Positive Health Online

Abstract

Pregnancy and labour are possibly the most significant events in the lives of many women, and constitute a normal, natural, physiological phenomenon. However, the ongoing paternalistic medicalization of childbirth, coupled with the defensive obstetric practice of an increasingly litigious society, have resulted in a backlash amongst both mothers and midwives and a demand for non-interventionist maternity care, including the use of complementary and alternative medicine. This growing enthusiasm for natural remedies has facilitated women to regain some control over their bodies and empowered them to become more involved in a partnership for their care. Of concern, however, are the recent guidelines on antenatal care from the National Institute for Clinical Excellence, which allege that there is insufficient research evidence to support the administration of any complementary therapies during pregnancy and actively discourage maternity professionals from advocating their use.

The philosophy of the Changing Childbirth Report[1] advocated 'choice, control and continuity' of care for expectant, labouring and newly delivered mothers. Maternity service policy for the 21st century[2] also appeared to be keen to respond to women's needs, making care more 'woman focused'. More recently, the government has expressed a desire to reduce the number of routine antenatal appointments, claiming that frequent consultations are unnecessary since the majority of women have uncomplicated pregnancies which do not require medical intervention.[3] However, pregnant women continue to be unhappy with conveyor-belt maternity care and the lack of time available to talk about issues of concern. Surveys conducted for the National Childbirth Trust and for Mother and Baby magazine in 2002 highlighted the comparative isolation that many expectant mothers experience and their need for more attention to be given to psychological and emotional needs.

Obstetric care continues to be notoriously interventionist, ostensibly on grounds of safety, without facilitating the normality of childbirth and enabling the woman's body to do the work for which it is designed. Britain now has a national Caesarean section rate of almost 25%,[4] and in many maternity units the birth of the baby is often expedited through induction and acceleration of labour, episiotomy or forceps/ ventouse delivery. Physical and emotional trauma to the mother frequently contributes to subsequent lack of success with breast feeding, postnatal depression and, in some women, the development of post-traumatic stress syndrome.[5]

Expectant mothers undergoing an essentially normal life event wish to remain in control of their bodies, to be involved in a partnership with midwives and doctors and to be facilitated to make informed decisions about their care. Complementary therapies offer more choice for women who may not be able to or may not wish to resort to pharmacological drugs or conventional treatment for the myriad discomforts and psychological concerns which affect them at this time, such as nausea, backache, tiredness, mood changes and anxiety. Women often feel that GPs and obstetricians dismiss these aches and pains because they are physiological and normal, but they can be severe enough to affect their ability to carry on with their day-to-day commitments. Conventional healthcare is considered by users to be dis-empowering and mechanistic,[6] while the emphasis of complementary medicine on the holistic approach to individuals, including the psychological and spiritual aspects of health, is valued.[7]

Demand for complementary medicine within maternity care has come initially from consumers, in response to disillusionment and dissatisfaction with the de-personalised, conveyor-belt routines of antenatal monitoring. However, there is now an increasing integration of many of the most commonly used therapies into orthodox maternity care. In the UK approximately one person in three, two thirds of whom are women, has used complementary medicine.[8] Many women have consulted a complementary practitioner prior to conception, or may choose to seek alternative treatment for conditions during pregnancy, such as osteopathy for backache and sciatica or acupuncture for sickness. Other women may be familiar with self-administration of natural remedies, including homeopathic or herbal medicines, Bach flower remedies or aromatherapy essential oils, and it is suggested that the use by pregnant women of herbal remedies may be anything between 7% and 55%.[9][10] In addition, in response to local consumer demand, midwives are increasingly offering some form of complementary therapy service in their practice; according to one survey, this may be as high as 34%.[11] Midwives, GPs and obstetricians are frequently asked for advice about different therapies, such as homeopathic arnica for postpartum perineal bruising, raspberry leaf herbal tea to tone the uterus in preparation for labour, or the safe use of aromatherapy essential oils during pregnancy, or for recommendations of practitioners of hypnotherapy, homeopathy or chiropractic.

Some maternity service managers are actively supporting staff in developing complementary maternity services. For example, Queen Mary's Hospital, Sidcup in Kent has offered a complementary therapy antenatal clinic for nine years, to treat women with physiological discomforts of pregnancy, and includes specialist sessions for women with nausea and vomiting and those wishing to seek alternatives for turning a breech-presenting foetus to head first. This clinic was 'highly commended' in the first annual Prince of Wales' awards for Healthcare in London in 2001.[12] Midwives at the Barrett Maternity Home in Northampton provide massage, aromatherapy, reflexology and yoga as standard components of midwifery care, a service which was short-listed for the 2003 Integrated Healthcare awards from the Prince of Wales' Foundation for Integrated Health.[13] The John Radcliffe Hospital in Oxford has provided aromatherapy in the delivery suite since the early 1990s and has conducted the largest clinical aromatherapy trial, studying over 8000 women using essential oils in labour.[14] Other units offer acupuncture services during pregnancy and labour, including Derriford Hospital in Plymouth,[15] which won joint first prize in the 2002 Integrated Healthcare awards.

In Britain it is illegal for anyone other than a midwife or doctor, or one in training under supervision, to take sole responsibility for the provision of maternity care, except in an a emergency, therefore any therapies offered professionally to pregnant and childbearing women must be complementary rather than alternative to conventional care. In general many patients fail to inform their doctors about their use of alternative medicine for fear of disapproval, but there is then an increased risk of problems such as interaction with drugs or other conventional treatments,[16] and pregnant women must be encouraged to inform their midwives or doctors if they are using any form of complementary therapy or natural remedy. There is a misconception that, because these therapies and remedies are natural, by inference they are also automatically safe, but this is not necessarily the case. Even midwives and doctors, in an effort to be seen to support women's wishes to consider alternative options, fail always to acknowledge the potential for adverse effects from some of the therapies.

However, one of the often-quoted justifications for dismissing complementary medicine is the apparent lack of scientific evidence to support its claims of efficacy and safety. This is not the case, although maternity-specific research is sparse, but it is appropriate to apply the principles of generic trials to the care of pregnant women, since, in many cases, it would be unethical to conduct trials on expectant mothers when the effects on the foetus are unknown. Additionally, sceptical practitioners of conventional medicine are unlikely to know where to look for the required evidence, especially as editorial bias can be seen in many professional journals, with reports of lack of efficacy or statistics for adverse reactions being published in orthodox medical publications,[17] while conventional medical databases such as MEDLINE and CINAHL have limited inclusion of complementary medicine research. This perceived dearth of evidence is further reinforced by an over-dependence of the orthodox sector on the 'gold standard' randomized controlled trial (RCT), although this must be balanced with the argument that many aspects of conventional medicine have been introduced without adequate preliminary investigation, notably in the field of surgery.

It is scandalous that the recent guidelines on maternity care for women with uncomplicated pregnancies, issued by the National Institute for Clinical Excellence,[3] should denigrate complementary and alternative medicine so definitively that healthcare professionals are actively discouraged from promoting or using any aspect when caring for pregnant and childbearing women. The paternalistic, judgmental and ill-informed 'authorities' responsible for developing these NICE guidelines have singularly failed to acknowledge that women will use natural remedies and consult complementary practitioners despite – and perhaps because of – any conventional medical moves to stop them, nor do they appreciate the benefits to be derived from many of the most accepted and commonly used therapies. This attitude is outdated, inappropriate, contrary to any attempts to offer 'woman-centred' maternity care and potentially dangerous in the extreme, as it may serve merely to dissuade women from informing their caregivers about concomitant use of complementary therapies. An example of possible problems arising from concealed use of natural remedies might be the multigravid woman who self-prescribes ginger for a prolonged period of gestational sickness yet who is also taking prophylactic aspirin to prevent a recurrence of pre-eclampsia. There is sufficient evidence to suggest that ginger, taken over a long period, adversely affects clotting mechanisms and may therefore theoretically interact with aspirin,[18] yet in a sub-section of the NICE guidelines, ginger is irresponsibly advocated as a universal alternative treatment for nausea and vomiting in pregnancy.

Conclusion

Despite the continued socio-political control exerted over pregnant and labouring women, through the hospital-focused, 'birth is only normal in retrospect' attitude of obstetricians, and the publication of government-driven policies to control and restrict maternity care under the guise of risk reduction, the use of complementary medicine appears to be here to stay. Healthcare users are increasingly looking to the holistic, mind-body-spirit approach which the various therapies offer, and expectant mothers, perhaps more than any other consumer group, appreciate the gentle, non-pharmacological aspect of natural remedies, to help them to cope with the physiological impacts of pregnancy. They also enjoy the sense of relaxation, which can be achieved from many of the therapies and the facility to take 'time out' for themselves, easing the effects of antenatal stress and tension. Most importantly, the additional choices which complementary therapies offer act as a powerful means of empowering women to reclaim control over their bodies, enabling them to be more actively involved in their care and promoting the normality of childbirth as a universal life event.

References

1. Dept of Health. Changing Childbirth: Report of the Expert Maternity Group. HMSO. London. 1993.
2. Dept of Health. Maternity Service Policy for the 21st Century. HMSO. London. 1998.
3. National Institute for Clinical Excellence (NICE) Clinical Guideline Number 6: Antenatal Care – Routine Care of the Healthy Pregnant Woman. Accessed via www.rcm.org.uk . 2003.
4. Pollock L. Why are an Increasing Number of Women Turning to Caesarean Sections? Midwives: Journal of the Royal College of Midwives. 7(1): 11-12. 2004.
5. Ballard CG, Stanley AK, Brockington IF. Post Traumatic Stress Disorder (PTSD) After Childbirth. British Journal of Psychiatry. 165(3): 525-528. 1995.
6. Barrett B, Marchand L, Schneder J, Appelbaum D, Chapman M, Jacons C, Westergaard R and St Clair N. Bridging the Gap between Conventional and Alternative Medicine. Journal of Family Practice. 49(3): 234-9. 2000.
7. Hebert RS, Jenckes MW, Ford DE, O'Connor DR and Cooper LA. Patient Perspectives on Spirituality and the Patient-Physician Relationship J Gen Intern Med. 16(10): 685-92. 2001.
8. Thomas KJ, Nicholl JP and Coleman P. Use and Expenditure on Complementary Medicine in England: a Population Based Survey. Complementary Therapies in Medicine. 9(10): 2-11. 2001.
9. Hepner DL, Harnett M, Segal S, Camann W, Bader AM and Tsen LC. Herbal Medicine Use in Parturients. Anesth Analg. 94(3): 690-3. 2002.
10. Mabina MH, Pitsoe SB and Moodley J. The Effect of Traditional Herbal Medicines on Pregnancy Outcome: The King Edward VIII Hospital Experience. South African Medical Journal. 87: 1008-1010. 1997.
11. NHS Confederation. Complementary Medicine in the NHS: Managing the Issues. NHS Confederation Birmingham. 1997.
12. Tiran D. Complementary Strategies in Antenatal Care. Complementary Therapies in Nursing and Midwifery. 7(1): 19-22. 2001.
13. Ager C. A Complementary Therapy Clinic – Making it Work. Royal College of Midwives. Journal. 5(6): 198-200. 2002
14. Burns E, Blamey C, Ersser SJ, Lloyd AJ and Barnetson L. The Use of Aromatherapy in Intrapartum Midwifery Practice: an Observational Study. Complementary Therapies in Nursing and Midwifery. 6(1): 33-4. 2000.
15. Budd S. Moxibustion for Breech Presentation. Complementary Therapies in Nursing and Midwifery. 6(4): 176-9. 2000.
16. Crock RD, Jarjoura D, Polen A and Rutcheki GW. Confronting the Communication Gap between Conventional and Alternative Medicine: a Survey of Physicians' Attitudes. Journal of Alternative Therapies in Health and Medicine. 5(2): 61-6. 1999.
17. Kayne SB. Homeopathic Pharmacy: an Introduction and Handbook. Churchill Livingstone. Edinburgh. ISBN 0-443 05018-X. 1997.
18. Ernst E, Pittler, M Stevinson C and White A (Eds.) The Desktop Guide to Complementary and Alternative Medicine an Evidence-Based Approach. Mosby Edinburgh. ISBN 0-7234-3207-4. 2001.

Bibliography

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