Fundamentals of Midwifery: A Textbook for Students (131 page)

Table 14.3
United States Department of Health and Human Services suggest these useful categorisations of CAM (US Department of Health and Human Services 2008)
Group 1: Natural products
Herbal medicines (botanicals)Vitamins and minerals
Group 2: Mind and body medicine
MeditationYogaAcupunctureDeep breathing exercisesGuided imageryHypnotherapyProgressive relaxationQi gongTai Chi
Group 3: Manipulative and body-based practices
Spinal manipulation (Including chiropractors, osteopath practitioners, naturopathic physicians)Massage therapy
Group 4: Other CAM practices
Whole medical systemsAyurvedic medicineTraditional Chinese medicineHomeopathyNaturopathy308pregnancy and birth (Steel et al. 2012). Given these figures, it is likely that student midwives and midwives may be involved in discussions with women on the subject of CAM and therefore it is helpful to be informed about this continually evolving aspect of healthcare. Hall et al. (2011) reports a significant challenge when interpreting the literature on the prevalence of CAM use by pregnant women; this results from a lack of information about the instruments used for data collection, and differences between how CAM has been defined for each study. Indeed, it has to be said that research into CAM is complex, and aspects such as safety, effectiveness and satisfaction are difficult to explore for a number of reasons. Hall et al. (2011) highlight the lack of clarity in relation to data collection and definitions of CAM can further complicate some of the research issues.
The CAM philosophy‌
The ideas, the principles, and the way in which users and practitioners consider CAM are oftenreferred to as the‘CAM philosophy’; which underpins practice. The term philosophy in this sense relates to the fundamental theories which contribute to the effectiveness of CAM. The philoso- phy is one which acknowledges the successes of the CAM intervention based on the links between the mind, the body, and spirit, alongside the relationship between the therapist and the individual who is engaging in the treatment. As identified earlier, health and disease are believed to involve a complex interaction of physical, spiritual, mental, emotional, genetic, environmental, and social factors (University of Maryland Medical Centre [UMMC] 2011). It would make sense then, that during consultations, CAM practitioners often search for emo- tional, physiological, psychological, spiritual and environmental factors which may be affecting someone’s health. Box 14.1 is an example treatment for back pain with acupuncture, where the interplay of mind-body, and external factors are given due consideration to the healing approach.
Box 14.1 Clinical consideration: acupuncture and a back problemThe practitioner will consider the lifestyle of the patient as well as their general health and wellbe- ing. The lower back is where the kidney Qi is stored, considered in Traditional Chinese Medicine (TCM) to be the source of original (inherited) Qi. TCM attributes emotions to the different energy systems as well as physical functions. The emotion associated with the kidneys is fear. Pregnancy and childbirth are very taxing on kidney Qi and anxiety about the forthcoming birth and parent- hood is common in late pregnancy. Exposure to environmental factors such as cold (due to inap- propriate clothing in winter) can lead to stagnation of Qi in the lower back also resulting in pain. An acupuncturist would therefore work on introducing heat where there is cold, supporting kidney Qi and alleviating anxiety when treating back pain during pregnancy as well as assessing any muscular-skeletal problems.
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The growth of interest in CAM
So far in this chapter, it is recognised that there are limited UK reports of CAM use in pregnantwomen; however, the data which is currently available does indicate that a proportion of preg- nant women may be interested in adopting some non-biomedical approaches to healthcare during the course of their childbearing episode. Of those patients/consumers who have used CAM in the past, much of the evidence given by the Consumers’ Association and the Patients’ Association in relation to CAM treatment suggests that patient satisfaction is high (House of Lords 2000), and this is likely to account in part for a significant proportion of CAM use generally, certainly among those who have previously engaged with CAM.It remains unclear what is responsible for the growth of interest in the general population. Suggestions that overall trust in medical care has declined and efforts to portray CAM use as a means of increasing the amount of control a patient has over their care have not been consist- ently supported with research; however these factors may contribute to patients becoming more engaged with, and proactive in, managing their health. There is some evidence to suggest310that the general popularity of CAM in Europe, Australia and North America is reportedly linked with a number of factors including disappointment with biomedical healthcare alongside the rise of chronic health complaints (Nissen 2011).
A generation ago, healthcare appeared to be based on the notion that doctors were the ‘sole gatekeepers’ to medical and healthcare information; however within contemporary healthcare, patients now have access to unlimited medical knowledge and insights. Today, the internet provides access to a wealth of information and research, with health professionals increasingly caring for a new generation of well-informed patients. Information technology increases patient involvement in healthcare management and evidence suggests that a growing number of people are shifting away from being the dependant patients of old (Accenture 2010). Patients have significantly more information available to them; at times, expectations may differ from what the NHS or ‘state funded’ healthcare can provide. A 2010 survey of over 12,000 people across 12 countries showed that nearly two-thirds (64%) of people who use the internet to research health do so to check up on their medicines, or evaluate alternatives (Park and MacDaid 2011). With consideration given to the unlimited access patients have to information about their health and healthcare, the growth of CAM could be representative of a major transformation of the relationship between doctors and their patients and doctors and the larger community (Turner 2004).
CAM and patient satisfaction
Whilst the holistic approach of CAM and the individual emphasis are considered to be relativelyappealing to patients, it is also the consultation style of CAM practitioners that is believed to be an important aspect of its popularity (House of Lords 2000). It is worthwhile discussing what is known about the differences between the approaches of the practitioners, and the differences of the consumer experiences of Eastern and Western medicine. This should provide some context to the claims of high patient satisfaction.Goldner (2004) suggests that a patient’s relationship with a CAM practitioner is different because of the expectation that consumers will take individual responsibility for their health, and thus become empowered, and most, if not all CAM practitioners would support this claim. Whilst little is known about the mechanisms which facilitate patient empowerment in the context of CAM activity, it is generally recognised that CAM use is considered an empowering experience for people, in comparison to their experiences within a conventional healthcare system. In support of this, a study by Barrett et al. (2003) revealed that patients using CAM perceived themselves to be empowered in their healthcare decision processes. The qualitative accounts from patients illustrated the concept of empowerment through narratives of being
‘put in the driver’s seat’
by the practitioner, in contrast to conventional medicine, where they often felt disempowered by their perceptions of being
‘a cog on the machine’
(Barrett et al. 2003). The benefits of a healthcare approach where individuals are expected to take personal respon- sibility, as opposed to society taking responsibility for health, are currently being debated across both the fields of academia and practice; there appears to be a growing body of evidence sup- porting the importance of individual responsibility for health, suggesting that this concept has benefits for some members of society. Warriner et al. (2013) conclude that the notion of wellbe- ing encapsulates a demand for being recognised as an active, empowered and knowledgeable agent on the part of those using CAM, and there is anecdotal evidence to suggest that there is an association between an individual sourcing and taking steps to provide their own form of treatment, and consequently feeling responsible for bringing about their own‘healing’, recovery and wellbeing.In the UK, whilst a growing number of patients opt to have some or all of their investigations and treatment privately, healthcare and medical consultations are dealt with predominantly through the NHS. A recent Department of Health (DH) initiative in which NHS patients in England have formal rights to make choices about their General Practitioner (GP) surgery and GP (DH 2013), demonstrates that steps are being taken to provide greater flexibility and choice, which may enhance the concept of empowerment for some patients.
Women, midwifery and CAM
The reported growth of interest in the use of CAM by pregnant women is thought in part to bedue to a desire to regain control over a normal life process which has become ever-more tech- nological and medically dominated (Tiran 2007). The integrated approach of mind–body and healthcare with which CAM practice is associated, appears to have strong links with the concept of achieving‘normality’ within childbirth. Interview data from pregnant women in an Australian antenatal clinic suggests that CAM use is a reflection of women’s health beliefs, and amongst this population of women, CAM use did not appear to reflect dissatisfaction with conventional care or medicine (Gaffney and Smith 2004). Hall et al. (2011) identifies in a literature review on the use of CAM by pregnant women, that there is limited data on the motivations for CAM usage; however a belief that CAM offers a safer alternative than pharmaceuticals was high- lighted in one study (Hall et al. 2011). Alongside this is the notion that CAM therapies give pregnant women more control and satisfaction in childbirth (Gaffney and Smith 2004; Mitchell and Williams 2007). Choice and control featured as a theme in a study by Warriner et al. (2013), aimed at exploring the nature of CAM use in a sample of pregnant women. Women in this sample viewed CAM as outside of biomedicine and part of an approach to health and wellbeing over which they are able to maintain personal control, instead of being told what they should do by doctors and midwives (Warriner et al. 2013).The demand for advice on non-pharmacological means of managing with symptoms of pregnancy, pain in labour and postnatal discomforts, parallels the rise of the movement away from what many view as the medicalisation of childbirth (Warriner et al. 2013). Increased job satisfaction, fulfilment of the midwifery role, and added individual enthusiasm were found to be associated with CAM use by midwives within a number of studies, which allude to a consumer-driven demand (Tiran 1996; Mitchell et al. 2006; Mitchell and Williams 2007). Fur- thermore, empirical evidence drawn from two qualitative studies supports the concept of mid- wives experiencing informal rewards, such as the extension of occupational roles, and enhanced relationships with women (Mitchell and Williams, 2007; Cant et al. 2011). In a qualitative study exploring CAM in hospital midwifery in Australia, Adams (2006) highlight that CAM integration is far from a clinical issue. There is a suggestion that the promotion of CAM by midwives feeds into ‘wider professional boundary and power struggles inherent in the hospital care of preg- nancy and birthing’ (Adams 2006). Interview data from midwives demonstrates that midwifery is considered distinct from, what is known as the ‘medical model’ and obstetrics, and Adams (2006) suggest that the integration of CAM equips midwives with a resource for challenging the dominance of the medical model. Included in the discussion of this study is an acknowl- edgement of CAM providing an additional range of treatment options to childbearing women, a fact that is less acknowledged in the CAM literature, as much of the research which is cur- rently ongoing in this field of healthcare focuses on the sociological and professional issues, which, whilst very important, have the potential to render the other aspects of CAM use less significant.