Thirty-four certified nurse-midwives (41.5%; 95% CI 30.7%, 52.9%) reported receiving formal training in different complementary and alternative medicine therapies. The five most commonly cited modalities were herbal (n = 19), massage (n = 10), acupressure (n = 4), homeopathy (n = 4), and therapeutic touch (n = 4). Twenty-nine nurse-midwives (35.4%; 95% CI 25.1%, 46.7%) reported some training in alternative therapies during nurse-midwifery training, the most common being herbal therapy (n = 10), massage (n = 6), acupressure (n = 5), mind-body interventions (hypnosis, biofeedback, and relaxation techniques) (n = 3), spiritual (n = 2), homeopathy (n = 1), therapeutic touch (n = 1), and acupuncture (n = 1).
Sixty of 82 (73.2%; 95% CI 62.2%, 82.4%) respondents reported using, recommending, or referring patients for herbal therapy in the past year. Indications for use of herbal therapies and information specific to herbal therapy for each indication are listed in Table 3. Listed herbal agents are limited to those cited by more than one respondent and the three most commonly cited, or those with more than 10% of respondents reporting use. Forty-six (76.7%; 95% CI 64.0%, 86.6%) respondents who used herbal therapy reported use for labor stimulation (postterm prevention, labor induction, or labor augmentation).
Of the nurse-midwives who used herbal therapy (n = 60), the reasons given for using herbs included use concurrent with allopathic medicine (71.7%; 95% CI 58.6%, 82.5%), patient preference (58.3%; 95% CI 44.9%, 70.9%), use before allopathic medicine (36.7%; 95% CI 24.6%, 50.1%), personal preference (31.7%; 95% CI 20.2%, 45.0%), safer than traditional allopathic medicine (31.7%; 95% CI 20.%, 45.0%), less expensive (30.0%; 95% CI 18.8%, 43.2%), offer alternative when allopathic medicine fails (13.3%; 95% CI 5.9%, 24.6%), more effective than traditional allopathic medicine (10.0%; 95% CI 3.8%, 20.5%), and more available to nurse-midwives (6.7%; 95% CI 1.8%, 16.2%).
Our results showed that complementary and alternative medicine is common practice among certified nurse-midwives in North Carolina. The most common complementary and alternative medicine therapies used or recommended during pregnancy were herbalism, massage therapy, chiropractic, mind-body interventions (hypnosis, biofeedback, and relaxation techniques), and acupressure. Common indications for herbal remedies in pregnancy included nausea and vomiting, labor stimulation (post-dates prevention, labor induction, and labor augmentation), postpartum perineal discomfort, and lactation disorders. Most of those treatments have not been adequately investigated for safety and efficacy in pregnancy. Existing studies were often plagued by weaknesses such as lack of randomization, lack of a control group, patients serving as their own controls with a crossover design, inadequate placebo use, and reporting statistically significant outcomes with limited clinical significance.3,4
Medicolegal and ethical questions associated with the use of complementary and alternative medicine treatments must also be addressed. Should health care providers prescribe treatments for which there is limited safety and efficacy data available? Should alternative medical treatments be discussed with all patients or only when patients inquire, or only when allopathic medical treatments fail? Some of those issues were addressed in our survey. Most nurse-midwives stated that they use herbal therapy concurrently with allopathic medicine, suggesting that allopathic treatments are not being withheld in favor of alternative treatments. Most midwives indicated that herbal therapy is used because of patient preference. Although not addressed in this survey, prior research has suggested that patients do not choose alternative medicine out of dissatisfaction with conventional medicine.6 Most patients surveyed believed that alternative medicine is more congruent with their values, beliefs, and personal philosophy toward health.6 Conversely, 37% of nurse-midwives in this survey offer herbal treatments before allopathic medicine and 30% believe that they are safer than allopathic medicine, although research data do not support that. However, many allopathic medical interventions also have become routine without adequate safety and efficacy data (eg, bed rest for the treatment of high-risk conditions in pregnancy).7
Although our study did not provide estimates of the frequency of use of herbal medicine among pregnant women in North Carolina, it did suggest that the use of certain complementary and alternative medicine therapies is relatively more prevalent than others. This study was limited by the fact that the only obstetric care providers surveyed were nurse-midwives, which will give a biased view of the use of complementary and alternative medicine in professional obstetric services because nurse-midwives might be more or less likely to offer or recommend it than obstetricians or family practitioners. Because the response rate was less than 100% (68.3%), there was potential for responder bias. It is possible that those who did not respond were less interested in complementary and alternative medicine, therefore less likely to use it. To investigate the effect of that potential bias, data can be analyzed as a percentage of those surveyed. That calculation provides a conservative estimate of the percentage of complementary and alternative medicine used by nurse-midwives in North Carolina, assuming that none of those who did not respond used those approaches. From that conservative approach, we estimated that at least 64.2% (95% CI 55.0%, 72.7%) of all certified nurse-midwives recommended some type of complementary and alternative medicine and at least 50.0% (95% CI 40.7%, 59.3%) specifically recommended herbal therapy. We also can hypothesize that some of the nonrespondents might have been strong advocates of and frequent users of alternative medicine but were hesitant to participate in the survey because of concerns about confidentiality. They might have been uncomfortable divulging information to physicians associated with a university medical center who might disapprove of that type of therapy.
No complementary and alternative medicine therapy discussed here has been studied sufficiently to determine its efficacy and safety during pregnancy.3–5 Some of the commonly used modalities involve minimal risk to women or fetuses (eg, acupressure for nausea and vomiting) and might be efficacious, even by placebo effect.5 However, the use of unstudied herbal agents with unknown pharmacologic activity does pose a potential risk to women and fetuses.
Findings from this survey advance the understanding of the patterns of use of complementary and alternative therapies in pregnancy. These results should be useful in developing population and provider surveys. Population-based studies are very much needed because the prevalence of alternative therapies in pregnancy is unknown. Nurse-midwives use alternative therapies because of patient preference, and women who desire alternative therapies might gravitate to midwives, or midwives might provide an environment that allows women to feel safe in reporting use of complementary and alternative medicine. Many women in obstetric and family medicine practices might also be using alternative therapies during pregnancy and lactation but avoid mentioning them for fear of censure. This survey underscores the urgent need for carefully designed prospective clinical trials to study efficacy and safety of all therapies currently used by pregnant women.
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© 2000 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.
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