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Keywords:

  • Attitude;
  • complementary therapies;
  • health personnel;
  • healthcare surveys;
  • obstetrics;
  • pregnancy

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgement
  9. References
  10. Supporting Information

Objective

The aim of this study was to investigate the use of complementary and alternative medicines (CAMs) therapy by UK healthcare professionals involved in the care of pregnant women, and to identify key predictors of use.

Design

A prospective survey.

Setting

Maternity services in Grampian, North East Scotland.

Sample

All healthcare professionals (135) involved in the care of pregnant women (midwives, obstetricians, anaesthetists).

Methods

Questionnaire development, piloting, and distribution. Descriptive and inferential statistical analysis.

Results

A response rate of 87% was achieved. A third of respondents (32.5%) had recommended (prescribed, referred, or advised) the use of CAMs to pregnant women. The most frequently recommended CAMs modalities were: vitamins and minerals (excluding folic acid) (55%); massage (53%); homeopathy (50%); acupuncture (32%); yoga (32%); reflexology (26%); aromatherapy (24%); and herbal medicine (21%). Although univariate analysis identified that those who recommended CAMs were significantly more likely to be midwives who had been in post for more than 5 years, had received training in CAMs, were interested in CAMs, and were themselves users of CAMs, the only variable retained in bivariate logistic regression was ‘personal use of CAM’, with an odds ratio of 8.26 (95% CI 3.09–22.05; < 0.001).

Conclusion

Despite the lack of safety or efficacy data, a wide variety of CAM therapies are recommended to pregnant women by approximately a third of healthcare professionals, with those recommending the use of CAMs being eight times more likely to be personal CAM users.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgement
  9. References
  10. Supporting Information

The World Health Organization defines ‘complementary and alternative medicine’ (CAM) as a ‘broad set of health care practices that are not part of that country's own tradition and are not integrated into the dominant health care system’.[1] Therefore, the scope of CAM is broad and varied, encompassing a vast number of approaches, such as acupuncture, aromatherapy, herbal medicines, and spiritual healing, to name but a few.[2] Unlike conventional licensed medicines, few CAM approaches to health care are supported by robust efficacy, effectiveness, or safety data.[3-5] Despite this lack of data, the use of CAMs appears to be widespread, with women reportedly being the major users, both for health and for disease.[6] The high level of CAM use reportedly extends to pregnant women and women undergoing fertility treatment.[7-10] The reasons for the use of CAMs during pregnancy are not entirely clear, but appear to centre on the women's desire to maintain/improve health and to alleviate pregnancy-related symptoms.[7-10] A further factor underlying the use of CAMs may be, at least in part, any recommendations made by attending health professionals.[11]

Over the last 5 years, ten surveys from Europe, North America, and Australia have reported on health professional views and experiences of using CAMs in their own obstetric practice, demonstrating extensive use by healthcare professionals.[12-21] These studies were primarily conducted in Europe,[12-16] however, and focused largely on midwives,[12, 16-20] with sample sizes ranging between 36 and 1009,[13, 21] and with response rates of 30–100%.[13, 16, 17] A common key weakness in the majority of these studies was a failure to define CAMs, leading to difficulty in interpreting and generalising the data to other populations and healthcare systems.[13-17, 20]

The aim of this study was to investigate the use of CAM therapies by UK healthcare professionals involved in the care of pregnant women, and to identify key predictors of use.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgement
  9. References
  10. Supporting Information

Participants, setting, and recruitment

The participants were all healthcare professionals (midwives, consultant/trainee obstetricians, and consultant/trainee anesthetists; n = 135, after excluding the pilot study participants), primarily involved in the care of pregnant women in the Grampian region of North East Scotland. A named study pack containing a questionnaire was sent directly to all consultant/trainee obstetricians and consultant/trainee anesthetists identified from duty lists held within the maternity hospital. Study packs were also handed directly to all midwives and trainee midwives working in the Grampian region, identified from staff lists held within the Aberdeen Maternity Hospital.

Questionnaire development, validation, and piloting

A pilot questionnaire was developed from the published literature on CAM-related healthcare professional recommendations to pregnant women.[12-21] CAM was defined as referring to the ‘diagnosis, treatment and prevention of illness by various practitioners using therapies such as herbal medicines, homeopathic medicines, acupuncture, aromatherapy, chiropracty, vitamins and minerals and certain food products’. The questionnaire was reviewed for face and content validity by four individuals with experience in the care of pregnant women and associated research, followed by piloting in a random sample of 20 midwives and five obstetricians and anaesthetists. Minor modifications were made to the questionnaire after piloting.

The final questionnaire contained three sections of closed questions and Likert-type statements on: the use of CAMs in pregnant women, including CAMs recommended (a detailed checklist of 22 CAM modes was included, with space for respondents to list any additional modes); factors influencing decision making, such as respondent use of CAMs for their personal health care, any concerns associated with the use of CAMs in pregnancy, and any specific training related to CAMs (ten items); attitudes towards the use of CAMs in pregnancy (seven items); and personal and practice demographics (eight items).

The questionnaire was distributed together with a study invitation letter, information leaflet, and envelope to be returned to the investigators via the internal mail. No reminders were issued.

Analysis

Data were coded and entered into spss 21.0 (SPSS Inc., Cary, NC, USA) then analysed using descriptive statistics to profile respondents. The chi-square test was used to analyse associations between variables (e.g. age, practice experience, further training) and the outcome measure of recommending (prescribing, referring, or advising) CAM use to pregnant women. Variables identified as significant in univariate analysis were entered into bivariate logistic regression: P < 0.05 was considered to be statistically significant.

Governance

This research was approved by the National Health Service (NHS) North of Scotland Research Ethics Committee and NHS Grampian Research and Development Committee.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgement
  9. References
  10. Supporting Information

Demographics

A total of 117 responses (77 from midwives and 40 from obstetricians/anaesthetists) were received, giving an overall response rate of 86.7%. The majority were female (92.3%, 108), and had obtained their primary medical or midwifery qualification in the UK (83.8%, 98). Although just over half of respondents (55.6%, 65) expressed an interest in CAMs, few had received any specific training in CAMs (12.0%, 14). Just over half of respondents (53.8%, 63) had used CAMs for their personal health care, and a third of respondents reporting previous pregnancy (31.9%, 22/69) had used CAMs during their own pregnancy. A full description of respondent characteristics is reported in Table 1.

Table 1. Respondent demographics
 % (n)
  1. = 117.

  2. a

    Three missing values.

Profession
Midwife65.8 (77)
Consultant/specialist obstetrician5.2 (6)
Consultant/specialist anaesthetist3.4 (4)
Trainee obstetrician23.9 (28)
Trainee anaesthetist1.7 (2)
Gender
Female92.3 (108)
Male7.7 (9)
Length of time in post
Up to 5 years38.5 (45)
6–10 years16.6 (19)
11–15 years12.8 (15)
More than 15 years32.5 (38)
Primary qualification in UK
Yes83.8 (98)
No16.2 (19)
Length of time since gaining qualification a
Up to 5 years31.6 (37)
6–10 years8.5 (10)
11–15 years17.1 (20)
More than 15 years40.2 (47)
Ethnic origin
White British80.3 (94)
Other19.7 (23)

Predictors of CAM use and CAMs recommended

A third of respondents (32.5%, 38) had recommended (prescribed, referred, or advised) the use of CAM to pregnant women (Table S1). Although univariate analysis identified that the recommenders of CAMs were significantly more likely to be midwives (= 0.038), to have been in post for more than 5 years (= 0.009), to have received training in CAMs (= 0.019), were interested in CAMs (= 0.007), and were themselves users of CAMs (< 0.001), the only variable retained in bivariate logistic regression was ‘personal use of CAMs’, with an odds ratio of 8.26 (95% CI 3.09–22.05; < 0.001).

A total of 18 different CAM therapies were recommended, the most commonly being: vitamins and minerals (excluding folic acid; 55.3%, 21); massage (52.6%, 20); homeopathy (39.5%, 15); acupuncture (31.6%, 12); yoga (31.6%, 12); reflexology (26.3%, 10); aromatherapy (23.7%, 9); herbal medicine (21.1%, 8); nutraceuticals (15.8%, 6); chiropractic (15.8%, 6); acupressure (13.2%, 5); shiatsu (10.5%, 4); reiki (5.3%, 2); mind and body (2.6%, 1); Alexander technique (2.6%, 1); Chinese medicine (2.6%, 1); cranial osteopathy (2.6%, 1); and meditation (2.6%, 1).

Perceived influences on CAM recommenders and sources of information

When CAM recommenders were asked which factors influenced their decision to recommend CAMs to patients, the principal influences on their decision were: professional experience based on patient feedback, ‘seeing is believing’ (63.2%, 24); feedback from the respondent's own family and friends (36.8%, 14); patient request/demand for CAMs (36.8%, 14); personal experience of positive results on own health (28.9%, 11); direct evidence of patient benefit when referred to a CAM provider (26.3%, 10); their own belief in the benefits of CAM (21.1%, 8); and continuing CAM treatment started by others (10.5%, 4).

Common sources of CAM information cited by recommenders were: other health professionals (57.9%, 22); personal experience (47.4%, 18); professional journals (42.1%, 16); clinical experience (34.2%, 13); the internet (28.9%, 11); family and friends (23.7%, 9); lay magazines (7.9%, 3); British National Formulary (7.9%, 3); and CAM providers (5.3%, 2).

Concerns expressed by CAM recommenders and non-recommenders

Recommenders expressed concerns related to the use of CAMs during pregnancy in terms of: safety (52.6%, 20); their lack of training (50.0%, 19); their lack of access to prescribing information (36.8%, 14); the lack of efficacy (23.7%, 9); and reports of bad patient experiences (5.3%, 2).

The reasons given for not recommending CAM use by the 79 non-recommenders were: their lack of training (75.9%, 60); the lack of evidence-based guidelines (41.8%, 33); the lack of evidence of safety (35.4%, 28); their lack of competence (36.7%, 29); and no requests from patients (27.8%, 22).

Attitudes of recommenders and non–recommenders towards CAM use

Although the majority of respondents (69.2%, 81) agreed that there was some value in CAM use during pregnancy, recommenders were more likely to agree with this statement than non-recommenders (= 0.004). Similarly, only a small number of respondents (6.0%, 7) agreed that patients should never use CAMs during pregnancy; however, few of the respondents (12.8%, 15) agreed that CAMs were a safer alternative to conventional prescribed medicines during pregnancy. There was a strong level of agreement by all respondents (93.2%, 109) that healthcare professionals should be informed of a patient's use of CAM during pregnancy, and more than half of respondents (61.6%, 72) agreed that during pregnancy patients should only use CAMs recommended by healthcare professionals. Almost all respondents (89.7%, 105) agreed that irrespective of their personal beliefs, all healthcare professionals should have knowledge about common CAMs. Approximately three-quarters of respondents (76.1%, 89) agreed that all healthcare professionals should be taught about CAMs during their undergraduate curriculum. A full description of respondents to attitudinal statements is reported in Table S2.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgement
  9. References
  10. Supporting Information

Main findings

This is the first study to identify that the personal use of CAMs by professionals for their own health care is the only independent predictor of their recommendations to pregnant women to use CAMs. Those using CAMs for their own health care were eight times more likely to recommend (prescribe, advise, refer) CAMs to pregnant women during their professional obstetric practice, compared with non-recommenders.

Strengths and limitations

Despite achieving a high response rate, this study relied on self-reported data from a single centre, which may limit the generalisability to other settings; however, our findings are similar to the results of previously published studies in terms of the scope of CAMs recommended and the proportion of healthcare professionals who report a belief in the value of CAM therapies in pregnancy.

Interpretation

The recognition of the importance of personal CAM use in determining professional practice is paramount when considering the global drive to implement evidence-based approaches to patient care.[22] The role of personal CAM use in defining professional practice and the evident failure to adopt a systematic, objective, evidence-based approach is further reinforced by a reported reliance on the experiences of family and friends, and to a lesser extent their own clinical experience, and that of other healthcare professionals, as relevant sources of information. Interestingly, the main reason given by non-recommenders for not using CAM in their obstetric practice was a lack of training rather than a lack of evidence-based guidelines or concerns over safety.

In this study approximately a third of healthcare professionals recommended CAMs to pregnant women, which is markedly lower than the levels reported from Europe, the USA, and Australia.[12-21] The reasons for the lower level of use in our sample population are unknown, but possibly reflect differences in study design, healthcare systems, and cultures.

The safety of CAMs was also a key concern for both recommenders and non-recommenders, with just over 10% of all respondents agreeing that CAMs were a safer alternative to conventional prescribed medicines. This level of concern is in close agreement with that reported by Koc et al. in a study of midwives in Turkey.[12] Of greater significance is the finding that despite using CAMs the majority of recommenders also expressed concerns about the safety and efficacy of CAM therapies, including six respondents who reported concerns as a consequence of adverse events affecting their own patients. Nevertheless, 70% of all respondents still agreed that there was value in CAM use during pregnancy: a finding similar to those reported for studies of midwives from Turkey (69%), the USA (50%), and New Zealand and Canada (71%).[12, 19, 21]

Despite the widespread use of evidence-based guidelines in obstetric practice, the failure to reconcile practice with evidence, in relation to CAM use in pregnancy, highlights the need for further undergraduate and postgraduate education and training. Three-quarters of all respondents in this study agreed that CAM approaches should feature in undergraduate curricula. Although this merits further consideration it is essential that the primary role of evidence, rather than personal experience, is highlighted. In light of these findings and with an increasing recognition of potential adverse events associated with CAM use,[23-27] further research is warranted to understand the factors driving professional practice.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgement
  9. References
  10. Supporting Information

Despite the lack of safety or efficacy data, a wide variety of CAMs are recommended to pregnant women by approximately a third of healthcare professionals, with those recommending CAM use being eight times more likely to be personal CAM users.

Disclosure of interests

None of the authors have any conflicts of interest or financial disclosures to declare.

Contribution to authorship

JSM was principle investigator and lead for the conception, planning, carrying out, protocol development, analysing, and writing up of the work, as well as the ethics and research and development submissions. DS assisted fully in the conception, planning, protocol development, carrying out, analysing, and writing up of the work, as well as the ethics and research and development submissions. ARP assisted fully in the conception, planning, carrying out, protocol development, analysing and writing up of the work, study recruitment, as well as the ethics and research and development submissions. AS assisted in the conception, planning, carrying out, protocol development, analysing, and writing up of the work, and in study recruitment. BP assisted fully in the conception, planning, study recruitment, analysing and writing up of the work.

Details of ethics approval

This study was approved by the North of Scotland Research Ethics Committee (11/AL/0094).

Funding

This study was funded from internal institutional resources.

Acknowledgement

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgement
  9. References
  10. Supporting Information

We acknowledge all of the respondents for their participation.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgement
  9. References
  10. Supporting Information
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    Wiebelitz KR, Goecke TW, Brach J, Beer AM. Use of complementary and alternative medicine in obstetrics. Br J Midwifery 2009;17:16975.
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    Dennehy C, Tsourounis C, Bui L, King TL. The use of herbs by California midwives. J Obstet Gynecol Neonat Nurs 2010;39:68493.
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    Samuels N, Zisk-Rony RY, Singer SR, Dulitzky M, Mankuta D, Shuval JT, et al. Use of and attitudes toward complementary and alternative medicine among nurse-midwives in Israel. Am J Obstet Gynecol 2010;203:341.e17.
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    The Cochrane Collaboration. [www.cochrane.org/]. Accessed 17 April 2013.
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    Patel DN, Low WL, Tan LL, Tan MM, Zhang Q, Low MY, et al. Adverse events associated with the use of complementary medicine and health supplements: an analysis of reports in the Singapore Pharmacovigilance database from 1998 to 2009. Clin Toxicol (Phila) 2012;50:4819.
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    Posadzki P, Watson LK, Ernst E. Adverse effects of herbal medicines: an overview of systematic reviews. Clin Med 2013;13:712.
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    Posadzki P, Alotaibi A, Ernst E. Adverse effects of aromatherapy: a systematic review of case reports and case series. Int J Risk Safe Med 2012;24:14761.
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    Ernst E, Posadzki P. Reporting of adverse effects in randomised clinical trials of chiropractic manipulations: a systematic review [Review]. N Z Med J 2012;125:87140.
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Supporting Information

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgement
  9. References
  10. Supporting Information
FilenameFormatSizeDescription
bjo12618-sup-0001-TableS1.pdfapplication/PDF33KTable S1. Comparison of CAM recommenders and non-recommenders.
bjo12618-sup-0002-TableS2.pdfapplication/PDF34KTable S2. Responses of recommenders and non-recommenders to attitudinal statements regarding CAM use.

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