Fundamentals of Midwifery: A Textbook for Students (132 page)

311312
Promoting normality and reducing unnecessary intervention
The internet is replete with websites providing information about the use of CAM for pregnancy
and labour. The discourse is largely focused on promoting the use of CAM for relaxation or pain relief, and facilitating a normal birthing experience. Whilst there is a limited scientific evidence base for the effectiveness of many forms of CAM used in pregnancy and labour, there is wide- spread belief and acknowledgement that the incorporation of aspects of CAM into the birthing experience by the attending midwife, in particular, those aspects which are aimed at promoting relaxation, for example, massage therapy and aromatherapy, may be one way in which a midwife can assist women to avoid unnecessary medical intervention, and experience spontaneous vaginal birth. This may account for some of the reported increase in interest in CAM use by pregnant women in the third trimester, identified in the study by Bishop et al. (2011). As some women approach their expected date of birth they may be more engaged in discussions with midwives about the strategies they should adopt to induce labour and to avoid medical inter- vention during labour and birth. It is important that midwives who are advising on, administer- ing, or involved in administering, any form of CAM have the knowledge base, and have achieved the appropriate training requirements of the organisation within which they practice. The 2013 Cochrane review by Sandall et al. (2013), of midwifery-led models of care in developed coun- tries, concluded that women attended by midwives were consistently more likely to labour without major intervention and analgesia and more likely to experience a spontaneous vaginal birth. The results from Cochrane may be used to explore the potential for midwives incorporat- ing CAM into their practice in an attempt to avoid unnecessary intervention and facilitate normal birth.Among the indications given to pregnant women for the use of CAM in maternity care are outlined in Box 14.2.The Information presented in Box 14.2, accessible by pregnant women via the internet and patient leaflets, is often based on a degree of what is called anecdotal evidence. ‘Anecdotes’ are best defined as interesting accounts or stories of an individual’s experience of something, and there are mixed views about the reliability this type of evidence. The National Institute for Health and Care Excellence (NICE) has the responsibility of evaluating the evidence for different NHS treatments, and expresses concern about the validity of anecdotal evidence. Whilst anecdotal
Box 14.2 Indications given to women for the use of CAM in maternity services

To provide relaxation, for the relief of anxiety, fear, tension and stress in pregnancy, labour or early postnatal period.

To offer alternative options for helping mothers to cope with pain and discomfort in late preg-nancy and labour, including contractions, backache, nausea, tiredness and constipation.

To provide additional choice for situations that may require medical intervention or attempt to prevent the need for medical intervention, such as induction of labour.

To aid recovery from birth and adaptation to parenthood, to relieve pain and discomfort,stress and tension in order to facilitate breastfeeding and reduce the impact of postnataldepression.evidence may not have been acquired through rigorous scientific research, there may be ele- ments of truth within the accounts, and sometimes this type of evidence can be a useful point of reference in lieu of more reliable information.When examining the concept of relaxation, it is helpful to consider the mechanisms of the relaxation response, a term first used by Herbert Benson in 1975, in response to observations of physiological changes which occur during transcendental meditation. It is defined as a natural innate protective mechanism which facilitates the removal of harmful effects from stress through changes that decrease heart rate, lower metabolism, decrease rate of breathing, and bring the body back into a healthier balance (Benson and Klipper 2000).Proving‘relaxation’ by scientific means, that is measuring and demonstrating that a relaxation response has occurred, within the context of a scientific research study, is complex and involves the observation of a number of activities. Roche (2011) identifies the following as eliciting the relaxation response:

Your metabolism decreases.

Your heart beats slower and your muscles relax.

Your breathing becomes slower.

Your blood pressure decreases.

Your levels of nitric oxide are increased.At the time of writing this chapter, no evidence could be found of any research studies that have successfully scientifically observed and measured a relaxation response during labour and birth when a form of CAM has been incorporated; therefore at present, the claims of increased measurable relaxation in the context of labour and childbirth can not be substantiated with any other form of evidence other than that of anecdote.It is important to bear in mind that whilst a wide range of pain management methods are available to women during childbirth, including both pharmacological and non-pharmacological interventions, little evidence is currently available which facilitates assessing the effectiveness of CAM. A 2006 Cochrane review of evidence for complementary and alternative therapies for pain management in labour concluded that acupuncture and hypnosis may be beneficial for the management of pain; however, the number of women studied was small. In addition to these findings, the review further concluded that few other complementary therapies have been subjected to rigours scientific study (Smith et al. 2006).
Evidence for the safety and efficacy of CAM
Despite its rising popularity over the last two decades, CAM remains in the margins of NHS care.It is necessary to understand the general state of the CAM evidence base, in order to consider the reasons. CAM has been criticised by some for not having scientific evidence to back its claims, and some CAM practitioners openly admit to not adopting a ‘scientific approach’ to treatment. The scientific approach may be described as a body of techniques for undertaking research investigations. Many conventional medicines have been proven to be safe and effec- tive as a result of a research which has taken a scientific approach, and the use of the ran- domised controlled trials (RCT) is one way in which treatments are tested for their safety and efficacy. An RCT is defined by NICE (2013) as:
. . . A study in which a number of similar people are randomly assigned to two (or more) groups to test a specific drug or treatment. One group (the experimental group) receives the treat- ment being tested; the other (the comparison or control group) receives an alternative
313314
Systematic review of RCTs with or without meta-analysisRCTsCohort studies Case-control studies
Case series Case reports Opinion
Figure 14.1
Hierarchy of evidence. Source: Akobeng 2005, Figure 1, p. 841. Reproduced with permission of the BMJ Publishing Group.
treatment, a dummy treatment (placebo) or no treatment at all. The groups are followed up to see how effective the experimental treatment was. Outcomes are measured at specific times and any difference in response between the groups is assessed statistically. This method is also used to reduce bias . . .
It is recognised that some research designs are better than others in their ability to answer research questions about safety and effectiveness. Akobeng (2005) highlights that this notion gives rise to what is known as a ‘hierarchy of evidence’ (see Figure 14.1).The ranking has an evolutionary order, moving from simple observational methods at the bottom, through to increasingly rigorous methodologies (Akobeng 2005). The RCT is considered to provide the most reliable evidence on the effectiveness of interventions because the pro- cesses used minimise the risk of ‘confounding factors’(aspects of the study situation that distort the association between the intervention and the participants), influencing the results. Evans (2003), states that the findings generated by RCTs are likely to be closer to the true effect than the findings generated by other research methods. RCTs have become the underlying basis for evidence-based medicine (Stolberg et al. 2004); however the relevance of the RCT to CAM research is continually being debated and discussed among researchers, academics and prac- titioners. There is some dissatisfaction of the concept of EBM. Aickin (2010) points out the failing of RCTs are that they focus exclusively on the treatment of groups of patients, and usually dis- courage the extension of findings to subgroups, never recommending extending the findings to individuals.Although many scientists see RCTs as the ultimate analytical tool, RCTs may not fully embrace the CAM philosophy. So, for example, one aspect of the philosophy relies on the fact that the success of the treatment is based upon the positive relationship between the therapist and the individual who is engaging in the treatment. However, the randomisation and control pro- cesses of an RCT will in most cases prevent that relationship being based on an individualised and personal approach. Some CAM practitioners suggest that RCTs cannot do justice to theindividualised, person-centred approach of therapies (House of Lords 2000). Comparative effec- tiveness research (CER) is a method which may be considered more appropriate; the core ques- tion in CER being which treatment works best, for whom, and under what circumstances? However, CER has at present, very limited recognition as a reliable and methodologically rigor- ous research design. Clearly, CAM and research evidence is an evolving area, and there is ongoing debate about the most appropriate research methods for establishing safety and effi- cacy. This controversial absence of a scientific evidence base for the safety and efficacy of those more widely used therapies by childbearing women has the potential to impact upon the mid- wifery role and responsibilities.
The role of the midwife in CAM administration
Whilst there are a wealth of statements within Nursing and Midwifery Council (NMC) documen-tation (NMC 2008; NMC 2012) about midwives’ responsibilities in the context of CAM use, these do’s and don’ts offer very little to midwives in relation to managing difficult discussions with women when they choose to adopt an aspect of CAM into their care which has not been fully recognised and acknowledged as being safe. Maternity Matters (DH, 2007) set out a strategy that placed women and their partners at the centre of maternity provision, with a commitment to women having opportunities to make well-informed decisions about their care throughout pregnancy, birth and postnatally (DH 2007). The legacy of Government policy in relation to choice and decision-making means that midwives should support women and remain commit- ted to maintaining strong, positive relationships, whilst having to negotiate difficult situations, for example, when women make decisions about their care which may not always be the safest or the most sensible. Sometimes, due to the lack of evidence for safety and efficacy of certain CAM treatments, midwives may have to engage in difficult discussions with women and they may feel that they are unprepared for this challenging aspect of their role. The midwife has to somehow find the correct balance between not appearing to be overly authoritative, whilst ensuring that the wellbeing of the woman and the fetus or baby remain central to her role. However, if women feel that they are not full partners in decision-making; this could increase their anxiety during pregnancy and affect how they labour (Hall et al. 2011). It is likely that some midwives encounter anxieties and may feel insufficiently skilled to challenge women if their choices appear to border on being unsuitable in the CAM context. Whilst most midwives aim to provide excellent care; both from a clinical, and a public health perspective, they need to feel empowered to discuss such aspects of care confidently. As a result of the Government pledge to providing women with increased choice and decision-making, there is a growing need for midwives to become confident and equipped with the skills to support women in their choices and expectations; however midwives can often feel under prepared for this aspect of their role. It is important, as a student midwife and a midwife, that the relationship between you and the women in your care, and her partner, remain positive. It is vital that women do not feel inade- quate as a result of these discussions; moreover, the outcome of any discussions such as those mentioned above will be very dependant on good communication and interpersonal skills on behalf of the midwife. Sometimes the involvement of a third party can be helpful, for example a Supervisor of Midwives or a midwifery manager. At all times however, the midwife should be guided by the relative NMC documentation as detailed below.The NMC (2012), state that the system of regulation and registration of complementary therapists in the UK is voluntary self-regulation through the Complementary and Natural Healthcare Council (CNHC). Whilst the CNHC has been set up with Government support to establish and maintain a national register for practitioners, the NMC regulates the
315practice of nurses and midwives who practice complementary and alternative therapies (NMC 2012).The NMC information for midwives practising CAM is clear and concise. Midwives practising CAM are accountable through The Code: standards of conduct, performance and ethics for nurses and midwives (NMC 2008). The NMC urges practitioners to:
Ensure that the use of CAM is safe and in the best interests of those in your care.
(NMC 2008)Furthermore, Standard 23 in the Standards for Medicines Management states that:
Registrants must have successfully undertaken training and be competent to practise the administration of complementary and alternative therapies.
(NMC 2012)
316For those midwives who are not practising CAM, the advice in The Midwives Rule and Stand- ards (NMC 2012) states that: