Introduction

Complementary therapies (CTs) are increasingly popular with both consumers and professionals and are based on a philosophy of holism and an interaction between body, mind and spirit in which it is believed that all components in combination contribute to the whole. Within midwifery, use of CTs has been driven by mothers looking for strategies to help them cope with pregnancy and labour discomforts and to aid relaxation. It is thought that as many as three quarters of women may self-administer substances such as herbal, homeopathic, aromatherapy or Bach flower remedies (Refuerzo et al 2005), and it has previously been estimated that over a third of midwives use CTs in their practice (NHS Confederation 1997), although this figure is likely to have been exceeded in the last few years.

Classification of complementary therapies

There are in excess of 200 therapies considered complementary – or perhaps, alternative – to mainstream healthcare, the top 20 or so most commonly in use in Britain being classified by the House of Lords (2000) into three main groups.

Group 1 therapies are professionally organized, complete systems of healthcare with national standards of education, statutory or voluntary self-regulation, disciplinary codes of practice and a reasonable body of research evidence.

Osteopathy has been statutorily regulated since 1993 by the General Osteopathic Council and is based on the principle that misalignments of the neuro-musculoskeletal system adversely affect homeostasis; treatment aims to re-align and re-balance the whole person. Craniosacral therapy, or cranial osteopathy, a branch of osteopathy, uses gentle manipulation of the bones of the skull, meningeal membranes and nerve endings in the scalp to re-balance the cranial rhythmic impulse, running throughout the body, and has been used effectively to treat infants with colic (Hayden & Mullinger 2006).

Chiropractic has been statutorily regulated since 1994 by the General Chiropractic Council and is similar to osteopathy. The main difference is that osteopaths are concerned with mobility of joints whereas chiropractors deal with relative positions of joints. Different manipulative techniques are used and many chiropractors use more X-rays to aid diagnosis (although not during pregnancy). Osteopaths also use more soft tissue massage prior to manipulation than chiropractors. Both osteopathy and chiropractic can be useful techniques for pregnant women with musculoskeletal problems such as backache, sciatica, symphysis pubis discomfort and carpal tunnel syndrome, as well as soft tissue disorders including hyperemesis, heartburn, indigestion and constipation (Lisi 2006, Wang et al 2005). In addition, obstetric conditions such as breech presentation are thought by these practitioners to result from misalignment of the spine and bony pelvis, causing an accentuated angle of inclination of the pelvic brim, which may be corrected with either osteopathy or chiropractic.

Acupuncture, regulated by the British Acupuncture Council (BAcC), works on the principle that the body has energy lines (meridians) running through it which pass through a major organ, after which they take their name, e.g. Bladder meridian, Kidney meridian, linking one part of the body to another. In optimum health, the energy flows freely around the body, but physical, mental, emotional or spiritual disorder causes blockages or excesses of energy. Acupuncture, the insertion of needles, attempts to correct this imbalance. Sometimes thumb pressure is applied to the points (acupressure); on other occasions, heat is used to stimulate deficient energy via moxa sticks (see moxibustion for breech presentation) or suction can be used to draw out excess energy by covering the points with special cups (cupping). Acupuncture needles may also be stimulated with mild electrical pulsations, similar to transcutaneous nerve stimulation. Certain points are contraindicated antenatally as they may trigger contractions, but acupuncture can be used to treat many pregnancy conditions including hyperemesis, backache and varicosities, while intrapartum use may facilitate progress and ease pain, anxiety and tension.

Herbal medicine: Most practitioners are registered with the National Institute of Medical Herbalists (NIMH) or the European Herbal Practitioners’ Association (EHPA). Herbal medicine involves the therapeutic use of plants in various forms, which work pharmacologically. There is a common misconception that because herbal remedies are natural they are automatically safe but there is now a growing body of evidence about the risks of possible interactions between herbal and conventional medicines. Many herbal remedies should be avoided during the preconception and antenatal periods and when breastfeeding, because they may induce uterine bleeding or other systemic effects on the mother or because fetal effects are unknown, e.g. St John’s wort, blue cohosh and kava kava, and others which should be used with caution, including raspberry leaf (Tiran 2003a, 2005a) (see Box 50.1).

Homeopathy: Homeopathy is not the same as herbal medicine but is a form of ‘energy’ medicine which uses minute, highly diluted doses of substances that, if given in the full dose, would actually cause the symptoms being treated. For example, a highly diluted form of arsenic is used to treat certain types of severe vomiting and diarrhoea, yet ingesting arsenic could actually cause these symptoms. Most homeopathic medicines are in tablet form but do not work pharmacologically and will not interact with prescribed drugs, although certain drugs may inactivate the homeopathic remedies, since they are chemically fragile. Homeopathy treats the whole person and takes into account the personality of the individual, as well as any factors which increase or reduce the symptoms. It is not however, completely ‘harmless’ since it can be very powerful; inappropriate or prolonged use of an incorrect remedy can cause a ‘reverse proving’ in which the person starts to develop the symptoms for which the remedy is intended. It is therefore important to inform women how to take homeopathic remedies correctly (Box 50.2). Medically-qualified homeopaths are registered with the Faculty of Homeopathy; lay or classical homeopaths are primarily registered with the Society of Homeopaths.

Group 2 therapies are complementary or supportive to other healthcare, with less available evidence; many therapies are in the process of regulatory development but it is not yet mandatory to be nationally regulated; most organizations have chosen voluntary self-regulation. Many group 2 therapies are practised by midwives, nurses and physiotherapists, as they lend themselves to incorporation alongside conventional care, but these therapies are not normally classified as discrete systems of treatment.

Aromatherapy, regulated by the Aromatherapy Council, involves the use of highly concentrated plant essential oils administered via the skin (massage, water or compresses), via the respiratory tract (inhalations and vaporizers), via mucous membranes (pessaries and suppositories) and, occasionally, via the gastrointestinal tract (orally). Clinical aromatherapy combines the therapeutic properties of the oils’ chemical constituents with mood-enhancing effects of the aromas and relaxation effects of the administration method, particularly massage. Essential oil molecules enter the body when the aromas are inhaled, reaching the limbic centre in the brain, the circulation and major organs: this is important to remember when essential oils are used in the maternity unit, as all people exposed to the aromas will be inhaling the chemicals and could, theoretically, be adversely affected, e.g. pregnant staff or epileptic relatives. All essential oils act in the same way as pharmaceutical drugs, being absorbed, metabolized and excreted via similar biochemical pathways, and may therefore theoretically interact with prescribed medications. Essential oils are largely assumed to be safe in pregnancy because there is no real evidence to the contrary, but midwives should continue to be cautious when advising expectant mothers about their uses (Tiran 2007). Inappropriate or inaccurate use may cause dermal irritation, photosensitivity, or changes in blood pressure, temperature or fluid balance. There are many oils which should not be used in pregnancy, although some may be used in labour and postnatally (see Tiran 2000, 2004a). Essential oils should not be used on neonates: the universal antibacterial action of essential oils may adversely affect the baby’s extrauterine immunological development, the aromas may interfere with the mother–infant ‘bonding’ process which relies partly on odour recognition and some chemical constituents may cause skin irritation. Antenatal aromatherapy treatments can aid relaxation, thereby reducing the possible adverse effects of maternal anxiety on the fetus (Bastard & Tiran 2006).

Reflexology/reflex zone therapy involves precise pressure point manipulation, sedation and stimulation and is based on the principle that one small part of the body represents a map of the whole, such as the feet, hands, back, face, tongue or ear; it is not simply foot massage. Reflexology is widely thought to work via acupuncture meridians, although there are several other theories regarding its mechanism of action, and the zones may have a part to play in facilitating identification of changing physiopathology, aiding diagnosis (Tiran & Chummun 2005). Reflexology is a powerful therapy that can be very effective when used appropriately, but there are some contraindications, precautions and possible side-effects and complications of treatment (see Tiran 2002). Pregnant women often have very rapid and very profound reactions to reflexology so midwives should advise women to consult practitioners who have relevant training and experience to treat expectant mothers. Small scale research studies suggest it may be useful towards term to improve labour outcomes, and for oedematous ankles (McNeill et al 2006, Mollart 2003). Reflexology is not yet formally regulated.

Massage is the applied use of touch – there are many different forms, including traditional Swedish massage, lymphatic drainage, Hawaian lomi lomi and specific deep techniques, such as Rolfing. It is not yet formally regulated. Massage has been shown to be very relaxing, reducing blood pressure and increasing excretory processes, however it is also not without risks (Box 50.3). In labour it assists in reducing pain, aiding relaxation and easing fear and tension (Chang et al 2006, McNabb et al 2006).

Shiatsu is a Japanese variation of acupressure which originated in the 1950s. It utilizes the same meridians as acupuncture and focuses on re-establishing internal energy or ‘Ki’. Shiatsu is very relaxing, helping to relieve anxiety, tension and pain in pregnancy and childbirth and useful for headaches, sickness, insomnia and depression. The therapy is not yet formally regulated.

Hypnotherapy/hypnosis uses advanced ‘day dreaming’ and deep relaxation, incorporating techniques relating to inner consciousness to heal core causes of problems in life such as habitual behaviour. It has been successfully used to reduce pain in labour, termination of pregnancy and infertility treatment (Cyna et al 2006, Levitas et al 2006, Marc et al 2007). Note: Some methods of maternity hypnotherapy are referred to by trade names which are almost synonymous with the concept of childbirth hypnosis, in the same way that Hoover™ has become synonymous with ‘vacuum cleaner’; it is important for midwives to use the generic terms ‘hypnosis’ or ‘hypnotherapy’ when advising mothers, unless they can vouch for a particular commercial method from professional experience.

Bach flower remedies encompass the healing properties of flowers used to treat disease by relieving mental and emotional symptoms thought to be its cause. Rescue Remedy is a universal anti-stress remedy and is safe to take in pregnancy, although studies of its effectiveness have been inconclusive (Armstrong & Ernst 2001, Pintov et al 2005, Walach et al 2001).

Other therapies in Group 2 include yoga, which focuses on harmony between the mind and body using movement, breath, posture, relaxation and meditation; Reiki, an holistic form of non-touch ‘laying on of hands’; the Alexander technique, which involves adjustment and correction of habitually misaligned body posture, to relieve muscle tension and allow the body to move with greater ease and efficiency; nutritional therapies and stress management.

Group 3 therapies are alternative, largely unregulated therapies with little or no body of evidence, divided into two sub-groups:

Group 3a – traditional systems, e.g. Traditional Chinese Medicine (TCM), Indian Ayurvedic medicine, Tibetan medicine, Japanese kampo, anthroposophical medicine, naturopathy

Group 3b – diagnostic therapies, e.g. crystal therapy, dowsing, iridology, kinesiology, radionics.

It is not the intention of this chapter to discuss these therapies as they currently have little or no direct application or evidence base in relation to maternity care; interested readers are referred to the sources of further reading and resources at the end of the chapter.

Use of complementary therapies in maternity care

Women are the most frequent users of complementary therapies and it is natural that they should wish to continue to use different therapies once pregnant (Thomas et al 2001), although many do so without informing their midwife or doctor (Ranzini et al 2001). It would be wise for midwives to ask routinely, at booking, if the mother is using any complementary therapies or self-administering any natural remedies, in the same way as enquiring about use of prescribed and over-the-counter drugs. Expectant mothers are keen to use complementary therapies because they provide a range of additional strategies for dealing with symptoms of pregnancy at a time when drugs are largely contraindicated, especially since physiological discomforts are often dismissed by the medical profession as ‘minor disorders’. Also, many women wish to achieve as natural a birth as possible without recourse to drugs for pain relief in labour and some may request the presence of a complementary practitioner at the birth. Demand for and interest in natural remedies is high and their use may empower mothers to retain control of their bodies. General dissatisfaction with many aspects of conventional maternity care and its dependence on technology, the continuing ‘conveyor belt’ approach to antenatal care, lack of time to individualize care and staff shortages often prevent the allocation of quality interactions with each mother for the provision of holistic care.

The integration of CTs into midwifery is well publicized (Ager 2002, Mousley 2005, Tiran 2001) and there is an increasing body of CTs research-specific to maternity care (Burns et al 2000, Ingram et al 2005, McNabb et al 2006) although the National Centre for Health and Clinical Excellence (NICE) has so far failed to recognize this and has recommended that women should be actively discouraged from using natural remedies during pregnancy (National Collaborating Centre 2003), even though many will do so despite professional advice to the contrary, possibly compromising maternal or fetal well-being (Tiran 2005c).

Complementary therapies for pregnancy and childbirth

Nausea and vomiting

Ginger is a well-known traditional herbal remedy for sickness and there is considerable research to demonstrate that it is an effective antiemetic (Jewell & Young 2003, Vutyavanich et al 2001, Willetts et al 2003), although other studies have disputed these claims (Arfeen et al 1995, Visalyaputra et al 1998). However, ginger is not suitable or safe for all women and may exacerbate nausea and cause heartburn (see Box 50-5). Ginger biscuits, an almost universal ‘tip’, should not be advised as any temporary improvement in nausea is attributable to the sugar, since there is insufficient ginger for any real therapeutic effect; furthermore, the sugar is likely to trigger peaks and troughs in serum glucose levels, making symptoms worse. There is increasing professional concern over the safety of herbal remedies in general (Marcus & Snodgrass 2005) and ginger in particular (Portnoi et al 2003, Tiran & Budd 2005), especially in relation to its effects on clotting times. Women who require ginger continuously for more than 3 weeks should be advised to request an investigation of blood clotting factors; those on prescribed medications, notably anticoagulants, anti-hypertensives and non-steroidal antiinflammatories should avoid ginger. An alternative remedy to ginger is peppermint, although this should not be taken by those with cardiac disease, epilepsy or concomitantly with homeopathic remedies.

Box 50.5 Case scenario 2: A little knowledge is a dangerous thing

The complementary therapy (CT) midwife saw Jean in her clinic for the treatment of severe nausea and vomiting persisting to 19 weeks’ gestation. Jean knew about certain possible natural remedies for the problem and had thought that ginger may help, but found that this had made the sickness worse. The CT midwife advised her about acupressure to the PC-6 point. However, the midwife was horrified when Jean said that her sister had told her about the acupuncture point in the webbing between forefinger and thumb (LI-4 point) – and started to demonstrate by stimulating the point vigorously. Jean was unaware of the fact that stimulation of this point could potentially trigger uterine contractions and also, like most women, had not known that ginger may exacerbate sickness if used inappropriately.

Certain homeopathic remedies may be effective but need to be prescribed according to the precise symptoms of the individual mother. Examples include nux vomica, for women whose symptoms are worse in the morning and who tend to be ‘workaholics’; ipecacuanha in severe cases with incessant vomiting and heartburn; cocculus, the remedy of choice when nausea is made worse by movement; colchicum for women who feel nauseated by odours; and pulsatilla for those whose symptoms and moods keep changing. There is no real evidence for the effectiveness of homeopathic remedies for nausea and vomiting in pregnancy, but anecdotal reports suggest that, when the remedies are prescribed appropriately, they do produce positive results, although whether or not this is a placebo effect is difficult to ascertain.

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Many women are familiar with travel sickness wristbands, which work on the Pericardium 6 (PC6) acupressure point on the wrist. The PC-6 point is found by measuring, with the mother’s own fingers, three fingers’ width up from the inner wrist crease where the hand joins the arm, approximately where the buckle of a watch strap might rest (Fig. 50.1). The point is between the tendons and there should be a slight dip and some sensation of tenderness or bruising when the point is pressed, which is worse the more severe the sickness. The bands should be placed on both wrists prior to rising in the morning and should remain in position for the duration of the symptoms. This is a simple means of relieving sickness for many women, but acupuncture can also be effective; a qualified acupuncturist would take into account all imbalances within the body and may need to work on additional points, for example those on the Stomach, Spleen or Conception Vessel meridians. There are numerous research studies which have shown that P6 acupressure and/or acupuncture can be effective for reducing or eliminating nausea and vomiting, not only in pregnancy but also for sickness of other aetiology. For a comprehensive exploration of complementary therapies for nausea and vomiting in pregnancy, see Tiran 2003b.

Figure 50.1 Diagram to show how to locate Pericardium 6 acupressure point. Use mother’s own fingers to measure three finger widths up from the crease where the hand and the wrist meet, between the tendons on the inner wrist.

Use of complementary therapies for labour

CTs offer an excellent adjunct to the midwife’s normal labour care, with the nurturing therapies such as massage, aromatherapy and reflexology really coming into their own. One of the largest studies in aromatherapy was undertaken by midwives at the John Radcliffe Hospital, Oxford over a 9-year period, where they used 12 essential oils on self-selected labouring women, for pain relief, to ease fear and anxiety, facilitate uterine action and reduce nausea (Burns et al 2000). Although this was not a randomized controlled trial and, as such, has been excluded from the NICE guidelines on caring for women in normal labour (NICE 2006), over 8000 women received intrapartum aromatherapy; results showed a reduction in analgesia use, increased maternal and staff satisfaction and a <1% incidence of side-effects. A more recent pilot study on the neuro-physiological effects of massage on pain in labour (McNabb et al 2006) has shown promising results and a full scale trial is pending (Kimber, pers comm). Reflexology performed in late pregnancy appears to have positive effects on labour duration and outcome (McNeill et al 2006), although this study lacked rigorous methodology as the sample size was very small and the number of occasions of antenatal reflexology performed on each woman was variable, with some women receiving only one session as late as 39 weeks’ gestation, which in no way can be said to have influenced intrapartum progress.

Acupuncture has been shown to be effective for intrapartum pain relief, reducing analgesia requirements (Kinge 2003, Nesheim et al 2003) and shortening labour duration (Gaudernack et al 2006, Ramnero et al 2002, Skilnand et al 2002); it may, conversely, prolong pregnancy in cases of threatened pre-term labour (Pak et al 2000). Recent research shows promising results for selected acupoints, stimulated either by needling or with the thumbs (acupressure), both for induction and acceleration (Ingram et al 2005, Lee et al 2004, Rabl et al 2001). These points can easily be learnt by midwives and could be incorporated into practice, potentially reducing the use of oxytocics in post-dates women.

Raspberry leaf is a popular herbal remedy long advocated for preparing the uterus for birth. It is thought that certain constituents within the leaves of the raspberry bush affect uterine muscle making it more efficient, possibly preventing postmaturity, easing discomfort in labour and enhancing uterine action. Very little research has been carried out to test this theory; investigations in Australia appear to suggest that women who take raspberry leaf products are less likely to have pre- or post-term gestation, and may be less likely to require ARM, caesarean section, forceps or ventouse delivery than those in control groups (Parsons et al 1999, Simpson et al 2001), although it is acknowledged that further research is necessary. Qualified medical herbalists occasionally use raspberry leaf to treat threatened miscarriage but midwives should advise women not to take it until the third trimester. The tea, made from dried raspberry leaves, is more effective than tablets, although some brands of capsules can be opened to release the dried leaf from within, so that a tea can be made.

There is a current trend among some midwives, who do not have sufficient knowledge to advise women appropriately, to suggest that they delay taking raspberry leaf until 36 or even 37 weeks’ gestation, in the belief that it will prevent pre-term labour, but as it takes time to take effect it should normally be started earlier than this. The remedy is thought to facilitate normal uterine action so in theory it should not over-stimulate the myometrium. However, it could be argued that it is not necessary to take raspberry leaf routinely, especially for multiparae who have had previous normal labours. They should, instead, be advised to allow their bodies to work normally and spontaneously. It is worth remembering that all herbal remedies act pharmacologically, so they may not be ‘harmless’ if used inaccurately or inappropriately. Furthermore, pregnancy and labour are normal physiological events, therefore any herbal preparation used should be viewed as a possibly unnecessary intervention which is simply an alternative to a conventional medical intervention.

Expectant mothers should commence taking raspberry leaf at about 30–32 weeks’ gestation, starting with just one cup of tea or one tablet daily, giving themselves a few days to become accustomed to the effects before increasing the dose, to a maximum of four cups or tablets daily. Occasionally, strong Braxton Hicks contractions occur when taking raspberry leaf and although there is no evidence that these are harmful to the fetus, the mother may experience considerable discomfort and the dose of raspberry leaf should be reduced accordingly. The tea can be drunk during labour, as long as uterine activity is normal and no hypertonic contractions occur; it is best avoided if medical augmentation (e.g. oxytocin) is administered. Any tea or tablets that the mother may have left after the birth can be taken postnatally to aid involution (Box 50.6).

Homeopathic remedies can also be useful in labour, and many women purchase homeopathic ‘birthing kits’ to bring with them into hospital or to use at home. If the midwife is caring for a woman in possession of one of these kits, she should enquire as to her knowledge and previous use of homeopathic remedies. The NMC advises midwives to act as the mother’s advocate and to facilitate those who wish to self-administer natural remedies, but suggests that, in the event of uncertainty as to the appropriateness or safety of a particular remedy, midwives should contact a relevant experienced practitioner and record in the notes if the mother continues to use remedies against advice (NMC 2004). The problem for the midwife is that she may not be aware of the indications for use, nor understand the mechanism of action of homeopathy and will therefore be unable to assess whether or not the proposed remedy is correct (see Box 50.7). The difficulty for the mother in labour is that she may be unable to assess objectively which remedy is required, possibly administering the wrong remedy or continuing to administer a remedy which is no longer relevant, with the risk of a ‘reverse proving’.

Some women appear to believe that homeopathic caulophyllum is suitable for inducing labour (sometimes starting it before the due date in an attempt to expedite delivery (Tiran 2006b). However, inappropriate use of this particular remedy can trigger massive prostin-like contractions in which the mother experiences considerable pain but there is little, if any, cervical dilation and uterine contraction and retraction. Alternatively, if the remedy is used when the mother is in early, but not fully established labour, caulophyllum can cause contractions to stop. There is no evidence from systematic reviews that caulophyllum has any value in initiating labour in the majority of women (Smith 2003), although one reputable placebo-controlled study on intrapartum use of homeopathy suggested that a combination of arnica and bellis perennis may have a positive effect on mild postpartum bleeding (Oberbaum et al 2005).

Postnatal discomforts

Many women are aware of the homeopathic remedy arnica, thought to combat shock, trauma and reduce bruising, available in both tablet and cream form and useful for post-episiotomy discomfort. Although some studies on the effectiveness of arnica have been inconclusive (Hart et al 1997, Ramelet et al 2000, Stevinson et al 2003), there are some promising contemporary results suggesting that it may assist in trauma management (Brinkhaus et al 2006, Seeley et al 2006, Tveiten & Bruset 2003). It can be also used in conjunction with homeopathic hypericum for wound healing, e.g. after caesarean section. Mothers can buy arnica tablets in health stores; the 30C strength is preferable; they should be advised to start the tablets within 1 hr of the birth, and to take 1 tablet 4-hourly for up to 5 days, then stop. If a mother has had an instrumental delivery, she should increase the frequency, taking 1 tablet every 2 hrs for the first 3 days, then 4-hourly for the final 2 days. Arnica cream should not be applied directly to an open wound but is useful if the mother has very bruised buttocks. Homeopathic arnica, in combination with bellis perennis, may be effective for mild postpartum bleeding (Oberbaum et al 2005). Homeopathic remedies do not interfere with breastfeeding, nor do they adversely affect the baby, and indeed, some breastfeeding problems may respond to homeopathy, although the research done to date has been in the veterinary use of remedies such as phytolacca in cows with mastitis (Holmes et al 2005, Varshney & Naresh 2005). Lavender aromatherapy oil may also ease the discomfort of perineal wounds following childbirth (Dale & Cornwell 1994).

Inadequate lactation can be stimulated with reflexology, working on the foot zones corresponding to the breasts and pituitary gland. A simple technique which mothers can do for themselves is to massage firmly between the knuckles of each hand, as this relates to the hand reflexology zones for the breast; there is a theory that women who have an intravenous cannula inserted in the back of the hand could, theoretically, have impaired lactation. However, it is possible that the relaxation effect achieved with reflexology may contribute to facilitating lactation, since it is known that stress adversely affects milk production (Sobrinho et al 2003, Tipping & Mackereth 2000).

Cabbage leaves are well known to midwives as a method of easing breast engorgement, although it is of concern that the majority do not give accurate advice to women, since they fail to understand the mechanism of action and to appreciate that, as a form of herbal remedy, they should have adequate knowledge to advise their use correctly. It is thought that dark green cabbage leaves are the most effective as a chemical in the chlorophyll aids the process of drawing off excess fluid, although one non-English abstract, found when searching the literature, appears to suggest that white cabbage is more effective (Waas 2003). The leaves should be wiped clean, not washed, as this interferes with the process of osmosis, by which they work. Most women prefer to cool them in the refrigerator, simply for comfort, although Roberts et al (1995) found no therapeutic differences between chilled and room temperature leaves. The leaves should be placed inside the brassiere and left until damp, then replaced with new leaves; this process is repeated until relief is obtained. Evidence on effectiveness is inconclusive to date (Nikodem et al 1993, Roberts et al 1998). For those who choose not to breastfeed, there has previously been some suggestion that the application of jasmine flowers could act as a herbal means of suppressing lactation (Shrivastav et al 1988).

Conclusion

It can be seen that there are many complementary therapies, many of which can be applied to the care of pregnant, labouring and postnatal mothers, although they are not always without risk and must be used accurately and appropriately. Midwives must acknowledge women’s wishes to use natural remedies and act as their advocate, while bearing in mind the health and well-being of both mother and fetus/baby. Enquiries should be made about women’s use of CTs and self-administration of natural remedies before and during pregnancy. It is preferable that advice and/or treatment are integrated into the care provided by midwives and others in the conventional maternity services, or by independent therapists who have been adequately trained to treat pregnant women. Some therapies may be incorporated into midwifery practice relatively easily, avoiding the fragmentation that might result from being administered by independent practitioners. CTs enhance the nurturing aspects of midwifery care and may offer potentially less-invasive alternative options for women to help them cope with pregnancy and labour discomforts or to treat specific problems.

Midwifery has, however, become such a diverse profession that maternity complementary medicine (CT) should now be considered a specialist area of expertise, both by midwives and by therapists. It is not feasible for every midwife to have sufficient applied, comprehensive, contemporary evidence-based knowledge on the subject, although an awareness is vital, irrespective of the attitudes and beliefs of the individual. A specialist midwife in each Trust would be able to facilitate the availability of consistent accurate information for mothers and act as a resource for midwives and obstetricians (Tiran 1995, 2007). Complementary medicine can no longer be viewed as an ‘alternative’ but should be accepted as a fundamental and now well-established component of normal maternity care.