, it is a unique and unrepeatable event. For those who assist her, the midwife, the obstetrician, it is a human experience that renews itself every time, with enormous responsibility.
Training these professionals requires adequate tools. High-fidelity simulation, robotic mannequins, simulated operating theatres, is valuable but expensive and not always accessible. Mental simulation, and in particular the natural metaverse, opens a different space: democratic, scalable, neuroscientifically grounded.
The message is simple: a technological simulator is not always needed to learn. Sometimes it is enough to close your eyes and listen.
Special thanks to Giulia Greco, actress, the narrating voice in the video, to Ilaria Perilli, midwife, and to Stefania Onorati, professional nurse
References
Burbach B, Barnason S, Thompson SA. Using “Think Aloud” to capture clinical reasoning during patient simulation. Int J Nurs Educ Scholarsh [Internet]. 2015;12(1):1–7.
Capogna G, Ingrassia PL, et al. Debriefing strategico per la simulazione avanzata Springer 2022
Dogan B PN, Alinier G. A form of mental simulation with significant enhancements enabling teamwork training. International Journal of Healthcare Simulation. 2021;1(1):56–60
Garelli S La visualizzazione in salutogenesi Gli Elementali 2022
Hayter MA, Bould MD, Afsari M, Riem N, Chiu M, Boet S. Does warm-up using mental practice improve crisis resource management performance? A simulation study. Br J Anaesth [Internet]. 2013;110(2):299–304
Koch C. (2012). Consciousness: Confessions of a Romantic Reductionist. Boston: The MIT Press.
Lim G, Krohner RG, Metro DG, Rosario BL, Jeong JH, Sakai T. Low-Fidelity Haptic Simulation Versus Mental Imagery Training for Epidural Anesthesia Technical Achievement in Novice Anesthesiology Residents: A Randomized Comparative Study. Anesth Analg. 2016;122(5):1516–23
Nardone G. (2019) Emozioni: istruzioni per l’uso, Adriano Salani Editore
Paige JT, Yu Q, Hunt JP, Marr AB, Stuke LE. Thinking it through: Mental rehearsal and performance on 2 types of laparoscopic cholecystectomy simulators. J Surg Educ [Internet]. 2015;72(4):740–8.
Roussin CJ, Weinstock P. SimZones: An Organizational Innovation for Simulation Programs and Centers. Acad Med. 2017 Aug;92(8):1114-1120. doi: 10.1097/ACM.0000000000001746. PMID: 28562455.
Searle JR. (1990). The Mystery of Consciousness. London: Granta Books.
READ ALSO
