MD, PhD, MAE, FMedSci, FRSB, FRCP, FRCPEd.

midwives

The Sunday Times reported yesterday reported that five NHS trusts currently offer moxibustion to women in childbirth for breech babies, i.e. babies presenting upside down. Moxibustion is a form of Traditional Chinese Medicine (TCM) where mugwort is burned close to acupuncture points. The idea is that this procedure would stimulate the acupuncture point similar to the more common way using needle insertion. The fifth toe is viewed as the best traditional acupuncture point for breech presentation, and the treatment is said to turn the baby in the uterus so that it can be delivered more easily.

At least four NHS trusts are offering acupuncture and reflexology with aromatherapy to help women with delayed pregnancies, while 15 NHS trusts offer hypnobirthing classes. Some women are asked to pay fees of up to £140 for it. These treatments are supposed to relax the mother in the hope that this will speed up the process of childbirth.

The Nice guidelines on maternity care say the NHS should not offer acupuncture, acupressure, or hypnosis unless specifically requested by women. The reason for the Nice warning is simple: there is no convincing evidence that these therapies are effective.

Campaigner Catherine Roy who compiled the list of treatments said: “To one degree or another, the Royal College of Midwives, the Care Quality Commission and parts of the NHS support these pseudoscientific treatments.

“They are seen as innocuous but they carry risks, can delay medical help and participate in an anti-medicalisation stance specific to ‘normal birth’ ideology and maternity care. Nice guidelines are clear that they should not be offered by clinicians for treatment. NHS England must ensure that pseudoscience and non-evidence based treatments are removed from NHS maternity care.”

Birte Harlev-Lam, executive director of the Royal College of Midwives (RCM), said: “We want every woman to have as positive an experience during pregnancy, labour, birth and the postnatal period as possible — and, most importantly, we want that experience to be safe. That is why we recommend all maternity services to follow Nice guidance and for midwives to practise in line with the code set out by the Nursing and Midwifery Council.”

A spokeswoman for Nice said it was reviewing its maternity guidelines. NHS national clinical director for maternity and women’s health, Dr Matthew Jolly, said: “All NHS services are expected to offer safe and personalised clinical care and local NHS areas should commission core maternity services using the latest NICE and clinical guidance. NHS trusts are under no obligation to provide complementary or alternative therapies on top of evidence-based clinical care, but where they do in response to the wishes of mothers it is vital that the highest standards of safety are maintained.”

On this blog, we have repeatedly discussed the strange love affair of midwives with so-called alternative medicine (SCAM), for instance, here. In 2012, we published a summary of 19 surveys on the subject. It showed that the prevalence of SCAM use varied but was often close to 100%. Much of it did not seem to be supported by strong evidence for efficacy. We concluded that most midwives seem to use SCAM. As not all SCAMs are without risks, the issue should be debated openly. Today, there is plenty more evidence to show that the advice of midwives regarding SCAM is not just not evidence-based but also often dangerous. This, of course, begs the question: when will the professional organizations of midwifery do something about it?

An article in THE TIMES seems worth mentioning. Here are some excerpts:

… Maternity care at Nottingham University Hospitals NHS Trust (NUH) is the subject of an inquiry, prompted by dozens of baby deaths. More than 450 families have now come forward to take part in the review, led by the expert midwife Donna Ockenden. The trust now faces further scrutiny over its use of aromatherapy, after experts branded guidelines at the trust “shocking” and not backed by evidence. Several bereaved families have said they recall aromatherapy being heavily promoted at the trust’s maternity units.

It is being prosecuted over the death of baby Wynter Andrews just 23 minutes after she was born in September 2019. Her mother Sarah Andrews wrote on Twitter that she remembered aromatherapy being seen as “the answer to everything”. Internal guidelines, first highlighted by the maternity commentator Catherine Roy, suggest using essential oils if the placenta does not follow the baby out of the womb quickly enough…  the NUH guidelines say aromatherapy can help expel the placenta, and suggest midwives ask women to inhale oils such as clary sage, jasmine, lavender or basil, while applying others as an abdominal compress. They also describe the oils as “extremely effective for the prevention of and, in some cases, the treatment of infection”. The guidelines also suggest essential oils to help women suffering from cystitis, or as a compress on a caesarean section wound. Nice guidelines for those situations do not recommend aromatherapy…

The NUH adds frankincense “may calm hysteria” and is “recommended in situations of maternal panic”. Roy said: “It is shocking that dangerous advice seemed to have been approved by a team of healthcare professionals at NUH. There is a high tolerance for pseudoscience in NHS maternity care … and it needs to stop. Women deserve high quality care, not dangerous quackery.” …

________________________________

The journalist who wrote the article also asked me for a comment, and I emailed her this quote: “Aromatherapy is little more than a bit of pampering; no doubt it is enjoyable but it is not an effective therapy for anything. To use it in medical emergencies seems irresponsible to say the least.” The Times evidently decided not to include my thoughts.

Having now read the article, I checked again and failed to find good evidence for aromatherapy for any of the mentioned conditions. However, I did find an article and an announcement both of which are quite worrying, in my view:

Aromatherapy is often misunderstood and consequently somewhat marginalized. Because of a basic misinterpretation, the integration of aromatherapy into UK hospitals is not moving forward as quickly as it might. Aromatherapy in UK is primarily aimed at enhancing patient care or improving patient satisfaction, and it is frequently mixed with massage. Little focus is given to the real clinical potential, except for a few pockets such as the Micap/South Manchester University initiative which led to a Phase 1 clinical trial into the effects of aromatherapy on infection carried out in the Burns Unit of Wythenshawe Hospital. This article discusses the expansion of aromatherapy within the US and follows 10 years of developing protocols and policies that led to pilot studies on radiation burns, chemo-induced nausea, slow-healing wounds, Alzheimers and end-of-life agitation. The article poses two questions: should nursing take aromatherapy more seriously and do nurses really need 60 hours of massage to use aromatherapy as part of nursing practice?

My own views on aromatherapy are expressed in our now not entirely up-to-date review:

Aromatherapy is the therapeutic use of essential oil from herbs, flowers, and other plants. The aim of this overview was to provide an overview of systematic reviews evaluating the effectiveness of aromatherapy. We searched 12 electronic databases and our departmental files without restrictions of time or language. The methodological quality of all systematic reviews was evaluated independently by two authors. Of 201 potentially relevant publications, 10 met our inclusion criteria. Most of the systematic reviews were of poor methodological quality. The clinical subject areas were hypertension, depression, anxiety, pain relief, and dementia. For none of the conditions was the evidence convincing. Several SRs of aromatherapy have recently been published. Due to a number of caveats, the evidence is not sufficiently convincing that aromatherapy is an effective therapy for any condition.

In this context, it might also be worth mentioning that we warned about the frequent usage of quackery in midwifery years ago. Here is our systematic review of 2012 published in a leading midwifery journal:

Background: in recent years, several surveys have suggested that many midwives use some form of complementary/alternative therapy (CAT), often without the knowledge of obstetricians.

Objective: to systematically review all surveys of CAT use by midwives.

Search strategy: six electronic databases were searched using text terms and MeSH for CAT and midwifery.

Selection criteria: surveys were included if they reported quantitative data on the prevalence of CAT use by midwives.

Data collection and analysis: full-text articles of all relevant surveys were obtained. Data were extracted according to pre-defined criteria.

Main results: 19 surveys met the inclusion criteria. Most were recent and from the USA. Prevalence data varied but were usually high, often close to 100%. Much use of CATs does not seem to be supported by strong evidence for efficacy.

Conclusion: most midwives seem to use CATs. As not all CATs are without risks, the issue should be debated openly.

I am tired of saying ‘I TOLD YOU SO!’ but nevertheless find it a pity that our warning remained (yet again) unheeded!

This sad story was reported across the world. It is tragic and, at the same time, it makes me VERY angry. A women lost her life after giving birth due to the incompetence of her midwife. On this website, we learn the following gruesome details:

Many question the culpability of Australian midwife Gaye Demanuele in the wake of the investigations into the death of Caroline Lovell during her home birth in 2012. And while Demanuele played a major role in Lovell’s passing, a closer look may show the real culprit: homeopathy. In January 2012, Demanuele, an outspoken home birth advocate, served as senior midwife in Lovell’s home birth. After giving birth, Lovell experienced severe blood loss and begged to call an ambulance. According to the investigating coroner, Demanuele refused several times, never checking her patient’s blood pressure or effectively monitoring her blood loss. Demanuele instead tried a homeopathic “remedy” to relieve Lovell’s anxiety. Only after Lovell fainted in a pool of her own blood and went into cardiac arrest was she taken to a hospital, where she died 12 hours later…

We know that many midwifes are besotted with alternative medicine. Their love-affair with quackery had to lead to serious harm sooner or later. This story is thus tragic and awful – but it is not surprising.

What makes me angry, is the complete lack of critical comment from homeopaths and their professional organisations. Where are the homeopaths who state clearly and categorically that the use of homeopathic remedies in the situation described above (and indeed in midwifery generally) is not based on sound evidence? In fact, it is criminal charlatanry!

Homeopaths are usually not lost for words.

Where is the homeopathic organisation stating that a bleeding patient does not need homeopathy?

How should we interpret this deafening silence?

Does it mean that those homeopaths who quietly tolerate charlatanry are themselves charlatans?

If so, would this not be 100% of them?

The aim of this survey was to investigate the use of alternative medicines (AMs) by Scottish healthcare professionals involved in the care of pregnant women, and to identify predictors of usage.

135 professionals (midwives, obstetricians, anaesthetists) involved in the care of pregnant women filled a questionnaire. A response rate of 87% was achieved. A third of respondents (32.5%) had recommended (prescribed, referred, or advised) the use of AMs to pregnant women. The most frequently recommended AMs modalities were: vitamins and minerals (excluding folic acid) (55%); massage (53%); homeopathy (50%); acupuncture (32%); yoga (32%); reflexology (26%); aromatherapy (24%); and herbal medicine (21%). Univariate analysis identified that those who recommended AMs were significantly more likely to be midwives who had been in post for more than 5 years, had received training in AMs, were interested in AMs, and were themselves users of AMs. However, the only variable retained in bivariate logistic regression was ‘personal use of AM’ (odds ratio of 8.2).

The authors draw the following conclusion: Despite the lack of safety or efficacy data, a wide variety of AM therapies are recommended to pregnant women by approximately a third of healthcare professionals, with those recommending the use of AMs being eight times more likely to be personal AM users.

There are virtually thousands of websites which recommend unproven treatments to pregnant women. This one may stand for the rest:

Chamomile, lemon balm, peppermint, and raspberry leaf are also effective in treating morning sickness. Other helpful herbs for pregnancy discomforts include:

  • dandelion leaf for water retention
  • lavender, mint, and slippery elm for heartburn
  • butcher’s broom, hawthorn, and yarrow, applied externally to varicose veins
  • garlic for high blood pressure
  • witch hazel, applied externally to haemorrhoids.

Our research has shown that midwives are particularly keen to recommend and often sell AMs to their patients. In fact, it would be difficult to find a midwife in the UK or elsewhere who is not involved in this sort of thing. Similarly, we have demonstrated that the advice given by herbalists is frequently not based on evidence and prone to harm the unborn child, the mother or both. Finally, we have pointed out that many of the AMs in question are by no means free of risks.

The most serious risk, I think, is that advice to use AM for health problems during pregnancy might delay adequate care for potentially serious conditions. For instance, the site quoted above advocates garlic for a pregnant women who develops high blood pressure during pregnancy and dandelion for water retention. These two abnormalities happen to be early signs that a pregnant women might be starting to develop eclampsia. Treating such serious conditions with a few unproven herbal remedies is dangerous and recommendations to do so are irresponsible.

I think the new survey discussed above suggests a worrying degree of sympathy amongst conventional healthcare professionals for unproven treatments. This is likely to render healthcare less effective and less safe and is not in the interest of patients.

To include conventional health care professionals amongst those who significantly contribute to the ‘sea of misinformation’ on alternative medicine might come as a surprise. But sadly, they do deserve quite a prominent place in the list of contributors. In fact, I could write one entire book about each of the various professions’ ways to mislead patients about alternative medicine.

There are, of course, considerable national differences and other peculiarities which render each specific profession quite complex to evaluate. The material is huge – far to big to fit in a short comment. All I will therefore try to do with this post is to throw a quick spotlight on some of the mainstream professions mentioning just one or two relevant aspects in each instant.

Nurses

Particularly in North America, many nurses seem to be besotted with ‘Therapeutic Touch’, an implausible and unproven ‘energy-therapy’. For instance, the College of Nurses of Ontario includes Therapeutic Touch as a therapy permitted for its members. In other regions, other alternative treatments might be more popular with nurses but, in general, many seem to have a weakness for this sector. Researchers from Aberdeen  recently conducted a survey to establish the use of alternative medicine by registered nurses, as well as their knowledge-base and attitudes towards it. They sent a questionnaire to 621 nurses and achieved a remarkable response rate of 86%. Eighty per cent of the responders admitted to employ alternative medicine and 41% were using it currently. Only five nurses believed that alternative medicine was not effective and 74% would recommend it to others. In other words, there is a strong likelihood of patients being misinformed by nurses.

Midwives

A recent article in the UK journal THE PRACTISING MIDWIFE (Sept 2013) by Valerie Smith (not Medline-listed) claimed that the Royal College of Midwives supports the use of homeopathic remedies during childbirth. This does come to no surprise to those who know that several surveys have suggested that midwives are particularly fond of un- or dis-proven therapies and that they employ them often without the knowledge of obstetricians. We investigated this question by conducting a systematic review of all surveys of alternative medicine use by midwives. In total,19 surveys met our inclusion criteria. Most were recent and many originated from the US. Prevalence data varied but were usually high, often close to 100%. Much of this practice was not supported by sound evidence for efficacy and some of the treatments employed had the potential to put patients at risk. It seems obvious that, in order to employ unproven treatment, midwives first need to misinform their patients.

Physiotherapists

Some physiotherapists promote and practise a range of unproven treatments, e.g. craniosacral therapy. I am not aware of statistics on this, but it is not difficult to find evidence on the Internet: One website boldly states that Physiotherapy & Craniosacral Therapy available with Charetred Physiotherapist with 20 years of experience in the NHS. Another one proudly announces:  Our main methods of treatment are through Physiotherapy and Craniosacral Therapy. A third site claims that Craniosacral Therapy is attracting increasing interest for its gentle yet effective approach, working directly with the body’s natural capacity for self-repair to treat a wide range of conditions. And a final example: Catherine is a registered Cranio-Sacral Therapist, a Physiotherapist, and is a tutor at the London College of Cranio-Sacral Therapy.  She is also qualified in acupuncture for pain relief and a member of the Craniosacral Therapy Association, the Chartered Society of Physiotherapy and Acupuncture Association for Chartered Physiotherapists.

Pharmacists

If you go into any pharmacy in the UK, you do not need to search for long to find shelves full of homeopathic remedies, Bach flower remedies, aromatherapy-oils or useless herbal slimming aids, to mention just 4 of the many different bogus treatments on offer. If you do the same in Germany, France, Switzerland or other countries, the amount of bogus remedies and devices for sale might even be greater. Pharmacists, it seems to me, have long settled to be shopkeepers who have few scruples misleading their customers into believing that these useless products are worth buying. Their code of ethics invariably forbids them such promotion and trade, but most pharmacists seem to pay no or very little attention. The concern for profit has clearly won over the concern for customers or patients.

Doctors

I have left my own profession for last – not because they are the least contributors to the ‘sea of misinformation, but because, in some respects, they are the most important ones. The general attitude amongst doctors today seems to be ‘I don’t care how it works, as long as it helps my patients’. I have dedicated a previous post on explaining that this is misleading nonsense; therefore there is no reason to not repeat myself. Instead, I might just mention how many doctors practice homeopathy thus misleading patients into believing that it is an effective therapy. Alternatively, I could refer to those charlatans with a medical degree who promote bogus cancer cures. In my view, misinformation by doctors is the most serious form of misinformation of them all: physicians involved in such activities violate their ethical code and betray patients who frequently trust doctors almost blindly.

Conclusion

It would be a misunderstanding to assume that, with this post, I am accusing all conventional health care professionals of misinforming us about alternative medicine. But some clearly do; and when they do abuse their positions of trust in this way, they do a serious disservice to us all. I hope that exposing this problem will contribute to conventional health care professionals behaving more responsibly in future.

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