CHAPTER 3   

Professional Issues

This chapter explores some of the professional issues affecting midwives and doulas in relation to the use of complementary therapies in pregnancy and childbirth. Maternity professionals have specific responsibilities towards their clients according to whether women wish to self-administer natural remedies or consult independent practitioners. Different matters arise if the midwife or doula refers to a therapist, or when complementary therapies are incorporated into mainstream maternity care. Further obligations apply when midwives choose to offer complementary therapies in private practice. The chapter concludes with a suggested professional code of practice for safe use of complementary therapies in pregnancy and birth.

This chapter includes discussion on:

• introduction

• autonomy, advocacy and equity

• safe, effective and compassionate use of complementary therapies in maternity care

• education and training in maternity complementary therapies

• regulation and indemnity insurance

• responsibilities of midwives in relation to complementary therapies and natural remedies

• midwives implementing complementary therapy services in conventional maternity care

All practitioners must maintain comprehensive contemporaneous records of any treatments and/or advice given to women (NMC 2015: 10). It is, however, concerning that many apparently informal conversations which midwives have with women on the subject of complementary therapies and natural remedies go unrecorded (Hall, Griffiths and McKenna 2013, 2015; personal communications with UK midwives). An example of this is the issue of raspberry leaf tea (see Chapter 8), a common question often asked casually by the woman at the end of a clinic visit. However, rarely do midwives adequately assess the woman for contraindications and precautions before advising her whether or not it is appropriate to take the remedy. Complementary practitioners should also record any conversations they have with clients relating to their pregnancies and avoid offering well-intentioned but sometimes misguided information outside the parameters of their therapy training. For example, it would be inappropriate for a hypnotherapist or acupuncturist to answer questions from clients on foods to be avoided in pregnancy unless the practitioner is qualified in nutrition and/or is up to date with current government recommendations on diet in pregnancy.

All caregivers should reduce as far as possible any potential for harm associated with their use of complementary therapies and should ensure that the therapies/remedies used are compatible with other care, treatment or medication that the woman may be receiving (NMC 2015: 18 and 19). This can be difficult if the midwife is unfamiliar with the mechanism of action of different therapies and remedies, in which case, expert advice should be sought.

Autonomy, advocacy and equity

Women have a right to use complementary therapies or self-administer natural remedies (NMC 2010). Midwives, doulas and others should support women’s choices and act as their advocates, but be prepared also to advise those whose conditions warrant discontinuation of the therapies/remedies (see Chapter 1, General contraindications and precautions to use of complementary therapies). Expectant mothers should be empowered to be autonomous in their decision-making but may need professional help to do so with regards to safety. However, this can sometimes cause conflict for midwives with little or no knowledge of the vast subject area of complementary therapies. Expectant mothers’ own lack of awareness can result in clinical situations in which either the materno-fetal condition or the safety of staff or other pregnant women may be at risk. Examples of this include the concomitant use of herbal remedies which have an anticoagulant effect by a woman who is taking warfarin or aspirin, or the use of uterotonic aromatherapy oils such as clary sage in an area where women (and midwives) in early pregnancy are also present (see Chapters 1 and 2; Tiran 2016a).

There has been a change in emphasis in healthcare generally since the 1990s, when national interest in integrating complementary therapies into conventional healthcare was at its highest and the process of implementing new strategies into mainstream healthcare was relatively lenient. However, in the 21st century, increasingly stringent clinical governance, the litigious nature of society and health service policy and funding have become central to the provision of maternity care, particularly in the UK. Whilst midwifery has always purported to be an autonomous profession, decades of conflict with other professionals over the “ownership” of birth, compounded by the current state of the maternity services, has diminished that autonomy to a level where midwives could admit to feeling unsure of their role. Incorporating complementary therapies into maternity care enables self-motivated midwives to extend their therapeutic repertoire and suggests that they may be able to regain some of their lost autonomy, although this is often not the case (Cant, Watts and Ruston 2011). The “alternative” genre of complementary therapies remains a barrier to complete integration, both in practice and in education. It is necessary first to convince sceptics of the value of introducing aspects of complementary therapy into mainstream care, and to justify that their benefits can exceed merely a relaxation or placebo effect, whilst being able to rationalise the use of modalities which often lack robust evidence and for which the scientific underpinning may be difficult to elucidate.

Conversely, it is vital that midwives can truly substantiate that their desire to include complementary therapies in their care of women is altruistic and not purely an unconscious means of regaining power and redefining their professional identity (Adams 2006). Even within the profession, there are examples of insidious battles for control, with the suggestion that those midwives who use complementary therapies somehow have supremacy over those who do not. This extends beyond the grass-roots clinical staff to managerial and operational levels, in which the belief that providing services not available in other local maternity units in some way raises the profile of those units offering complementary therapies. However, the principle of beneficence dictates that women’s wellbeing should be at the forefront of care provision and should guide clinical decision-making which, in turn, should be justifiable to the women.

Further, any demand for additional, extraneous services such as complementary therapies should be balanced with the priorities for existing service provision. The use of complementary therapies must be for the benefit of the women and their babies, and not for the egotism of midwives or other care providers. Where maternity managers wish to introduce complementary therapies into the maternity unit, a sound rationale must be identified based on how it can improve current services. Rather than enthusiastically and randomly attempting to “implement (one or more) complementary therapies” midwives would be wise to explore the issues facing the contemporary maternity services, such as unacceptably high levels of Caesarean sections and inductions of labour, or poor maternal satisfaction scores. Attempting to redress these issues through the use of complementary therapies provides a more sound rationale for implementation and can be more robustly audited and more easily compared to current conventional strategies in order to demonstrate their value to the overall service. Incorporating complementary therapies into care in this way can also provide a vehicle for research studies to underpin practice.

It is not appropriate for a maternity unit to train just a few midwives in several different therapies in an attempt to be able to offer a range of services. This will result in an inequitable service, fragmentation of treatment and a hierarchical system in which only a few select midwives are able to provide the therapies. A limited service which only enables a small proportion of the women to access it is morally indefensible, not cost effective and less likely to be allowed to continue in the long term. In today’s large maternity units in which there may be over 6000 births, it is logistically impossible to provide an equitable “relaxation service” with complementary therapies. It is preferable that several, if not most, of the midwives in a unit are able to incorporate into general care a range of complementary strategies for specific purposes. For example, aromatherapy or massage can be specifically applied and taught to all community and birth centre midwives so that it can be offered to women in normal labour, or groups of midwives could learn specific acupressure techniques known to initiate labour for women with post-dates pregnancy. Alternatively, providing services for specific groups of women also facilitates the identification of need, rather than simply a desire; for example, hypnotherapy services could be provided for women with a previous poor obstetric history, needle phobia or tocophobia; massage services for teenagers may improve antenatal clinic attendance and compliance. It may also be appropriate to train a limited number of midwives in a very specific aspect of complementary therapy which can be delivered in a cost effective way. An example of this would be providing moxibustion as part of a specialist clinic for women with breech presentation, which perhaps also includes facilities for external cephalic version, discussion of the option of vaginal breech birth and pre-operative planning for women needing or desiring Caesarean section (see Chapter 6).

Within conventional maternity care, the use of complementary therapies offers a mechanism to enhance care for women, by giving midwives some new tools, but enthusiasm can occasionally cloud the judgement of individuals (personal communications with midwives). Implementation must be coordinated within and between maternity units in a single health board or trust so that all midwives practise according to defined criteria and all women, except perhaps those with high-risk pregnancies, can be assured that they may have the opportunity to receive therapy as appropriate and that the quality is consistent. Offering strategies which are relaxing and which may contribute to a more normal birth is exciting, pleasurable and satisfying, but midwives need to be mindful of working within boundaries set by the NMC, by guidelines and protocols laid down at national level or by local maternity service employers, and by the extent of their complementary therapy training.

Safe, effective and compassionate use of complementary therapies in maternity care

Martin Bromiley, an airline pilot, founded the Clinical Human Factors Group1 after the death of his wife from minor surgery, which was later found to be due to “human factors”, including poor communication between individuals and departments. He reasons that a good safety record is seen as an essential feature when prospective passengers are choosing an airline with which they wish to fly. If we apply this principle to healthcare, patients should be able to choose those hospitals or practitioners with the best safety record.

Bromiley asserts that safety is integral to compassionate care and cannot be separated from it. Given that obstetrics has the highest expenditure on compensation for negligence than any other clinical field, it stands to reason that safety is fundamental to good maternity care. Safe practice involves everyone working in, and receiving, healthcare services. It is ongoing, with adjustments and adaptations being made, either directly as a result of safety incidents or indirectly, in response to efficiency drives and client and staff feedback. Safety is not achieved simply through the use of guidelines, policies or standardised processes; indeed the ease with which staff can adhere to these means that they risk doing so in an unthinking manner. Further, safe practice should not be based on a punitive measure of accountability in which it becomes an obligation for more personal reasons (such as avoiding disciplinary action) than for the overall wellbeing of those receiving care.

Safe practice requires commitment from every member of the team, with careful forethought and ongoing reflection. Every aspect of the healthcare experience must be safe, from the environment to the equipment and technology, and from the procedures, work schedules and staffing levels to the actual treatment and care provided. Communication is vital to this process, as are good team leadership, peer support and, importantly, a change from the current blame culture to one of mutual respect and learning. A safety culture, in which everyone shares the same values, beliefs and attitudes, is essential to compassionate care. A report from the Clinical Human Factors Group (Illingworth 2015) advocates that:

the pursuit of safety depends on volunteerism…and…is more about what people choose to do than about what they are required to do. Safety cannot, in any meaningful sense, be required of a workforce or, for that matter, of those they serve. (this author’s italics)

Where midwives have long-standing complementary therapy services in place, there is a risk of complacency which could threaten the safety – and thus the compassionate delivery – of the strategies provided. Midwives cannot assume that they can continue to practise any element of care continuously for several years without constantly reviewing and reflecting on it. All aspects of midwifery practice evolve and develop as a result of experience and the availability of new evidence. Services adapt in response to client and staff feedback, including formal audit processes and informal evaluation. This should apply equally to the incorporation of complementary therapies within maternity care, especially since these “alternatives” are often required to justify themselves twice over in order to convince the sceptics that they are safe, effective, satisfying and cost effective. Several maternity units are known to this author where, it could be argued, midwives no longer provide compassionate – or safe – complementary therapies to pregnant and childbearing women because there has been little, if any, ongoing updating, evaluation or development. Further, midwives often lose sight of the fact that their use of complementary therapies must be within the parameters laid down by their initial registration, namely by the NMC, and by the parameters of the culture in which they work.

Enthusiasm to use new, ostensibly pleasant and relaxing therapies can often override midwives’ adherence to NMC directives, putting them in a situation which, at the extreme, could jeopardise their registration. For example, in 2016, three midwives were brought before an NMC professional conduct hearing for failing to transfer a woman with fetal distress from her home to a main obstetric unit – because the labouring woman was apparently due to receive an aromatherapy treatment from one of the midwives. On eventual transfer to hospital an emergency Caesarean section was performed but the baby suffered brain damage and multiple organ failure; a claim for compensation was pursued in the courts. Interestingly, despite the NMC’s Code (2015) requiring midwives to prioritise care needs and to act in the woman’s best interests, the midwives were judged by the NMC not to have practised unsafely, particularly as it was not possible to establish if the delay in transfer, or the use of aromatherapy, contributed to the baby’s condition (Butterworth 2016). The lack of any punitive action by the NMC means that the case is not recorded on their website and information on this case has been found only in local newspapers. The fact that the midwives appeared to favour aromatherapy over transfer to hospital suggests misplaced obligations and a conflict between advocacy and accountability. However, it is, of course, impossible to judge without being in possession of the full facts and it is probable that other factors, perhaps involving the mother’s or family’s demands, may have contributed to the situation. In another case in 2009, a midwife in Wales was removed from the NMC register for inappropriate administration of aromatherapy oils to a labouring woman. Despite the maternity unit not having clinical guidelines for aromatherapy, the midwife used some of her own essential oils for a woman in labour. Unfortunately, she failed to give adequate information, resulting in the woman mistaking the blend for medicine, which she proceeded to drink. This case raised issues around drug administration and record keeping (Tozer 2009).

Nevertheless, some complementary therapy training courses are relatively short in terms of the required number of pre-qualifying hours and may be taught at a fairly basic academic level, particularly the supportive therapies. Worryingly, it is actually possible to find online distance learning courses in some therapies for a nominal fee, and it is still legally permissible under common law in England and Wales for “graduates” to start offering their services to the paying public (unless the therapy is statutorily regulated as in the case of osteopathy and chiropractic). On the other hand, since all health practitioners are now required to have professional indemnity insurance applicable to the specialism in which they work, those who have not completed an accredited course will find it difficult to obtain insurance cover (see NMC 2015: 12.1). This is especially relevant to the use of complementary therapies in pregnancy and even more so when it comes to caring for women in labour.

For midwives and doulas seeking complementary therapy training, clarifying the calibre and appropriateness of the numerous, widely available courses is complicated by the fact that many supportive therapies are not nationally regulated and there may be several regulatory organisations covering the same therapy, for example reflexology, of which there are several different styles (see Chapter 2). However, whilst most accredited training courses for supportive therapies, such as aromatherapy, massage and hypnosis, are part time, they often last 12 months or more, with considerable practice and case study work undertaken between taught sessions. Other therapies, notably those which are statutorily regulated (osteopathy, chiropractic) or voluntarily self-regulated at a national level, such as acupuncture and medical herbalism, may be full-time university degree programmes completed over several years.

The NMC permits midwives to use complementary therapies in their practice but specifies that they must be adequately and appropriately trained to do so and must practise in accordance with set parameters (NMC 2010: 23; 2015: 6.2). The issue of what constitutes “appropriate” education is contentious and very much open to debate and clarification. The NMC puts the onus of responsibility on the individual midwife to ascertain whether or not her training is appropriate, but this can be difficult if the midwife (or manager) is unaware of the requirements of the therapy and the issues related to using that therapy in relation to NMC registration and other directives and guidelines. Midwives wishing to learn specific therapies must ensure that the training is midwifery focused and not merely a generic qualification or a maternity-related course intended for therapists with no knowledge of pregnancy and birth. Indeed, it can sometimes be difficult for midwives with qualifications in particular therapies to apply the principles of those therapies to their use within midwifery practice.

Those who have fully qualified in one or more therapies may require some further learning, perhaps in the form of an “adaptation” course, as well as a comprehensive understanding of the NMC regulations and how these relate to the use of complementary therapies within midwifery practice. These same midwives also need to be up to date in the practice and theory of the specific therapy and should not assume that a complementary therapy qualification which they gained several years ago is still valid today, especially if they have not practised regularly since their initial training. In any case, many pre-registration therapy courses exclude maternity work as they view it as a post-qualifying area for continuing professional development (CPD). Even those CPD courses for therapists which claim to prepare them to specialise in working with pregnant clients are often taught by tutors with an enthusiastic interest in the subject but with little or no real clinical experience or in-depth knowledge. Personal experience of this author in teaching several hundred therapists from different disciplines indicates a concerning lack of understanding of basic issues, particularly the justification for specific practices. A very basic example is that many therapists who claim to have attended maternity CPD courses still lack adequate knowledge of anatomy and physiology to explain why a heavily pregnant woman should not lie flat on her back. It is also known that some therapists treat pregnant women without any training, maintain no records, never communicate with midwives or doctors and even, in the case of one reflexology clinic in London, arrogantly claim to be able to help a woman start labour without ever taking a history, referring to the woman’s handheld maternity notes or liaising with the woman’s midwife or doctor (personal communications).

Furthermore, some midwives have an increasingly self-important attitude to the inclusion of complementary therapies in their practice. This has resulted in midwives who complete introductory courses preparing them to use very limited aspects of a therapy who then presume to be competent and knowledgeable enough to teach other midwives (numerous personal communications with midwives and managers around the UK). This level of “cascade training” of complementary therapies is inappropriate, unsafe, unprofessional and unethical. Any midwife using aspects of complementary therapy in her own practice must not only be a “knowledgeable doer” (Cant 2011) but must also understand what she is doing, based on extensive clinical experience, before attempting to teach others. Clinical practice incorporating the therapy into midwifery care is essential to gain sufficient experience of the positive and negative effects of the therapy in pregnancy, birth or the postnatal period. Also, since students only retain a proportion of what they learn in the classroom, there is a natural dilution of content with each successive “cascade”. This egotism is misplaced, particularly since midwives would not condone therapists undertaking a short course on midwifery and then attempting to teach others.

Given the number of women now using complementary therapies, it is also imperative that student midwives are provided with an overview of the whole subject area, with specific reference to pregnancy and birth. It is, in fact, the ill-informed and injudicious use of complementary therapies, especially natural remedies, that predisposes women to iatrogenic complications, such as intrapartum uterine hypertonia and fetal distress. Despite the NMC’s Standards for Pre-registration Midwifery Education (NMC 2009) requiring midwives, at the point of registration, to be able to advise women on over the-counter remedies, this subject remains an area which is given scant coverage in midwifery training. Enjoyable “taster” sessions on massage and aromatherapy do not, in any way, equip student midwives to advise women knowledgeably and comprehensively on the safety of different therapies and remedies, nor can they adequately address the relevant professional accountability issues. Furthermore, these sessions perpetuate the trivialisation of complementary therapies as merely relaxation strategies, a factor which detracts from their therapeutic power when used appropriately and their potentially serious risks with inadvertent misuse or abuse. Complementary therapies education for students and midwives should provide sessions that help midwives to comply with NMC requirements and, once qualified, are suitable for NMC revalidation. Midwives with a particular interest in one or more therapies applied to pregnancy and birth should have the opportunity to study them as post-registration activities when they can consider the scientific basis of the therapy, its application to midwifery practice and the process of change management required to implement it in the workplace.

Continuing professional development is also essential for all those using complementary therapies with pregnant and childbearing women. Midwives, doulas and antenatal teachers should ensure that they update regularly, both in terms of the therapy and its application to maternity care. Therapists wanting to specialise in working with pregnant clients require further study and supervised experience of treating expectant mothers. They should acquire a good working knowledge of reproductive anatomy and physiology, and appreciate the conventional maternity services and any contemporary developments, as well as their roles and responsibilities when caring for maternity clients. Table 3.1 outlines the minimum requirements for education and training by midwives and doulas in any individual complementary therapy.

Regulation and indemnity insurance

However, in midwifery and other statutorily regulated health professions, the situation is much clearer than for many complementary therapies. Many of the principal complementary therapies have evolved a system of voluntary self-regulation, although both osteopathy and chiropractic were regulated by statute in 1993 and 1994 respectively. However, there remains a confusing plethora of organisations claiming to be the “lead body” for a particular therapy, and this can be confusing for the public and for conventional healthcare professionals. There are some overarching bodies with member organisations from various complementary disciplines, as well as associations related to just one therapy or a series of therapies with similar principles, for example massage therapies. Some therapies have more than one body, sometimes differentiating between “medical” or “western” reductionist therapy and holistic, “classical” or “traditional” practice, as with both acupuncture and homeopathy. Table 3.2 provides a summary of the main complementary therapy organisations in the UK.

Responsibilities of midwives in relation to complementary therapies and natural remedies

Women have the right to self-administer natural remedies and should be facilitated in their wishes where possible (NMC 2010). If the midwife is unsure whether the remedy is safe or appropriate, she should discuss this with the woman and consult a midwife or doctor who specialises in this field, or a therapy organisation. Women should be asked periodically throughout the pregnancy about their use of complementary therapies and natural remedies, for example at the booking visit, early in the third trimester in preparation for the birth and at the start of labour. Importantly, if the midwife feels unable to advise the woman, this must be recorded in the maternity notes, together with any advice about where to obtain appropriate information. Any informal advice given to the woman must also be recorded.

Frequently women self-administer natural remedies without informing their midwife, but this can lead to complications, which may be considered idiopathic by uninitiated staff, but which are, in fact, iatrogenic. For example, if a woman is admitted in preterm labour, or with complications for which no medical cause can be determined, it is wise to enquire of the woman if she has used any natural remedies, including herbal medicines or herbal teas, homeopathic remedies or aromatherapy essential oils, as these may have contributed to the onset of contractions. Also, many women from overseas use traditional remedies which are often strongly embedded in their own cultures, particularly plant remedies in preparation for birth and during labour.

The midwife should, if she is aware of the fact, record contemporaneously in the woman’s notes (and on the partogram and cardiotocograph printout, if in use) when the woman administers a remedy to herself, even if the midwife is not familiar with its actions. The midwife also needs to be aware of the risk of interactions between pharmacologically active natural remedies and any prescribed drugs, as many have similar mechanisms of action. Some remedies may also interfere with the results of investigations; for example, therapeutic doses of ginger tea or capsules for nausea (see Chapter 4) may reduce platelet aggregation, potentially increasing measures of bleeding time (Chen et al. 2011). If complications arise the midwife may need to advise the woman against continuing her use of natural remedies (see Chapter 2) and record in the notes whether the woman agrees to this.

If an independent therapist or doula accompanying a woman in labour administers complementary therapies or natural remedies, she is responsible for her own practice, but the midwife is ultimately responsible for the care of the woman during labour. Midwives should try to encourage women wishing to be accompanied in labour by a practitioner who intends to use complementary therapies to discuss this in advance, perhaps by including a question in their discussions on preparation for the birth. This may help to avoid any conflict when the woman is in labour. Doulas and other birth companions attending in a professional capacity should ensure that they inform the midwife of any natural remedies they administer or any complementary manual treatments they give to the woman.

Some maternity units require therapists and doulas to confirm in writing that they are in possession of professional indemnity insurance and that they understand they cannot rely on the hospital’s vicarious liability insurance to protect them in the event of complications leading to a compensation claim. It may also be wise to clarify professional boundaries and to ask the practitioner to acknowledge in writing that the midwife and/or doctor remains responsible for the mother’s and baby’s care and that, in the event of an emergency, the therapist/birth supporter agrees to step aside if asked to do so and/or to discontinue the complementary therapy. The midwife should record in the woman’s notes when therapy is in progress or remedies are given. A note here that therapists using aromatherapy should be forbidden to use any form of diffuser, vaporiser or burner whilst in the maternity unit or birth centre, and with caution in the woman’s own home, because of the risk to the mother, baby and other people (see Chapter 2, Aromatherapy).

The field of complementary medicine is a minefield, not least because there are so many different therapies, many of which lack a robust theoretical underpinning or evidence base. Unlike midwifery, nursing, medicine and related professions such as physiotherapy, there is little compulsion to “professionalise” many of the therapies and the majority remain largely unregulated. It can, however, be difficult for midwives, doctors and birth workers to identify how or to whom they should refer women seeking complementary therapy services outside the maternity care system. There is certainly a need for greater collaboration and communication between conventional maternity care providers and complementary practitioners, as well as an increased ability to discuss the subject of complementary therapies with pregnant clients (Adams et al. 2011). The NMC requires midwives to work cooperatively with colleagues, respecting their skills and expertise, and referring to others when necessary (NMC 2015: 2.1, 8.2).

It is interesting to note that the NMC also requires midwives to be able, at the point of registration, to “refer appropriately” to complementary therapists (NMC 2009). However, referral to the most appropriate practitioner is a very refined clinical skill which midwives studying limited components of one or two therapies are highly unlikely to be able to do. At the very least, it requires a good working knowledge of each of the numerous individual therapies. Additionally, unless they have personal clinical experience of combining several complementary therapies, they are unlikely to be able to appreciate the potential interactions that can occur when therapies are mixed with one another or with aspects of conventional maternity care. Without adequate understanding of the specific therapy, midwifery referral of a woman to a particular therapy may be inappropriate or, occasionally, unsafe.

Sometimes, midwives with no knowledge of complementary medicine may be sceptical and dismissive or, conversely, may view a therapy as purely for relaxation, with no appreciation of the potential risks associated with inappropriate referral. This is often seen when women seek complementary therapies at term to initiate contractions in order to avoid medical induction of labour. The therapist may request the client to check with her midwife as to whether she can receive the therapy; the midwife, with no understanding, perceives that anything that may help the woman to relax has some benefit and tacitly gives “permission” to the woman, who then returns to her therapist with the notion that the midwife has agreed that it is safe to go ahead. At no point has there been any specific professional, clinical debate and yet both practitioners believe that their indirect communication has sufficed.

It is also important to advise the woman not to engage in “therapy shopping” in which she seeks one therapy (or therapist) after another, nor that she combines several therapies at the same time, unless a combination strategy is advocated by a single therapist. Any therapy takes time to take effect, especially if the clinical picture of the woman’s condition is complex. There is often a healing reaction (see Chapter 1), and the practitioner needs to differentiate these from potential adverse effects of the therapy or, indeed, from an unrelated complication of the pregnancy. This particularly applies to therapies such as homeopathy, which treats the “whole person” but which can take time to resolve the symptoms fully, first producing the normal homeopathic aggravations which can be misconstrued by the uninitiated as side effects or complications of the treatment (Stub, Alraek and Salamonsen 2012).

Complementary practitioners also need to consider when and to whom referrals of their pregnant clients become necessary. Their role in maternity care is to supplement the care provided by members of the conventional maternity services, either midwives or doctors; they are not, by law in the UK, permitted to take on the sole provision of care during pregnancy and birth. Practitioners should be aware of the reasons not to treat potential clients (often referred to as “red flags”; see Chapter 1), or to discontinue or suspend treatment of current clients. If there is any cause for concern, the therapist should either advise the woman to contact her midwife or doctor, or make the initial contact themselves, by telephone or email, depending on the severity of the situation. In an acute emergency, the therapist should call an ambulance.

Midwives implementing complementary therapy services in conventional maternity care

The increased use of complementary therapies by pregnant and childbearing women has resulted in midwives wishing to introduce aspects of complementary therapy into their own practice, and many maternity units now offer aromatherapy, acupuncture, “hypnobirthing” or moxibustion. However, it is paramount that midwives implement complementary therapies within the framework of the NHS and their NMC registration, taking into account national directives and recommendations such as NICE, local limitations and even international law. There needs to be adequate rationalisation and justification for the introduction of a therapy, based on clinical need, patient demand and satisfaction and financial and practical considerations. The first priority is to the safety of women and babies, and the justification for any new initiatives must be based around this in order to offer complementary therapies in a safe and compassionate way.

It is essential to develop clinical guidelines to support those midwives who will be providing the service and to protect mothers and babies. These may also need to be cross-referenced to other clinical guidelines, in order to alert other caregivers to their use. For example, a guideline on moxibustion should be cross-referenced to the one on management of breech presentation; an aromatherapy guideline should be linked to those on intrapartum care, epidural anaesthesia and Caesarean section. Where a unit provides more than one complementary therapy, it is wise to develop just a single clinical guideline. For example, if aromatherapy, massage and reflexology are provided, it would be preferable to have one guideline with general issues such as training, indications, contraindications and precautions, followed by specific points for each therapy. This avoids repetition and prevents the inappropriate predominance of clinical guidelines on complementary therapies, possibly at the expense of others. Box 3.1 provides a summary of points to include in a clinical guideline for complementary therapies and gives guidance on the issues to be considered when implementing one or more complementary therapies into conventional midwifery practice.

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