ALLAIRE, ALEXANDER D. MD, MSPH; MOOS, MERRY-K FNP, MPH; WELLS, STEVEN R. MD
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology; and Department of Maternal and Child Health, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
Address reprint requests to: Alexander D. Allaire, MD, MSPH, 214 MacNider, CB# 7570, Chapel Hill, NC 27599. E-mail: email@example.com
Received April 8, 1999. Received in revised form June 25, 1999. Accepted July 15, 1999.
Objective: To determine the prevalence and types of complementary and alternative medicine therapies used by certified nurse-midwives in North Carolina.
Methods: Surveys were sent to all 120 licensed certified nurse-midwives in North Carolina requesting information concerning their recommendations for use of complementary and alternative medicine for their pregnant or postpartum patients.
Results: Eighty-two responses were received (68.3%). Seventy-seven (93.9%) reported recommending complementary and alternative medicine to their pregnant patients in the past year. Forty-seven (57.3%) reported recommending complementary and alternative medicine to more than 10% of patients. The percentage of nurse-midwives who recommended each type of complementary and alternative medicine was as follows: herbal therapy (73.2%), massage therapy (67.1%), chiropractic (57.3%), acupressure (52.4%), mind-body interventions (48.8%), aromatherapy (32.9%), homeopathy (30.5%), spiritual healing (23.2%), acupuncture (19.5%), and bioelectric or magnetic applications (14.6%). The 60 respondents who reported prescribing herbal therapies gave them for the following indications: nausea and vomiting, labor stimulation, perineal discomfort, lactation disorders, postpartum depression, preterm labor, postpartum hemorrhage, labor analgesia, and malpresentation.
Conclusion: Complementary and alternative medicine, especially herbal therapy, is commonly prescribed to pregnant women by nurse-midwives in North Carolina.
Complementary and alternative medicine is composed of medical systems, practices, interventions, applications, theories, or claims that are not currently part of the dominant or conventional medical system. The public and conventional medical care providers have shown increasing interest in complementary and alternative medicine. Two recent national surveys found that the use of alternative medicine by adults in the United States increased from 34% in 1990 to 42% in 1997.1,2 Unconventional therapy was common among those of reproductive age,1,2 and more common among women of reproductive age.2 Almost half of all women (48.9%) reported use.2 Therefore, it is possible that a significant number of pregnant women are currently using complementary and alternative medicine to treat disorders of pregnancy, although the percentage is unknown.
Pilot research, including review of nurse-midwifery professional publications, a pilot survey of nurse-midwives outside North Carolina, and discussions with local nurse-midwives, found that many nurse-midwives have incorporated complementary and alternative medicine into their practices. It is unknown how prevalent complementary and alternative medicine is among nurse-midwives. Almost no literature exists concerning the use of complementary and alternative medicine in pregnancy by physicians (obstetricians and family practitioners). Recent reviews of the literature showed that quality scientific research evaluating efficacy and safety of those agents is limited.3–5
The goal of this study was to investigate the use of complementary and alternative medicine by certified nurse-midwives in North Carolina. The primary objective was to determine the percentage of nurse-midwives offering those treatments, the conditions during pregnancy for which they are used, and the most common types being used. Pilot research suggested that herbal therapy was commonly used, so patterns of use of herbal therapies were studied in depth.
Materials and Methods
The names and business addresses of all 120 certified nurse-midwives in North Carolina were obtained from the North Carolina Board of Nurse-Midwifery. After approval from the institutional review board, a survey was mailed to each nurse-midwife with instructions to return the survey within 2 weeks. A reminder postcard was sent a week after the first mailing. One week after the initial deadline, a replacement survey was mailed to nonrespondents with instructions to return the survey within 1 week. The purpose of the survey was described in a cover letter. Recipients were urged to return the survey even if they did not use or recommend complementary and alternative medicine to their patients. Pilot research suggested that the most commonly used complementary and alternative medicine by nurse-midwives was herbal therapy; therefore, a series of questions was focused specifically on that alternative therapy. The questionnaire asked respondents to report use of complementary and alternative medicine for the past year.
In the survey, complementary and alternative medicine was defined as therapeutic interventions that are not currently part of the conventional medical system or not taught widely at United States medical schools or available at United States hospitals. A list of complementary and alternative medicine therapies was provided and respondents were asked whether they used, recommended, or referred women for those therapies in the past year for preconception, prenatal, or postpartum care. If a particular complementary and alternative medicine therapy was used, respondents were asked to list the specific indications for use. For data analysis we grouped indications for use into similar conditions.
Respondents were asked series of multiple-choice questions about herbal medicine. Specific potential obstetric indications for therapy were listed and respondents were asked to indicate whether they recommended herbal therapy for each indication during the past year. After each question, respondents were asked to list the herbal agents used for that indication in an open-answer format. The indications chosen were based on pilot research and a review of the literature. Basic demographic, practice, and training information was collected in a series of multiple-choice and short-answer questions.
The results of the survey were analyzed using STATA statistical software (Stata Corporation, College Station, TX). Means and standard deviations were calculated for continuous variables. Frequencies and percentages were calculated for categoric variables. Binomial 95% confidence intervals (CI) were calculated for categoric variables.
Eighty-two of 120 (68.3%) certified nurse-midwives responded. Characteristics of the respondents are shown in Table 1. Seventy-seven (93.9%; 95% CI 86.3%, 98.0%) respondents reported using, recommending, or referring patients for complementary and alternative medicine therapies in the past year. Forty-seven of 82 respondents (57.3%; 95% CI 45.9%, 68.2%) reported using, recommending, or referring more than 10% of their patients for complementary and alternative medicine. Seventy-three (89.0%; 95% CI 80.2%, 94.9%) respondents reported that their patients used complementary and alternative medicine therapies in the past year. The types of complementary and alternative medicine that were investigated are listed in Table 2. The number of respondents reporting use, the percentage of respondents, and the indications for use are also given in Table 2. Listed indications 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 for each treatment.
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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