By Matt Kaiser
Part I: what’s so wrong with it in pregnancy?
As someone of a sceptical persuasion, I have never really considered taking complementary or alternative medicine (CAM). I prefer my medicine evidence based.
During my first year as a dad, however, I have noticed that CAM seems particularly rife in pregnancy and childbirth. My anecdotal impression seems to be backed up by further analysis – a systematic review of scientific studies reported that more women than men use CAM in general and many continue to use CAM therapies throughout their pregnancy. Various analyses have estimated that, in the UK, at least 10% of people use some form of CAM within a given year, with other countries reporting a far higher usage. This supports a multi-billion pound global business, with the potential for a significant health impact on the population.
It started, for me at least, before my partner got pregnant. As is common, we didn’t conceive straightaway and so we started reading about how to maximise our chances. Many ‘natural health’ practitioners offer services for want-to-be mothers, such as reflexology, reiki (“prepare the body for birth”), acupuncture (“treatment of Kidney Yin and Yang”), dietary advice (“choose foods with strong life force!”), detox (‘fertility cleansing’), massage (“help the body to become balanced”) and homeopathy (“recondition the uterus, fallopian tubes and ovaries”). There are also treatments for male fertility, which promise to “stimulate the body’s own ability to heal itself” with homeopathy or by strengthening Kidney Jing with acupuncture (for at least three months, of course!).
This is despite no robust evidence to show that these treatments themselves actually boost fertility or increase conception rates. Reflexology or reiki does not provide ‘energy healing’, acupuncture has no effect on oviduct blockages or uterus blood nourishment, homeopathy does not change the cervical mucus or restore ‘sexual energy’, and massages cannot affect hormonal balance or the position of the uterus (all genuine claims). CAM practitioners’ websites invariably either quote testimonials, provide no research citations (even despite frequently stating that “research shows…”) or link to single, small-scale studies of dubious quality. More conclusive analyses, however, are severely lacking.
There is strong evidence of what does work to raise the likelihood of a woman conceiving: having frequent sex and timing intercourse at particular periods of the menstrual cycle, reducing or stopping smoking and losing weight, avoiding certain ‘teratogenic’ medications and agents, and conceiving at a younger age. It is also worth remembering that, on average, the probability of a women becoming pregnant within one menstrual cycle is around 20%, but that subfertility requiring specialist intervention affects only 10-15% of individuals. In effect, all that’s needed is time. In light of this, any testimonial claiming causality for a complementary fertility technique stands on pretty shaky ground.
What is even more disturbing, at least to me, is the promotion of various quack therapies to aid successful in-vitro fertilisation (IVF). These include distant spiritual healing to ‘nourish aura, chakras and meridians’, as well as opening relevant acupuncture channels to supply ‘more energy to the uterus and enhance receptivity’. Again, proper scientific scrutiny suggests these approaches do not work any better than placebo controls.
Assisted conception is a potentially anxious and distressing time, not to mention a potentially expensive one, and to my mind the last thing a couple needs is to invest faith and money in ‘therapies’ that don’t work.
But the ‘alternative’ care had only just started. Once the little blue cross appeared on the white stick, there was a host of holistic approaches to supposedly see through a stress-free and uncomplicated pregnancy. Many boast of their ability to help prevent miscarriage, such as with acupuncture, enzyme therapy, herbs, reiki and reflexology.
There are also promotions for certain clayey soil (“Nzu”) and some of the usual CAM suspects to ease morning sickness, Bach flower remedy to reduce anxiety (“acts directly on the emotions”!), homeopathy for haemorrhoids and indigestion, and chiropractic and moxibustion to reverse breech presentation.
As has been shown time and time again, many observed benefits of CAM are derived from a placebo effect: that is the improvement seen in a patient who believes that they’re taking an effective therapy, even if they’re actually taking a sham control. But, who cares if it’s a benign treatment if the whole experience leads to an improvement in wellbeing?
There’s some mileage in this argument when one considers that we know that a maternal stress during pregnancy can lead to adverse outcomes, such as low birthweight, prematurity and poor growth of the baby. And certain relaxation techniques may be effective at reducing anxiety. It categorically does not, however, mean that the many CAM practitioners should be able to make entirely false and unsubstantiated claims in advertising their products and services, as this sells something at a handsome price that should be part of standard care. It also legitimises CAM practitioners’ baseless declarations, so that patients may divert care from conventional medicine to CAM. This risks shunning effective treatment, which will also include an equivalent placebo boost, in favour of sham therapies that, at best, give rise to placebo only.
Again, there is plenty of evidence-based advice on how to reduce risks of complications in pregnancy, such as stopping smoking to reduce the risk of low birth weight, avoiding alcohol to prevent foetal alcohol syndrome, folic acid supplementation to lower occurrences of neural tube defects (also for preconception), addressing any nutritional deficiencies, and the proper treatment/management of a range of diseases known to adversely effect development.
One of the more varied stream of recommendations we received was how to induce labour. The list included raspberry leaf tea, cumin tea, spicy curry, sex (and other sexual practices!), nipple stimulation, a long walk, cream cakes, a glass of wine, castor oil, pineapple, scrubbing the floor, driving over speed bumps, flying and parsley (see the Mumsnet thread for some stunning cases of coincidental correlations: “X worked for me. I took it when I was due and I went into labour the next day!”). And we also have our familiar friends: herbs, acupuncture (again!) and homeopathy (although I’m not sure how pulsatilla, a herbaceous plant, relates to labour in a “law of similars” way).
Whilst the push for all things ‘natural’ is seen at all stages, never does it appear so forcefully advocated than when it comes to labour. I’ve heard quotes such as, “labour is the most natural thing a women can do”, “a women’s body is designed for childbirth” and “a women knows what to do in labour without drugs or machines”.
There is a sizeable demand for ‘natural’ approaches to pain relief during labour and there is a variety of treatments touted. These include electrical stimulation across the skin (‘TENS’), aromatherapy, audio-analgesia and acupuncture, mind-body interventions (e.g. yoga & hypnosis), homeopathy, traditional Chinese medicine, reflexology, and herbal medicines.
Unfortunately, there is insufficient evidence to make any call that these work or are more effective than placebo control (e.g. 1, 2, 3, 4 & 5). The Cochrane Pregnancy and Childbirth Group is undertaking a review into the efficacy of hypnosis for labour pain management, so the jury’s out on that one. Massage and relaxation techniques may help with pain and reduce the likelihood of obstetric intervention (but, guess what? More research needed!).
It is, on the whole, likely to bedifficult to carry out interventionist, randomised studies on pregnant women. Who’d write that in their birth plan? So the data that do exist tend to be self-selected, unblinded, observational, often self-reported and prone to a myriad of confounding variables. But I guess that wouldn’t stop a CAM practitioner from cherry-picking a sweet biased result or two.
I’m sure there are many more examples of alt med infiltrating pregnancy and childbirth, but I hope I’ve given a flavour of how widespread and enduring it is. My next post will be on the influence of mainstream healthcare professionals.