Midwifery managers’ views about the use of complementary therapies in the maternity services

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Complementary Therapies in Clinical Practice (2007) 13, 129–135

1744-3881/$ - sdoi:10.1016/j.c

�Correspondifax: +44 117 32

E-mail addmary.mitchell@

www.elsevierhealth.com/journals/ctnm

Midwifery managers’ views about the use ofcomplementary therapies in the maternity services

Julie Williams�, Mary Mitchell

Faculty of Health and Social Care, School of Maternal and Child Health, University of the West of England,Glenside Campus, Blackberry Hill, Stapleton, Bristol BS16 1DD, UK

KEYWORDSComplementarytherapies;Midwives’ views;Benefits;Promoters;Constrainers

ee front matter & 2006tcp.2006.01.001

ng author. Tel.: +44 11788411.resses: julie.williams@uwe.ac.uk (M. Mitchell

Summary The burgeoning interest in complementary therapies (CTs) in thegeneral population over the last decade has created a demand for CTs to be madeavailable within the NHS. There are some excellent examples of midwives who haveintroduced CTs into clinical practice and who are providing an enhanced service towomen as a result [Budd S. Moxibustion for breech presentation. ComplementTherap Nurs Midwifery 2000; 6(4): 176–9; Tiran D. Complementary strategies inantenatal care. Complement Therap Nurs Midwifery 2001; 7: 19–24; Ager C. Acomplementary therapy clinic, making it work. RCM Midwives J 2002; 5(6): 198–200;Burns E, Blamey C, Ersser S, Lloyd AJ, Barnetsson L. The use of aromatherapy inintrapartum midwifery practice: an observational study. Oxford: OCHRAD; 1999].Overall, however, service provision remains patchy and ad hoc with little evidence ofa robust integration into the maternity services.

This article presents the qualitative findings from a national survey of the headsof maternity services in England. They were asked to indicate their views andperceptions about the benefits, promoters and constrainers in relation to CTintegration within the maternity services. Our findings show that overall, views arepositive, with increasing consumer satisfaction, promotion of normal childbirth anda reduction in medical intervention being seen as the main benefits.& 2006 Elsevier Ltd. All rights reserved.

Introduction and background

The last decade has witnessed an enormous growthin the use of complementary therapies (CTs) in thegeneral population1 and this has created a con-

Elsevier Ltd. All rights reserv

3288562;

uwe.ac.uk (J. Williams),).

sequential demand for CTs to be available withinthe NHS. There is some evidence of this demandbeing met, particularly within the midwiferyservices: a survey amongst different NHS profes-sional groups identified that midwives reported thehighest rate of CT use, with 34% claiming to usesome form of CT in clinical practice.2

This is encouraging, as the philosophies andprinciples of CTs fit well with the midwiferyphilosophy of care, emphasising the links between

ed.

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J. Williams, M. Mitchell130

the mind, body and spirit and recognising thesignificance of the therapeutic relationship. Preg-nancy and childbirth are normal physiologicalevents, but represent a time of social change andpsychological adaptation that can put increasingpressure on women and their families. CTs may helpwomen to cope better at this time.3 In addition theuse of CTs may assist women in becoming in tunewith their bodies and offer them the opportunity togain an insight into the spiritual, empowering andcelebratory aspects of childbirth which the medicalmodel of childbirth does not. Moreover, the Houseof Lords4 support the introduction of CTs into theNHS, whilst a legislative framework exists thatprovides a set of principles through which midwivescan safely incorporate CTs into practice.5

The evidence from units where CTs have alreadybeen successfully integrated into midwifery prac-tice confirms their benefits. These units reportbenefits for women, midwives and the maternityservices. Budd6 reports an increase in cephalicversion with moxibustion. Demands from thewomen themselves exceeded Tiran’s7 capacity tomeet their needs when an antenatal clinic offeredCTs only 1 day a week. Ager8 reports on theestablishment of a service in Northampton offeringmassage and nutrition sessions, which has proved sosuccessful that it is being expanded to includeshiatsu and yoga. Burns et al.9 conducted anobservational study of the use of aromatherapy inlabour in the John Radcliffe Hospital in Oxford.Their findings reveal a positive evaluation from themothers and midwives using the service. In addi-tion, rates of pharmacological pain relief havefallen since the introduction of the service.Kimber10 reports favourable results from an estab-lished massage programme where midwives andpartners are taught specific massage techniques forsupporting women in labour. However, the integra-tion of CTs into the maternity services has remainedhaphazard and patchy, with the evidence for theiruse being largely of an anecdotal nature.

If there is to be a move away from suchhaphazard provision to a more robust integrationof CTs into midwifery practice, it is important toexplore the views and perceptions of those involvedin their implementation. In the UK, surveys of GPshave identified that a significant proportion ofthem view CTs favourably.11–13 There are, however,no reported studies on the perceptions of midwivesto CTs, or their views about integration within thematernity services, despite the fact that there area growing number of midwives undertaking quali-fications in these therapies.14 Conversely, Tiran15

cautions that an over-enthusiastic approach to theimplementation of CTs by midwives who may not

fully understand the therapies they are using is acause for concern. These confounding issues havecreated a situation where a great deal of uncer-tainty exists about the factors that both constrainand promote their use. A need to explore theextent of use, and the perceived value of CTs withinthe Maternity services thus appeared necessary,and it was upon this basis that our research studywas designed.

The aim of the research was to conduct anational survey in England of the use of CTs in thematernity services and the attitudes of heads ofmidwifery towards the integration of CTs into thematernity services. The quantitative data in rela-tion to the extent of CT use in the maternityservices is reported elsewhere; this paper isspecifically aimed at exploring the qualitative datagained from our study in relation to the views ofmidwife respondents about the integration of CTsinto midwifery practice.

Research methods

A semi-structured questionnaire was developedusing a theoretical framework derived from theliterature. The questionnaire included both openand closed questions relevant to 5 specific areas ofinvestigation: demographics, extent of CT use,perceptions of the value of CTs and factors thatboth promote and constrain the integration of CTsinto midwifery practice. The questionnaire wastested through a peer review process and piloted byfour midwifery managers who were not involved inthe main study. The questionnaire included addi-tional space for all questions in order to encouragerespondents to give fuller and detailed explana-tions if they wished. Ethics approval was obtainedthrough the Central Office for Research EthicsCommittees (COREC). The local research ethicscommittees of each trust were also notified of thissurvey.

Population and sample

The questionnaire was sent to the Heads ofMidwifery (HOMS) in all NHS maternity units inEngland as it was considered that the managerswould be knowledgeable about the use of CTs intheir departments. A total of 221 questionnaireswere mailed to the Heads of Midwifery in thisnumber of maternity units. The respondents,however, included not only midwifery managers,but also many other types/grades of midwives

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Use of complementary therapies in the maternity services 131

whom the HOMS had invited to respond because oftheir specialist interest in CTs. One hundred andsixty-seven completed questionnaires were re-ceived, and 67 of these included detailed qualita-tive information. Many respondents wrote atlength, both in the space provided for the openquestions and on additional sheets. The followingresults are drawn from the 60 respondents whoprovided the most information surrounding threemain issues, namely, the benefits, constrainers andpromoters of CTs in practice. It was evident thatrespondents had taken a considerable amount oftime to write about the issues affecting theirservices in relation to the integration of CTs intomidwifery practice.

Data analysis

The qualitative data was subjected to thematic andcontent analysis. The guidelines described byFielding16 for coding and analysing qualitativeinformation within a survey questionnaire werefollowed. To enhance trustworthiness and consis-tency, both researchers viewed the data separatelyand then together to identify the common themesthat emerged. The analysis and write-up were alsosubject to a peer review process. Three majorthemes, each with their own sub-categories wereidentified.

Theme 1: The benefits ascribed to CTs

1.1. Benefits for childbearing women

Midwives commented on the perceived benefitsthat CTs could offer to pregnant and childbearingwomen. Many of these comments were related tothe concept of choice: this fits readily with issuessurrounding women centred care and the philoso-phy of midwifery practice.3,17

Complementary therapies offer women choiceespecially in addition to medical care. (115)

The benefit of choice in this respect was oftencited as being a less interventionist form of care,and thus an approach that encourages normality. Itis also a perspective which fits with the concept ofholistic care to which midwives aspire. A midwifewho had been providing hypnosis for childbirthcited the benefits in promoting normality andenhancing postnatal recovery as follows:

Increased satisfaction in childbirth, shorterlabour, reduced uptake of pain relief, increased

success in breastfeeding and reduced postdelivery complications. (6)

In addition, offering women choice was per-ceived by the midwives as increasing feelings ofindividual control and empowerment in pregnancyand labour:

CTs offer choice and enable women to takecontrol of their pregnancy also offers non-invasive ways in which women can complementtheir health. (108)

Midwives reported very positive feedback fromwomen when CT services are provided. A midwifefrom a unit that offers reflexology cited examplesof how this therapy is used when the medicalprofession has nothing to offer:

offers an alternative when the medical profes-sion suggest ‘‘put up with it’’ or have aninduction of labour. (15)

Providing CTs for women was seen to improve thephysical and mental health of clients. This hasobvious benefits for the clients but also impacts onservice provision and illustrates how mutual bene-fits arise when women’s needs are met:

CTs improve physical and mental wellbeing,reducing the number of visits and inpatientstays. (159)

1.2. Benefits for midwives

Midwives also described in detail how the provisionof a CT service impacts on their job satisfaction andways of working. Providing a complementarytherapy service for clients enhances midwives’practice in a number of ways:

Complementary therapies extends the midwivesrepertoire, therefore gives midwives confidencein themselves in a more general way. Seems topromote pride in the service. (101)

Comments were also received in relation to theimportance midwives give to providing servicesthat place the woman at the heart of the serviceand promote normality:

Midwives enjoy the positive feedback fromclients and the normality which CTs providewithin childbirth. (126)

In addition when CTs are provided to staff they inturn benefit:

providing a massage service for staff makes themfeel valued. (166)

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We have funded a CT service for staff with R&Dmoney and now have reduced sickness in thedepartment. (206)

This quote underlines the impact that offering aCT service to midwives might have upon retentionand sickness figures. Given the concern that suchrates cause to NHS trusts and the government,managers would do well to look to the possibility ofproviding such services for both midwives and otherstaff.

Overall, midwives have noted these benefits andhave been proactive in bringing about changes inservice delivery. However, it was also evident thatmidwives faced many constraints in their efforts toprovide complementary therapy services.

Theme 2: Factors which constrain theintegration of CTs into the maternityservices

The demand for CTs exceeding the ability of theservice to provide them raised a number of issuesfor midwives, which were felt to act as constrainingfactors in relation to their use in the maternityservices.

2.1. Lack of resources

Many midwives cited the lack of available resourcesto fund either the implementation of the service orfurther development of an existing service. Formost, CTs were not viewed as a priority:

A lack of resources in the greatest inhibitor toCTs. Staff are under a great deal of pressure toprovide normal service and would feel verypressurised if they had to include anything else.(76)

Offering what can be seen as an ‘‘extra’’ in adirectorate which has an establishment wellbelow birth rate plus is not seen as a priority.(133)

This deficiency in resources was noted in funds,staff training and in relation to concerns overproviding an equitable service:

We already have trained staff, support fromother professional colleagues and venue but nofunds to run a clinic. (159)

We have midwives trained in acupuncture,reflexology and Indian head massage but becausewe cannot provide 24 hours service our trustdoes not offer anything. (76)

Thomas et al.18 also discuss the challenge offunding and providing equitable resources butsuggest that attitudes of those who hold the pursestrings are influential in determining priorities inservice delivery.

2.2. Influence of the organisation andcolleagues

Respondents also felt that this inability to providean equitable service was one reason cited by Trustboards and colleagues as a reason for not imple-menting CTs:

I am trained in acupuncture but not supported byPCT as we cannot provide a 24 hour service sounable to practice. (3)

In addition bureaucratic demands significantlyimpact on the ability of an organisation to beresponsive to consumer demands as this quoteillustrates:

There are ad hoc provisions but mostly womenarrange someone privately and we occasionallyprovide honorary contracts but these aretricky as we are required to do police checks,etc. for anyone providing service, this causessignificant delays and sometimes misses the birthdeadline. (61)

There also seemed to be a poor understanding ofthe benefits that could be ascribed to CTs and ageneral lack of knowledge surrounding these issues:

Medical profession very unsupportive—‘‘ban’’CTs. (203)

However, these attitudes were also foundamongst the midwifery profession:

Obstetrician in the unit generally sceptical andblocking progress, also some midwives don’t seeit as a priority (trying for 2 years to set up aservice). (99)

Midwives have found these constraining factorsfrustrating and stalling in their initiatives todevelop CTs services:

ysome units are flying ahead whilst others likeours are stuck in the mud, so much depends onknowledge power and the beliefs of those whohold purse strings, not giving up however. (99)

2 years have been working on setting upa service however bureaucracy and lack ofconsensus blocking our progress very frustra-ting. (98)

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Use of complementary therapies in the maternity services 133

2.3. Lack of an evidence base surroundingCTs

There may be many reasons behind this scepticism.Perhaps one of the main reasons behind theseattitudes is the lack of research evidence, dis-agreement in the literature and a lack of claritysurrounding issues of training, expertise and reg-ulation of complementary therapists. This is cer-tainly a theme that emerged in the midwivesresponses:

Lack of evidence from RCT in efficacy andsafety. (77)

Lack of multi-centred research project. (126)

Indeed the lack of research evidence is widelyquoted as being one of the main barriers to theimplementation of CTs into the NHS.4

A further constraining factor is the lack ofregulation and training of CT practitioners. TheHouse of Lords report4 recommends the formationof a single regulatory body for each therapy group.This is in progress for some therapies, such asreflexology and aromatherapy, but overall, progressis slow as disparate groups learn to work togetherand compromise.19

An additional issue is how to choose betweenthem, who is best qualified to offer sound andsafe services. (67)

difficult to determine which training/qualifica-tion ensures practitioner competent to providetherapies. (77)

Even expert groups fail to agree on the value ofCTs. A recent example of this is the antenatalguidelines developed by NICE,20 which demon-strates a lack of knowledge of CTs through theinclusion of conflicting information and dismissiveaccounts of the lack of evidence in relation tosafety of CTs in pregnancy:

The antenatal NICE guidelines was (sic) detri-mental to the development of this importantservice. (96)

NICE guidelines are very dismissive of CTs. (87)

However, it was evident that in many instancesmidwives were able to provide CT services despitethese constraining factors. There were manyexamples given of the factors that enabled mid-wives to implement CT services.

Theme 3: Factors that promote theintegration of CTs into midwiferypractice

Midwives wrote enthusiastically about their ser-vices and how they had come about and the factorsthey felt were important to successfully integrateCT services into mainstream maternity care.

3.1. Committed individual and managerialsupport

Perhaps the factor that emerged most strongly wasthe need for a committed individual to drive thechanges through:

Primarily developed by one midwife lecturerwho specialises in CTs. (174)

An outstanding midwife with vision and persua-sion, two more outstanding midwives who bothhad links with China—they went to China totrain. (1)

It was evident that the skills needed for midwivesdriving these changes through were those asso-ciated with success in managing change, such asleadership, business planning and the ability toconvince others of their vision.21 Additionally mid-wives needed the support of their managers:

proactive enthusiastic management, allocatedtime to promote and maintain the service. Anamed midwife with secretarial support, a goodbusiness plan. (126)

3.2. Demand from consumers and midwives

The respondents highlighted some of the drivingforces that have lead to the development andimplementation of CT services:

Consumer pressure is fundamental to the deliv-ery of our service. (160)

Consumer need/request and midwives’ interestand development. (118)

It is reassuring that the demand from consumersis seen as important in the development andimplementation of services.

The current context of midwifery and obstetriccare has also contributed to the development ofservices. Government, professional and publicconcerns in relation to the rising caesarean rateand the need to promote normal birth has also beeninfluential with many of respondents citing the

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contribution that CTs have in relation to promotingnormality as important:

We have formed a holistic midwifery group topromote normal birth using amongst others CTs,shiatsu and baby massage are in the planningstages. (147)

Growth of integrated birth centre, wanted tooffer forms of non-pharmacological pain relief,encouraged hands on approach to care givenby midwives, i.e. through massage. Promotesa calm relaxed environment with deliveryrooms. (16)

3.3. Need for a wider support network

Many respondents addressed the need for widersupport from professional bodies and the need forguidelines to assist with the challenges of integra-tion. This possibly reflects the general lack ofresearch evidence necessary to implement CTservices into the NHS where efficacy and costeffectiveness are considered a priority in develop-ing new service:

the use of CTs will require a clinical guideline tolay out the parameters of its use. This will needwriting and satisfying to the trust. A nationalguideline would be most helpful (hoping tointroduce an aromatherapy service). (129)

Support from RCM and NMC is essential formidwives providing the service. (209)

Certainly, the House of Lords report4 and theKings Fund22 both advise that the Nursing andMidwifery Council (NMC), Royal College of Nursing(RCN) and Royal College of Midwives (RCM) shouldwork together to provide agreed advice for nurses,midwives and health visitors who wish to incorpo-rate CTs into practice. The need for multidisciplin-ary input and consumer involvement was also seenas relevant:

Guidelines, staff education forums, and consul-tant midwives with remit for normal birth areimportant. (34)

need a joined up approach with consultant andconsumer involvement. (17)

This demonstrates the for need support fromcolleagues, and one way in doing this is to worktogether with the joint aim of providing services inresponse to consumer demands.

Discussion

The respondent group clearly documented theperceived benefits of providing a CT service formothers, midwives and the maternity services.Overall, respondents were convinced of the bene-fits of CTs and felt strongly that they should beoffered in the NHS. The main benefits cited ofincreasing consumer satisfaction, promoting nor-mal childbirth and decreasing medical interventionfit well with key public health issues and the policyagenda.17 It also confirms the findings of otherstudies which suggest that the growth of CTs in thegeneral population reflects a growing disillusion-ment with conventional medical practices23 andthe desire for holistic approaches.24 Certainly,these benefits reflect the main impetus for devel-oping CT services in relation to the maternityservices. It is clear that when women benefit fromimproved quality of care both midwives and theservice reap rewards. The findings of improved jobsatisfaction for midwives increases the likelihoodthat they will stay in the profession, particularly ifthey are able to incorporate their CT work intopractice, thus reducing problems with recruitmentand retention.25 Indeed, Andrews26 found that mid-wives with CT qualifications who were not able toincorporate their CTwork into clinical practice wereleaving the profession in order to practise privately.

If the benefits of providing CT services are to berealized, midwives need to be aware of the factorsthat impede implementation of CT. Resources willalways be problematic, but with appropriatebusiness planning, midwives may be able todemonstrate cost savings through promoting nor-mal birth. Some units have already demonstratedlower rates of pharmacological analgesia by provid-ing aromatherapy in labour9 and reducing caesar-ean sections by providing moxibustion for cephalicversion.6 The need for committed individuals withskills in change management is thus evident andnecessary in order to effect changes that have thepotential to support normality within childbirth.

Although the respondents have positive attitudesto CTs it seems that midwives face unfavourableattitudes in relation to the formal provision of CTs.In the main, these attitudes come from medicalcolleagues and Trust Boards. This finding is notreported by other studies, which on the whole,demonstrated positive attitudes towards CTs fromGPs, and physicians.13,18,27 Although research hasnot yet explored the attitudes of obstetricians, thisstudy shows that midwives must be prepared tochallenge some prevailing attitudes to CTs.

Nevertheless, midwives should adopt a criticalapproach towards CTs and their integration into the

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Use of complementary therapies in the maternity services 135

maternity services. CTs have a persuasive appeal andare perhaps viewed by many as innocuous andunlikely to cause harm.28 Evidence from this studysuggests that many midwives subscribe to this view.For example, aromatherapy is the second mostcommon CT offered; yet there are important safetyissues to be aware of when providing this therapy topregnant women. This supports Tiran’s15 assertionsthat over enthusiasm from midwives may be a causefor concern and that caution is required whenimplementing new therapies. A further cause forconcern is the fact that the midwives who are theprinciple providers of CTs within the maternityservices provide their CT mainly through informalmechanisms and ad hoc provision.

In addition, ad hoc provision raises the issue ofequity, and the respondents who cited constrainingfactors in the development of services acknowledgethis. This is certainly a challenging issue and should begiven due consideration, especially since the NSF17

standards set out clear guidelines for the developmentof services which are equitable and accessible to all.

Conclusion

This article, drawn from our national survey ofmaternity units in England, sought to explorethe attitudes of Heads of Midwifery towards theintegration of CTs into the maternity services.The results demonstrate that overall, attitudesare favourable towards the integration of CTs intothe maternity services with the main benefits beingcited as increasing consumer satisfaction, promo-tion of normal childbirth and a reduction in medicalintervention. These in themselves may become thedriving forces in developing CT services. Moreover,the need for committed and motivated individualscapable of dealing with unfavourable attitudes andresistance to change is evident. Since the provisionof CT services is seen to offer tangible benefits toboth mothers and midwives, we urge all midwivesto strive for recognition of the need for a formalprovision which can be evaluated for effectivenessand safety. There is no doubt that the benefits of CTprovision can contribute overall to the quality andcost effectiveness of the maternity services.

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