CHAPTER 1 Introduction to Complementary This chapter introduces the concept of complementary medicine and explores some of the theories that support it. The reasons for the increasing use of complementary therapies and natural remedies in pregnancy and childbirth are explored, together with the growing interest in its use amongst midwives and other maternity professionals. Finally, the main indications for the use of complementary therapies for expectant mothers are summarised in preparation for the detailed debate that follows in subsequent chapters. The chapter includes: • introduction to complementary medicine • the use of complementary therapies and natural remedies in pregnancy and childbirth • general contraindications and precautions to use of complementary therapies • conclusion. Introduction to complementary medicine Complementary medicine comprises a large number of therapeutic and diagnostic strategies that can be used in isolation or in combination with conventional healthcare. In the 1980s these therapies were considered “alternative”, “non-conventional” or “unorthodox” because they were little understood and segregated from conventional healthcare. The term “complementary” became popular in the 1990s as the interest and incidence of use amongst the general public increased and some therapies began to be used alongside medical care. A more contemporary term used by doctors, particularly in the USA, is “integrative medicine”, implying that these modalities are integrated within mainstream medicine, although this is still often not the case. Complementary medicine has previously been marginalised as being primitive, ineffective and, without any real evidence to the contrary, unsafe. In the 1990s a government working party was set up to examine the issues surrounding complementary medicine, concluding that there was a need for greater regulation, more research, better education of practitioners and more integration into the National Health Service (NHS) (British Medical Association 1993). Improved monitoring of conventional healthcare in the 21st century has gone some way towards achieving these aims, although many therapies remain poorly regulated and the amount and calibre of research and preparatory education varies according to the precise discipline. Integration into the NHS care remains sporadic, with the maternity, oncology and learning disability fields being the main specialisms to embrace the benefits, but the NHS generally takes a cautious approach in recommending or advising on complementary medicine (NHS Choices 2017). However, complementary medicine has gradually become more acceptable, with a growing reputation for offering valid, cost-effective options and being worthy of more scientific study to demonstrate efficacy and safety. There have always been traditional systems of medicine across the world, but the advent of biomedicine relinquished these systems to a place in which they were viewed as inferior to western medicine, the prerogative of tribal cultures, to be derided as being of no value. This disdain for traditional systems, sometimes called “folk medicine”, is reinforced by the spiritual beliefs, common in many countries, that evil forces such as witches or malevolent ancestors contribute to illness and disease. There is, however, a necessary distinction to be made between centuries-old practices that have a well-developed body of clinical “wisdom” embedded in the belief system of a particular society, versus practices introduced in recent years by a few well-meaning but unscientific practitioners working in isolation from their peers and without any rigorous testing. The former group includes acupuncture, massage and reflexology, which are thousands of years old, as well as the more recent disciplines of osteopathy and homeopathy, whereas the latter group includes many untested and, frankly, sometimes harmful treatments. This includes numerous therapies claiming (illegally in the UK) to “cure cancer” but which are embraced by desperate people. On the other hand, it is important to be cautious in dismissing those that have not yet been scientifically tested, since this does not mean that they are universally ineffective or harmful. There is a subtle difference between the terms “complementary medicine” and “complementary therapies”. The former is usually applied to modalities used by medical practitioners or by complementary professionals practising more mainstream disciplines such as acupuncture, medical herbalism, homeopathy, nutrition, hypnotherapy or osteopathy. This is politically reinforced by the provision of education on some of these subjects for general practitioners, dentists, anaesthetists and other medical specialists. On the other hand, the word “therapies” implies practices that are more supportive and tends to include those commonly used by midwives, nurses and physiotherapists and by practitioners of therapies that require less rigorous preparation for practice, such as aromatherapy, massage and reflexology. These therapies are often viewed as merely relaxing, without the capability to “cure” disease, although they are extremely popular with the general public. A further differentiation must be drawn between “complementary therapies” and “natural remedies”. The word “therapies” is often used to define manual strategies such as massage, reflexology, shiatsu and other touch techniques such as reiki or the “laying on of hands”. However, in the UK, the (non-party) political and medical appreciation of osteopathy and chiropractic, which involve manual manipulation of joints, ligaments and muscles, has elevated these two disciplines above the somewhat dismissive “therapy” group and aligned them with physiotherapy. Statutory regulation, in 1993 and 1994 respectively, has now given osteopathy and chiropractic the status of “professions supplementary to medicine”. It is interesting to note the current attention being given by pharmaceutical companies to plants traditionally used by indigenous populations for their apparent therapeutic properties (Drobnik and Drobnik 2016; Rivera et al. 2017; Salehi et al. 2016; Singh et al. 2016). Given that most licensed drugs originate from various plant products, this is perhaps not surprising, but unfortunately, the isolation of identified active constituents when produced synthetically for commercial medicines produces side effects that are not normally apparent in the plants (see Chapter 2, Herbal medicine). “Whole person” healing: holism and individuality Complementary therapies and natural remedies are very powerful therapeutic entities which, when used appropriately, have the power to improve health and wellbeing. Although each therapy has its own mechanism of action, all modalities share a common philosophy of treating the “whole person” rather than merely the presenting symptom or condition. Conventional medicine categorises people, diseases or symptoms, enabling practitioners to apportion a label, using a common language that is understood by the whole medical community. Allopathic (conventional) medicine claims to focus on the bio-psycho-social model, yet the physio-pathological aspects of health and disease predominate in the majority of specialisms. In reality, medical practitioners commonly take a dispassionate, mechanistic and reductionist approach, viewing people essentially as machines in which a single part becomes faulty and requires mending. Resolving the predominating symptoms or condition is seen as “fixing” the person, with little explicit awareness of associated emotional, social or spiritual issues. Causative factors tend to be seen in epidemiological terms rather than considering the reasons why a person has developed a particular condition at a particular time. There is a dependence on materialistic interpretation of physical clinical signs with costly, highly technological and invasive methods of treatment (surgery, radiotherapy, etc.). There is little attention to preventative medicine, possibly because health education requires a long-term strategy that is certainly longer than the duration of office of any one political party. In complementary medicine, each person is seen as a unique individual with her own inner resources. The same symptoms in two different people may have vastly different causes and effects. There is, in fact, no standard by which “normality” can be assessed, nor is there a single treatment for a common set of symptoms. In addition, not relying on diagnostic categorisation leads complementary therapy practitioners to deal with “functional” disorders including pain, nausea, stress or other symptoms conventionally regarded as subjective because they are more difficult to measure, unlike quantitative clinical signs such as blood pressure or urinalysis. Symptoms are regarded by complementary practitioners as precursors to, rather than the results of, disease; treatment is dependent on defining in detail the symptom picture of the individual. Unfortunately, these methods of diagnosis and treatment are viewed with scepticism because they do not fit with the contemporary biomedical model. The scientific community opines that complementary practitioners lack the training and expertise to diagnose “correctly” – that is, in terms of a medical label – and many doctors believe that this leads to missed or inaccurate diagnoses and, by inference, inappropriate or inadequate treatment. Further, they believe that, whilst complementary therapies may alleviate subjective symptoms, they cannot cure the condition. This is essentially because their views on the manifestation of illness and dis-ease differ from those of holistic practitioners. Doctors are concerned with disease, a relatively passive reaction of the person to invasion with microbes or apparently dangerous external environmental forces. Complementary medicine is concerned with identifying the causes of imbalance within the individual, and the therapeutic goal is to return the person to homeostatic equilibrium by whatever method is necessary. Imbalance may occur from invasion by external factors, but these are considered rarely to harm a person who is homeostatically balanced. Complementary healthcare tends to focus on facilitating the self-protective abilities of the individual, regaining, maintaining and strengthening them to prevent future ill health. This, then, is not curing but healing – and healing the whole person. Prevention of disease is, of course, part of conventional medicine but is achieved through different mechanisms, such as routine immunisation and regular screening. National health policy in all countries aims to work towards the needs of the majority, using drugs, surgery or other strategies to treat only those who are at risk or who have been identified as having a defined medical condition. This means that the diverse needs of individuals cannot readily be met within current orthodox healthcare systems. Their needs and wishes may even be disregarded, particularly when financial factors predominate, as can be seen when new but extremely expensive cancer drugs come on to the market but are offered to only a few in a sort of “postcode lottery”. Contemporary adherence to local, national and international guidelines and the use of routine procedures or investigations detracts from the ability of healthcare practitioners to reflect on individuals and may actually increase the chance that the clinical relevance of anomalous features is missed. An example of this is the routine postnatal examination of a mother, which focuses on the completion of “tick charts” in assessing her for pathological complications such as retained products of conception, breast abscesses or perineal infection. Further, this medicalisation of preventative biomedicine means that the responsibility of individual “patients” is effectively disengaged, tacitly permitting them to engage in risky behaviours, for example smoking, in the unconscious belief that medicine will resolve any adverse effects. Indeed, the use of the word “patient” implies a paternalistic approach to healthcare. Professionals need to redefine their brief for care and treatment, particularly in maternity care, in which a partnership with the individual woman is engaged, and which facilitates an in-depth assessment of the holistic bio-psycho-social aspects of that woman’s life. Figure 1.1 provides a model for practice that incorporates the multiple aspects inherent in a holistic approach to care. Figure 1.1 The holistic model for practice Self-healing and the healing reaction Health is more than the absence of disease or illness. Achieving health may be a means to an end or part of an ongoing process. Wellbeing is more than just psychological equilibrium, and involves an interaction between physical, emotional, social and occupational wellness (Hunter et al. 2013). In complementary medicine, achieving wellbeing involves facilitating the inner resources of the individual as an active participant in her own health. Health – or being healthy – is not something magnanimously conferred by professionals but results from the individual’s balance of internal resources with the external natural and social environment. Optimum health and wellbeing requires the person to work in partnership with the complementary health professional, who employs gentle methods of alleviating symptoms, usually with fewer side effects than orthodox medicine, and who focuses on prevention rather than the curing of disease. For these reasons alone, complementary therapies fit well with women wanting as natural a pregnancy and birth as possible, without unnecessary intervention, enabling them to remain in control and to have a satisfying psycho-social, physical and spiritual experience. This concept of the self-healing capacity of the body, with the practitioner merely being a facilitator or acting as a conduit in assisting the client to regain homeostatic balance, is fundamental to the ethos of complementary medicine. The focus is on the person to be healed, rather than on the healer. Clinical assessment involves a consideration not only of why the person is unwell but of how to facilitate the body to repair itself. There is a complex interaction between the body, mind and spirit in which the individual can influence one part of this trilogy with another. One only has to think of a dying person, who waits for a relative to travel halfway round the world to see them one last time before expiring, to appreciate this dynamic balance. Conversely, over-stimulation of one element can trigger disharmony in the other aspects, such as the impact of emotional stress or distress on the physical body, a feature very common to complementary diagnosis and treatment. Therapists consider the development of symptoms as a means by which the body attempts to rid itself of toxins in order to return to homeostasis. For example, pyrexia is the body’s response to bacterial infection, since heat kills bacteria, sneezing expels cold viruses and vomiting empties the stomach of undesirable substances. Unfortunately, conventional medicine often seeks to suppress these symptoms rather than to determine the underlying aetiology. An example here is that of anti-inflammatory creams that reduce skin irritation (working from the outside) rather than treating the whole person (from the inside) to eliminate the need for the skin to react, as it does in response to chronic stress. In this example, identifying the emotional stress warrants treatment with stress-reducing strategies to avoid the manifestation of physical symptoms. A further complication in the conventional treatment of skin conditions is that the application of creams acts not only as a barrier to infection gaining entry to the body but as an obstruction to the release of toxic substances from the body. Whole person healing occurs in response to one or more strategies facilitated by the complementary practitioner. This may involve physical therapy as with massage or shiatsu, direct psychological treatment such as hypnotherapy or neuro-linguistic programming, or indirect emotional care through the use of relaxation therapies. The process of healing attempts first to rid the body of harmful toxins in order to cleanse the system, which then facilitates a return to homeostasis. Ongoing treatment is designed to maintain homeostatic balance throughout the body, mind and spirit. Common reactions that are experienced in response to many therapies include headache, nausea, lethargy, general aches and pains, skin reactions, congestion, mood swings and emotional effects, or worsening of the presenting symptoms. Many pregnant women will report changes in their sleep patterns following treatment, either sleeping better than normally, or experiencing difficulty in getting to sleep, with frequent waking and vivid dreams. Clients should be asked to note any reactions such as these and report them at the next appointment, or beforehand if they have any concerns. It is common – and sensible – practice to advise women to drink plenty of fluids (ideally water) and to avoid stimulants such as caffeine, chocolate, alcohol, cola and other high-sugar soft drinks and to limit excessive activity for a few hours after complementary therapy treatment, to encourage the body to heal itself. Obviously, in maternity work, it is essential that the practitioner can differentiate between a normal healing reaction, an adverse reaction (side effect) to the therapy through inappropriate or incorrect use, or the onset of a pathological complication of pregnancy. For example, a woman in late pregnancy reporting a headache following treatment could be experiencing a normal healing reaction, a side effect of therapy overdose, a relatively normal stress or tiredness headache, or she could be developing pre-eclampsia. In the event of skin irritation, this could be due to the normal detoxification process of the therapy, a side effect of a natural remedy (such as aromatherapy oils, herbal medicines or energy-based homeopathic or Bach flower remedies), or it could be physiological pruritus or emerging pathological obstetric cholestasis. As a general rule, healing reactions will arise and resolve spontaneously within 24 to 48 hours, whereas side effects may not; untreated pathology will often worsen over a course of hours or days and is, of course, much more serious and requires medical management. It is worth debating here whether or not women should be warned about a possible healing reaction prior to starting complementary treatment for a specific condition. Some practitioners consider that this could trigger anticipatory symptoms, such as may sometimes be seen in cancer patients: an anticipation of nausea, a common side effect of chemotherapy, may actually induce the nausea. However, this author believes that, in pregnancy, the woman should be informed of the possibility of a healing reaction since lack of knowledge may lead her, in such an event, to report to the maternity unit with symptoms for which no ostensible cause can be found and which may be misinterpreted by colleagues as an obstetric complication. Also, since many pregnant women only seek complementary treatment for specific problems when their symptoms become intolerable, a warning that the presenting problem could potentially become temporarily worse gives her the opportunity to decline treatment if she feels she could not cope. In practice, most women are, by this time, so desperate to feel better that they are prepared to do anything which may help, and the thought of another 24 hours of symptoms somewhat pales into insignificance against the hope that the treatment may improve the condition. Table 1.1 summarises the healing reaction.
Therapies in Maternity Care
Table 1.1 The healing reaction | |
Common symptoms occurring during treatment | Common symptoms within 24 to 48 hours of treatment (usually worst with first treatment) |
Sense of deep relaxation, drowsiness | Tiredness, changes in sleep pattern, vivid dreams |
Headache | Headache, usually occipital due to dehydration |
Change in body temperature, sweating, clamminess, feeling cold in whole or part of body | Increased perspiration, profuse sweating |
Increased thirst | Increased thirst, changes in appetite |
Nausea and/or vomiting, retching | Increased urination, changes in bowel habits, flatulence |
Increased mucus, saliva, nasal secretions | Increased mucus, saliva, vaginal or nasal secretions, spots and skin irritation |
Sneezing, coughing | Cold and influenza-like symptoms |
Pain in areas of presenting symptoms or old injuries or surgery | Muscle aches and pains, resurgence of pain in areas of old injuries or surgery |
Release of emotions – crying, giggling | Heightened emotions – crying, mood changes, irritability |
After-care advice for self-care following treatments: drink plenty of water; avoid stimulants, e.g. alcohol, caffeine, cola; eat lightly; relax to allow body to recover and react to treatment; avoid excessive work, exercise, stress, etc. | |
The therapeutic relationship and the placebo effect
One of the criticisms often directed towards complementary medicine is that any apparent improvement in the clinical condition is only a placebo effect. Others surmise that, unlike in NHS practice, the facility for the therapist to give each client her time and focused attention in some way makes the client feel better, or even that the fact that the client pays for the service gives her control over her health and contributes to an increased sense of wellbeing. Sceptics also suggest that belief in the therapy has a positive effect on subjective improvement, implying conversely that no relief will occur if the client is unconvinced. In fact, all of these aspects may contribute to the overall positive response – indeed, the placebo response is in itself a powerful entity – but this is not the only mechanism of action.
In medical terms, a placebo is generally defined as an inert substance or control method used to evaluate the physio-psychological implications of new treatments or drugs. However, the placebo response is somewhat different, being seen by some as unpredictable, unreliable and impacted by non-specific mechanisms that are usually dismissed as immeasurable and irrelevant. It could however be said that every therapeutic intervention, whether conventional or complementary, has a placebo effect, since the recipient is likely to have a degree of faith in its effectiveness, based on her trust in the practitioner. People who seek out complementary therapies tend to have an expectation that their symptoms will be resolved or lessened, but they appear also to be looking actively for practitioners offering a holistic approach that improves their quality of life and facilitates them to be involved in their own care (Richardson 2004). Clients perceive complementary therapists as being “caring” and have high satisfaction levels with their experiences and with the practitioners (Luff and Thomas 2000) with, surprisingly, little difference between consultations in private practice or the NHS (Wye, Shaw and Sharpe 2013).
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