MIDIRS Essence > April 2008 > Midwifery News
Is midwives’ use of complementary therapies always justified?
Originally posted on Apr 2008
A risk assessment tool to guide practice
Abstract
Complementary therapies are extremely popular with expectant mothers, and with midwives, offering various means to relieve physical and emotional symptoms and reducing the need for obstetric intervention. There is, however, growing concern over the safety of complementary therapies, particularly in pregnancy, and the indiscriminate enthusiasm of midwives has resulted in some injudicious practice in which complementary therapies are used, not only unnecessarily, but also inappropriately and often incorrectly. This paper explores the current state of complementary therapy use within midwifery practice, challenges midwives to consider whether their use is always justified, and presents some controversial issues to encourage professional debate. A suggested tool is proposed to assist midwives to make decisions regarding the appropriateness of complementary therapies for mothers in their care.
Introduction
The rising interest in complementary therapies (CTs) to aid progress in pregnancy and childbirth has led to the establishment of comprehensive therapy facilities by midwives in some UK maternity units, although service provision within the NHS generally remains patchy. Heads of Midwifery are largely supportive, viewing the introduction of CTs as a way of improving maternal satisfaction, promoting normal birth and reducing medical intervention (Williams & Mitchell 2007). The advent of low-risk birthing units and the need to normalise birth and reduce escalating caesarean section rates has prompted many to consider formal implementation and provision of relevant CTs training for their staff (Expectancy, personal communications). There are numerous examples in the professional literature of midwives who have successfully implemented CTs into their practice, especially aromatherapy (Mousley 2005), massage (McNabb et al 2006), reflexology (McNeill et al 2006) and shiatsu (Ingram et al 2005). In addition, midwives frequently meet women who self-administer natural remedies or who consult independent practitioners for therapies such as reflexology, massage or aromatherapy for relaxation, hypnosis preparation for birth or acupuncture for relief of specific symptoms, even though many fail to inform their caregivers unless specifically asked.
Complementary therapies as power
It has been estimated that over a third of midwives use one or more therapies in their practice (NHS Confederation 1997), although it is probable that an up-to-date survey would show an significant increase in this number. Reasons most often quoted for the phenomenal rise in interest are that they enable the midwife to return to being ‘with woman’ (Wickham 2006), provide new or different options for managing pregnancy and labour symptoms and normalise birth outcomes (Tiran 2006a) and empower women. It has also been suggested that midwives’ enthusiasm for CTs reflects a desire to regain autonomy, and to differentiate the roles between midwives and obstetricians (Adams 2006). It is interesting to note that the traditional differences between midwives and doctors – the bio-medical approach versus the psycho-social, the prospective versus retrospective acceptance of normality, as well as ‘management’ versus ‘care’ issues – appear also to be reflected in the use of and acknowledgement of CTs.
Although there is a general lack of knowledge about CTs among both obstetricians and midwives (Tiran 2006b) – a factor which is not confined solely to the UK (Bayles 2007) – medical staff are more concerned with evidence of safety and effectiveness in an attempt to minimise the risk of litigation, a possible contributory barrier to greater integration (Maha & Shaw 2007). Conversely, midwives promote the relaxation factor and the ‘holistic’ nature of CTs (Gaffney & Smith 2004) which is in keeping with the philosophy of woman-focused care. However, a further differentiation may be apparent between midwives who encompass CTs and those who do not, perhaps mirroring the varying opinions between midwives who practise proactively and those who practise defensively. It is also possible that some midwives enjoy the perceived autonomy which comes from using CTs, and the sense of power they gain from making clinical decisions and prescribing and administering treatments based on a restricted, elitist knowledge-base, which sets them aside from their midwifery and medical colleagues.
This is becoming more evident as midwives experienced in CTs push the boundaries of practice ever further, for example, offering moxibustion to convert a breech to cephalic presentation as an alternative to external cephalic version. The majority of midwives implementing this service have been well trained, work according to contemporary evidence-based practice and within the constraints of institutional policies and procedures, in accordance with the requirements of the Nursing and Midwifery Council (NMC), but a few individuals known to this author do not. An example is midwives, usually working privately, who contravene currently accepted practice in relation to moxibustion by offering the procedure to women who have previously had caesarean sections. While there is an argument in traditional Chinese medicine that moxibustion is safe despite the existence of a uterine scar (Dharmananda 2004), it is inappropriate for those primarily working within the remit of their NMC registration to dispute what is currently considered to be appropriate midwifery practice until such time as further studies have been undertaken.
There is also a trend for some midwives to use aspects of CTs as a form of ’labour priming’ ostensibly to facilitate cervical ripening to prevent women going beyond their due dates. Undoubtedly, there is some promising evidence for the effectiveness of CTs such as shiatsu, acupuncture and aromatherapy, in inducing or accelerating contractions (Burns et al 2000, Gaudernack et al 2006, Ingram et al 2005). Similarly there is some suggestion that therapies such as reflexology and aromatherapy, performed regularly in the last few weeks of pregnancy can facilitate a normal outcome for labour (Field et al 2005, Bastard & Tiran 2006, McNeill et al 2006) by reducing stress hormones and facilitating oxytocin release. However, it must be remembered that midwives are responsible for caring for women with normal pregnancies, labours and puerperia, therefore any means of directly encouraging the onset of labour is as much an intervention as the use of prostaglandins, syntocinon or artificial membrane rupture. Surely, midwives should be informing women that the spectrum of normality means that labour onset can occur any time between 37 and 42 weeks’ gestation, and should not condone mothers’ attempts to expedite labour to suit their psychosocial circumstances? Using CTs to facilitate homeostasis as term approaches, or employing them post-dates as a possible way of avoiding a threatened medical induction, is laudable and may indeed offer a positive way forward, but promoting them specifically to encourage the onset of labour before 40 weeks is not only misleading to women but also professionally deplorable.
Many midwives undertake training in a complementary therapy at their own expense and in their own time, and then wish to introduce a CTs service within the maternity unit. However, a generic qualification in a therapy does not adequately equip a midwife to use it within her practice, especially within an institution. Most CTs courses include a minimal amount of study and little practice on the application of the therapy to the treatment of pregnant and newly-delivered mothers, while labour is often omitted completely. In many training courses for the ‘supportive’ therapies (House of Lords 2000), eg massage, reflexology, aromatherapy and hypnosis, there is little, if any, discussion on the evidence-base of the therapy, with any application to maternity care being incidental. Significantly, no basic therapy courses prepare students to transfer their knowledge and skills to the NHS, nor do they consider the health and safety issues pertinent to institutional use. This dilemma implies an urgent need for adaptation courses to facilitate the application of generic theory to midwifery practice.
Of most concern is the somewhat larger proportion of midwives who are not qualified in any therapy but who insist on giving women advice about aspects of CTs, on natural remedies in particular. Examples of this ‘information’ – or misinformation – include superficial details and safety checks on women enquiring about raspberry leaf tea to tone the myometrium in preparation for labour, inconsistent advice on homeopathic arnica for postnatal perineal bruising and even lack of knowledge on the mechanism of action of cabbage leaves, commonly advised by midwives for relief of breast engorgement. Furthermore, there are some scandalously negligent – or perhaps unbelievably naive – examples known to this author in which midwives have taken it upon themselves to offer advice, sometimes based on nothing more than overhearing colleagues or talking to women about folk remedies (see below).
Safe integration of complementary therapies into conventional maternity care
It has been argued that CTs are both a science and an art, therefore it is necessary to distinguish between their use as a belief system and their application to clinical practice; the debate on the challenges of integrating complementary with conventional health care is ongoing (Oguamanam 2006), and requires consideration within midwifery. An ethical justification for CTs in midwifery must be based on the issues of beneficence and non-maleficence (Mertz 2007) – in other words, offering benefits without harm. While evidence for the effectiveness and safety of CTs in pregnancy and childbirth is growing, not all research conforms to the scientific ‘gold standard’ of the randomised controlled trial and there are very few systematic reviews on maternity CTs, apart from the use of P6 acupressure for ‘morning sickness’. This led the National Institute for Health and Clinical Excellence (NICE) to advise professionals to discourage expectant mothers from using CTs (National Collaborating Centre 2003), although this has been challenged by Tiran (2005). However, there is growing concern that midwives rarely appear to consider research findings in relation to CTs; to this end a national investigation is currently underway to explore midwives’ and nurses’ use of an evidence-base when incorporating CTs into their practice (Ruston 2007, personal communication).
A risk assessment tool to assist midwives to justify their use of CTs
Although many midwives wish to incorporate CTs into their practice, it appears difficult for managers, supervisors and educators to encourage a balance of the undoubted enthusiasm of individual midwives with a degree of cautionary practice, in order to protect mothers and babies. Midwives in those units where implementation of CTs is currently being explored are most likely to consider the risks and benefits of their actions and are not the colleagues whose practice is questioned. However, where no therapies are in use or, occasionally, where there is an established CTs service, a tool to guide practice may be of value. This risk assessment tool aims to assist midwives to justify their use of CTs and to facilitate supervision and management within a unit. In keeping with the requirements of the NMC, the issues of accountability, safety and evidence are used as the basis of the tool and focuses on the responsibilities of individual midwives, institutions and the profession as a whole.
A worked example of the risk assessment tool (based on an actual example known to this author)
Alison is expecting her second baby and wishes to give birth at home, but during the third stage of her last labour she was transferred to hospital due to a retained placenta. Her community midwife advises her to drink dandelion tea at 39 weeks’ gestation to prevent the problem recurring. It transpires that the midwife gained this information from another mother who was Turkish; she had a history of retained placenta in two previous labours. During her third pregnancy she returned to Turkey and was advised by the women in her village to drink dandelion tea at 39 weeks; she did not have a retained placenta in the third labour.
Using the tool as a template to determine the midwife’s justification for this piece of advice one could start with the issue of the evidence-base to support practice and demonstrate the mechanism of action, indications, contraindications and precautions. Dandelion is known to act as a diuretic, may have anti-inflammatory effects and possibly increases insulin production (Hussain et al 2004). It is thought to have immunostimulant activity as well as antioxidant and cytotoxic effects (Hu & Kitts 2003). However, despite an extensive search of herbal medicine research databases, nowhere was any evidence found to suggest its value in preventing retained placenta, although diuresis occurs due to vasoconstriction, which may impact on placental separation. Furthermore, adverse effects include anaphylaxis and dermatitis (Chivato et al 1996) and its known high potassium content may compromise cardiac function (Williams et al 1996). Animal studies suggest that dandelion may inhibit liver enzymes, possibly slowing detoxification and potentiating drug metabolism (Maliakal & Wanwimolruk 2001). Its use during pregnancy remains debatable, although various consumer pregnancy websites advocate dandelion tea for oedema, constipation and sluggish digestion and to prevent anaemia.
This midwife does not appear to have a working knowledge of the mechanism of action, nor an ability to relate this to the altered physiology of pregnancy, but has relied on folk medicine, provided second-hand by another mother. She has not compared the efficacy of existing conventional methods of managing retained placenta with unproven alternatives, neither does she seem to recognise that the mother’s condition is already compromised because of the previous retained placenta. She did not provide the mother with sufficient information to give informed consent, and it is assumed that the advice given was not recorded in the notes. The employing authority is presumably unaware of the midwife’s action, has not given permission for her to offer such advice and there are no unit policies to protect her practice, nor the wellbeing of the mother and baby. It is likely that this relatively minor incident would escape the notice of the supervisor of midwives, who may not have sufficient knowledge herself on this topic. Finally, this catalogue of malpractice arising from one apparently insignificant piece of advice effectively invalidates the midwife’s right to indemnity insurance cover through the hospital’s vicarious liability system.
The verdict is therefore that the midwife is not adequately justified in giving this advice without further education and that she is working outside the parameters of her professional practice.
On reflection: what are the implications of this scenario for the mother, the midwife, the Trust in which she works and the profession as a whole?
Conclusion
CTs offer opportunities to attend to mothers’ physical and psycho-social well-being and their benefits in enhancing midwifery practice have been demonstrated in many maternity units. However, as more and more midwives become involved in CTs, or observe or overhear colleagues treating or advising mothers, there is an increased possibility of adverse incidents arising from misuse or abuse, and the risk that midwives will overstep the boundaries of their practice.
Fortunately, increasing numbers of midwives have received appropriate education to incorporate CTs into their own practice, but those who have generic therapy qualifications should consider a period of adaptation to enable them to relate it to midwifery practice. Existing CTs services should be audited regularly and midwives should receive relevant ongoing education to help them maintain the service. Supervisors and managers must remain alert to the practices of their staff and acknowledge the ramifications of their use of CTs.
All midwives must remember that it is a requirement of the NMC that they are able to justify their professional actions and should consider the use of a tool, such as the one proposed here, to assist in this process.
References
Adams J (2006). An exploratory study of complementary and alternative medicine in hospital midwifery: models of care and professional struggle. Complement Ther Clin Pract 12(1):40-7.
Bastard J, Tiran D (2006). Aromatherapy and massage for antenatal anxiety: its effect on the fetus. Complement Ther Clin Pract 12(1):48-54.
Bayles BP (2007). Herbal and other complementary medicine use by Texas midwives. J Midwifery Womens Health 52(5):473-8.
Burns EE, Blamey C, Ersser SJ et al (2000). An investigation into the use of aromatherapy in intrapartum midwifery practice. J Altern Complement Med 6(2):141-7.
Chivato T, Juan F, Montoro A et al (1996). Anaphylaxis induced by ingestion of a pollen compound. J Investig Allergol Clin Immunol 6(3):208-9.
Dharmananda S (2004). Moxibustion: practical considerations for modern use of an ancient technique. Available from www.itmonline.org/arts/moxibustion [Accessed February 2008].
Field T, Hernandez-Reif M, Diego M et al (2005). Cortisol decreases and serotonin and dopamine increase following massage therapy. Int J Neurosci 115(10):1397-413.
Gaffney L, Smith CA (2004). Use of complementary therapies in pregnancy: the perceptions of obstetricians and midwives in South Australia. Aust N Z J Obstet Gynaecol 44(1):24-9.
Gaudernack LC, Forbord S, Hole E (2006). Acupuncture administered after spontaneous rupture of membranes at term significantly reduces the length of birth and use of oxytocin. A randomized controlled trial. Acta Obstet Gynecol Scand 85(11):1348-53.
House of Lords Select Committee on Science and Technology (2000). Sixth report on complementary and alternative medicine. London: Stationery Office.
Hu C, Kitts DD (2003). Antioxidant, prooxidant, and cytotoxic activities of solvent-fractionated dandelion (Taraxacum officinale) flower extracts in vitro. J Agric Food Chem 51(1):301-10.
Hussain Z, Waheed A, Qureshi RA et al (2004). The effect of medicinal plants of Islamabad and Murree region of Pakistan on insulin secretion from INS-1 cells. Phytother Res 18(1):73-7.
Ingram J, Domagala C, Yates S (2005). The effects of shiatsu on post-term pregnancy. Complement Ther Med 13(1):11-15.
Maha N, Shaw A (2007). Academic doctors' views of complementary and alternative medicine (CAM) and its role within the NHS: an exploratory qualitative study. BMC Complement Altern Med 7:17 pages.
Maliakal PP, Wanwimolruk S (2001). Effect of herbal teas on hepatic drug metabolizing enzymes in rats. J Pharm Pharmacol 53(10):1323-9.
McNabb MT, Kimber L, Haines A et al (2006). Does regular massage from late pregnancy to birth decrease maternal pain perception during labour and birth? A feasibility study to investigate a programme of massage, controlled breathing and visualization, from 36 weeks of pregnancy until birth. Complement Ther Clin Pract 12(3):222-31.
McNeill JA, Alderdice FA, McMurray F (2006). A retrospective cohort study exploring the relationship between antenatal reflexology and intranatal outcomes. Complement Ther Clin Pract 12(2):119-25.
Mertz M (2007). Complementary and alternative medicine: the challenges of ethical justification. A philosophical analysis and evaluation of ethical reasons for the offer, use and promotion of complementary and alternative medicine. Med Health Care Philos 10(3):329-45.
Mousley S (2005). Audit of an aromatherapy service in a maternity unit. Complement Ther Clin Pract 11(3):205-10.
National Collaborating Centre for Women’s and Children’s Health (2003). Antenatal care: routine care for the healthy pregnant woman. London: NICE.
Oguamanam C (2006). Biomedical orthodoxy and complementary and alternative medicine: ethical challenges of integrating medical cultures. J Altern Complement Med 12(6):577-81.
Tiran D (2005). NICE guideline on antenatal care: routine care for the healthy pregnant woman – recommendations on the use of complementary therapies do not promote clinical excellence. Complement Ther Clinical Pract 11(2):127-9.
Tiran D (2006a). Midwives’ responsibilities when caring for women using complementary therapies during labour. MIDIRS Midwifery Dig 16(1):77-80.
Tiran D (2006b). Complementary therapies in pregnancy: midwives' and obstetricians' appreciation of risk. Complement Ther Clin Pract 12(2):126-31.
Wickham S (2006). Holistic therapies, proof and plausibility. Pract Midwife 9(10):51.
Williams CA, Goldstone F, Greenham J (1996). Flavonoids, cinnamic acids and coumarins from the different tissues and medicinal preparations of Taraxacum officinale. Phytochemistry 42(1):121-7.
Williams J, Mitchell M (2007). Midwifery managers' views about the use of complementary therapies in the maternity services. Complement Ther Clin Pract 13(2):129-35.
Resources
www.expectancy.co.uk
Expectancy Ltd – the Expectant Parents’ Complementary Therapies Consultancy – provides university accredited courses on the safe use of complementary therapies in midwifery practice; bespoke courses can be delivered in-house.
www.nccam.nih.gov/camonpubmed
Excellent UK/USA database of abstracts related to complementary therapies (free).
Denise Tiran | Director | Expectancy Ltd
Your Comments
Have your say! Register now and post your comments on this article here.
Sorry, there are currently no comments for this article.