Comptementary

ffiwFvw6.".*'+h4'e,n.ELSEVIER

Therapies in Ctinical Practice (2006\ '12, 48-54

Complementary Therapies in

Clinical Practice

www. elsevierhealth.com / journals/ctnm

Summary Antenatal anxiety has been Linked to maternal hypothatamic-pituitar'y-adrenal axis changes which can affect fetat devetopment and may have lastingeffects on the chitd's psychotogicat devetopment. Treatments for anxiety havehitherto focused on psychotherapy techn'iques or antidepressant drugs but these donot atways effect long term improvement. Aromatherapy and massage havesuccessfulty been used to produce significantty greater improvement in reductionof anxiety. Midwives may hightight anxiety in some of the mothers in their care andcan incorporate the hotistic approach of aromatherapy and massage into theirpractice. However, further research is required to estabtish the efficacy and cost-effectiveness of aromatherapy and massage in the antenatat period'o 2005 Elsevier Ltd. Att rights reserved.

lntroduction

A degree of anxiety during pregnancy is normal forrori*or"n, particutarty in the first trimester, 1 asthey adjust to its physicaI and pyschosociat impact.As pregnancy progresses altered body image canincrease anxiety,2 and external factors, such asstress at work, financiat, social or retationshipdifficutties may atso contribute.3-6

Anxiety is a comptex phenomenon which mayincrease between 18 and 32 weeks gestation, aperiod which coincides with various antenataIscreening tests,T and can easity be exacerbatedby an over-zealously supportive professionaI struc-

*Correspondin g author. Tel. : +44 708 302 267 8x3029 or 4640.E-mail address: warwick1945@ao[.com (J. Bastard).

1744-3881/5 - see front matter @ 2005 Elsevier Ltd. Atl rights reserved'doi: 1 0.1 01 6/j. ctcp.2005.07.001

ture and excessive medicatisation.s-10 Antenataltesting for fetal abnormalities can increase anxietyin pregnancy and if women are confronted with apositive matformation scan the levets of anxiety areunchanged.ll Studies have confirmed that women'sfears of pregnancy, childbirth, previous loss of ababy, tack of support, financia[ and unreatistic workexpectations manifest as symptoms of anxi'ety.s'12'13 lt is important that midwives attowwomen time to express their anxieties, as pressures

. of a busy clinic can create constraints and essentiatinformation missed. to-t 6

ldentifying, a reliable screening anxiety scatecoutd hetp the midwife to clarify the nature andretationship of the anxiety, but many_ screeningtools are not suitable for pregnancy.lT Scates tomeasure antenatal anxiety have been vatidated,

Aromatherapy and massage for antenatal anxiety:Its effect on the fetusJanet Bastardu'*, Denise Tiranb

"KentWomen'sWing,Queenlvlory'sHospital NHSTrust, FrognalLane,Sidcup,Kent,DAl46LT,UKblJniversity of Greenwich, London ond Director, Expectancy Ltd, UK

KEYWORDSAromatherapy; -Massage;Anxiety;Pregnancy;Fetus

Aromatherapy and massage for antenatal anxiety: lts effect on the fetus 49

but in order to obtain an adequate evatuation ofanxiety; it may be necessary to measure theinfluences of psychotogical and body changes atdifferent stages of pregnancy.lE 22 lt is importantthat these anxiety scates are interpreted correctty,as professionats may see that the benefits ofantidepressants outweigh the risks in pregnancyand coutd encourage their use in late pregnancy.z'Atthough the risks of teratogenesis is [ow, there isno conctusive evidence on the safety of antide-pressants in late pregnancy.2a'2s

Parent education classes provide opportunitiesfor women to express their fears and worries andthese opportunities can go some way towardsatteviating the severity of anxiety,26 28 atthoughctasses may have tittte effect on those moreseverely affected.a Treatments for anxiety princi-pally focus on psychotherapy techniques, but thesedo not atways resutt in long term improvement andhave resourcing imptications, as they are facili-tated by trained professionats.2e

Bio-psycho-social effects of anxiety onthe fetus

Anxiety is a comptex phenomenon but the currentclinical definition is as a psychosocial condition inwhich worry fear, and apprehension are combinedwith physical symptoms (Box 1,'o). A mothers'response to anxiety is determined by the hypotha-lamus, which acts on the autonomic neryous systemand the endocrine system resutting in physiotogicalchanges.3l Prolonged anxiety (more than threeweeks and up to six months' duration) without

intervention may resutt in a maladaptive responseto pregnancy.32

Recent studies have attempted to disentanglethe different environmental and genetic factors,and to link specific exposures to specific ef-fects.33-3s Antenatal anxiety has been tinked withchanges to the maternal hypothalamus-pituitar-y-adrenal axis (HPA). During pregnancy the cortico-trophin reteasing hormone (CRH) increasessubstantia[[y before detivery, with placentat CRHretating to the duration of pregnancy.36'37 Antena-tal anxiety increases CRH and has been associatedwith premature labour.38'3e Mancuso et al.a0 de-monstrated that women, who detivered prema-turely had significantty higher levets of CRHcompared with women who detivered at term andmay predispose the mother to spontaneous abor-tion.alGitau et at.az found a potential tink inpregnant women between ctinicalty-indicated fetalbtood sampting and acute fetaI distress, suggestingthat the increase in CRH derives from the ptacentarather than the fetus in response to stress.

It is increasingly apparent that antenatal anxietycan have lasting effects on the psychotogicaldevetopment of the chitd.a3 The changes in thefunctioning of the HPA axis are linked to antenatatanxiety and the subsequent disturbances in off'spring account partly for cognitive and neurologicaldevetopment.aa ln a cohort study of 10,000 preg'nant women, O'Connor et at.as identified a tinkbetween maternal anxiety in the- third trimesterand behaviourat/emotionaI problems in the result'ing chitdren at four years. The researchers foundthat setf-reported antenatal anxiety at 32 weekspredicted severe behaviourat/emotionaI probtemsin both sexes, but anxiety in tate gestation appearsto be significantty associated with hyperactivity/inattention in boys.as Mixed handedness, dystexiaand autism may atso resutt.a6

It is interesting to note that anxiety occurring atdifferent gestations produces variabte fetat ef-fects.aT For example, severe life events in the firsttrimester has been shown to resutt in a 50%increase in neurat tube abnormatitiesa8 and otheranomaties, such as cteft patate.ae ln contrast,anxiety in late pregnancy, when neuraI connectjonsare being made in the brain, produces behavioural/emotionaI outcomes.a6

Massage and aromatherapy for anxiety inpregnancy

It is known that massage improves setf imageduring pregnancy, and may aid acceptance of

Box 1 Symptoms of anxietY.

r Patpitations, acceterated heart rateo Trembting or shakingr Difficutty in breathingo Chest pain or discomfortr Feeting dizzy, faint, tight headedo Fear of tosing controt, passing outo Sweatingr Dry moutho Feeling of chokingo Nausea or abdominal discomfortr Feeting that objects are unrealr Fear of dyingi Numbness or tingting sensationsr"Hot flushes or cotd chitls3o

50 J. Bastard, D. Tiran

physicat changes in the mother.s0 The wet[-re-searched retaxation effects atso extend to thefetus.51's2 Massage stimutates production of endor-phins and decreases btood pressure, through itseffect on the parasympathetic nervous system,53'sawhich may reduce the severity and prognosis ofpregnancy-induced hypertensionss's6 and potentia[maternal and fetal morbidity and mortatity. Withthese claims of transientty reducing blood pressuremidwives shoutd be mindful of supine hypotensionand the woman's position when performing mas-sage.57 Massage has been found to reduce anxietyin labourss and may be more effective than breathcoaching,5e atthough it is difficutt to extrapolatefrom these studies whether the reduction inanxiety arose from the massage or the use ofessentia[ oits.60'61

Massage facititates absorption of essentiaIoits via the skin,62 and aromatherapy is one of theprimary comptementary therapies used for thetreatment of anxiety.63 Although essentiaI oilsare known to cross the ptacentaI barrier andcan be transferred to the infant in breastmitk,6a'65 aromatherapy is targety non-interven'tionist when compared to the side-effects andlong-term complications of anxiolytic drugs.As the pregnant woman's body mass increases,it woutd be prudent of the therapist to reducethe area massaged (e.g. back or feet and hands),as the penetration of the essential oils wittincrease, due to their affinity with the celtutarmembranes.66

EssentiaI oits are partty absorbed through theprocess of otfaction by stimutating areas associatedwith smetl in the limbic system of the brain andevidence that odours effect emotions and cognitionhave received empiricaI support,6T atthough odourmemories can sometimes heighten women's anxi-eties and fears.68'6e lt may be significant thatotfaction is the first of the senses to devetop inutero: many connections from the otfactory nerveto the higher brain centres are made before thebaby is detivered.T0-72 However, the hyperosmicstate of many women during pregnancy, caused byvascutar congestion as a resutt of increasedcircutating oestrogen, suggests judicious use ofessentiaI oits.73 Studies have demonstrated thechoice of area to treat a woman could increase heranxieties, especiatty in the hospital environ'ment. Ta'75

Certain essentiat oi[s, such as lavender androsemary, have been investigated repeatedly fortheir effects on anxiety in general,5l'74'76'77 andspecific chemical constituents, for exampte, [ina-toot and tinalyt acetate, have been identified ashaving anxiolytic actions.Ts-80

There have been very few studies using essentialoils specificatly in pregnancy, therefore it isnecessary to appty the findings from animal studiesand from human studies in which aromatherapyhas been used both for healthy volunteers and foritt patients. However, animal studies shoutd beviewed with caution, as short-term, [ow-doseapptications, given for therapeutic reasons topregnant women, are noticeabty different fromtests performed on rats or mice given excessivetylarge doses.81'82 In ctinicaI studies, cancer patientsfound that their anxiety levets were reduced whengiven massage with citrus sinensis oitTa and it isinteresting to note a gender-related issue, withcitrus oits appearing to have a greater effect onwomen than on men.t'-tu

There are few empirical studies that demon-strate the efficacy and safety of essential oils withhumans, but there are studies relating to anxiety inlabour, pattiative care, dementia, but not preg'nancy.Ta'7s'86-es'108 The complexity of anx'iety as avariabte is not suitabte to be analysed statisticatty,as fat[ in btood pressure does not necessarilyimpty fatt in anxiety tevets.e6 Researchers havesuggested that patients who received aromather-apy reported significantly greater improvement intheir level of anxiety for short periods, and a betterquatity of tife.77 The targest maternity-specificstudy was conducted by Burns et at.e7 who offeredaromatherapy to 8058 women in labour using tenessentiat oits, with no detrimentaI effects onmother and baby. The effect of aromatherapyreduced fear and anxiety by 62/0, as wetl asrelieving physicaI symptoms such as pain andnausea; lavender and frankincense oits being themost frequentty used.

The use of aromatherapy can be perceived as anon-interventionaI therapy in contrast to anoxioty'tic drugs and there is insufficient evidence tosupport their safety in pregnancy, due to thepossibitity of teratogenic and mutagenic effectson the fetus.6a'65 On investigation benzodiazepinesand cannabis have been found in breast milk, andbeen associated with sedation and hypothermia inbabies.32'e8-100 Likewise, Menetta et at.101 estab-lished when pregnant women ingested gartic italtered the odour of the amniotic fluid, whichsuggests that essential oits cross the ptacenta' Aworking knowtedge of essential oil toxicotogy isrequired and crossing the ptacenta does notnecessarity mean that there is a risk of toxicity tothe fetus, as each component of the essentiat oitdepends on the toxicity and the ptasma concentra'tions of the compoun6.102'103 Mothers see aro-matherapy, which does not have the stigmaassociated with psychiatric drugs, as a treatment

Aromatherapy and massage for antenatal anxiety: lts effect on the fetus 51

with nice smetty oits and having another option ofaromatherapy, instead of prescription drugs couldempower women.loa

Anxiety can magnify minor discomforts of eartypregnancy, but many of the essentiat oils arecontraindicated during earty fetal formation dueto there abortifacient and emmenagogic effectsand the chattenge for midwives is to appty the sameprinciptes of prescribing essentiaI oils, as they do toconventional pharmaceuticals.l02 For example,high doses of citrat administered oratty to ratsresutted in intrauterine growth retardation andbone abnormatities.l05 ln view of the higher thannormat circutating levets of metanocytic hormone,women's skin sensitivities are increased in preg-nancy and the phototoxic effects of citrus oils maybe potentiated, therefore patch testing would beadvised.l06'107

Conclusion

Although pregnancy is a normal physiotogicat tifeevent, high levels of anxiety increase physio-pathotogicaI comptications and adversety affectmaternal and fetal outcome.

Midwives could be pivotal in identifying womenwho are anxious and reduce anxiety by introducingaromatherapy to a maternity unit. The evidenceindicates that the pharmacotogicaI activity ofessential oils facititates optimal heatth in anxiouspregnant women thus benefiting the fetus. Re-searchers have intimated that essentiat oiI compo'nents are abte to cross the ptacenta and reach thefetus, but this does not mean there is a risk oftoxicity, as studies have demonstrated the safe useof essential oils has no detrimentat effects onmother and baby.

The greatest chatlenge that [ies before usinvotves adapting the scientific method, so that itcan accurately test and exptore the complexity ofhuman variabtes, and midwives need to draw onboth the data from science and the wisdom fromtheir human experience. The current concept ofbenefit is often timited to clinicat benefits, butconsiderations to social and tifestyle benefits needsto occur and these medicaI decisions shoutd inctudecosts effectiveness to decrease adverse neonataloutcomes. Audit and evaluation of the aromather-apy is important to identify costs for futureresearch and to evaluate the effectivenbss andsafety. Patients perceive it as reducing anxietylevels, but what is not known is for how long thereduction in the tevet of anxiety is maintained. Weneed to integrate aromatherapy more fulty into

midwifery practice, as it would be a greatdisservice for the future of mother and baby by[imiting and narrowing our view.

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