ETHICAL ISSUES

Ethical Issues: Complementary and Alternative Medicine (CAM) Use During Pregnancy Anna Maksimovich 00841057

Submitted in partial fulfillment of the requirements in the course: Nursing 330: Nursing Care of the Childbearing Family Old Dominion University NORFOLK, VA Spring 2013

ETHICAL ISSUES Introduction The use of complementary and alternative medicine (CAM) during pregnancy and labor

is becoming an increasingly popular topic in the Western world, as research suggests that there is ample evidence to prove that these is a widespread use of CAM in Western countries (Adams et al., 2009) and it is known to have been used for many, many centuries in other parts of the world. There appears to be much potential in CAM products and therapies for womens health and wellbeing, including the use of CAM during pregnancy, which has attracted much attention recently. Unfortunately, there is limited documentation on the safety and efficacy of many herbs and other CAM modalities commonly used during pregnancy. Without such evidence, it is difficult for midwives and other healthcare professionals to provide safe advice and proper education. In fact, evidence has found that the most common source of referral for CAM use is friends and family, whereas medical professionals and allied health care practitioners play a relatively insignificant role in the referral of complementary treatment (Adams et al., 2009, p 239). This is why CAM use during pregnancy sparks such a controversy among medical professionals, and can be classified as an ethical issue. What is CAM? The National Centre for Complementary Medicine defines complementary and alternative medicine as diverse health care systems, practices, and products that are not generally considered part of conventional medicine (as cited in Mitchell, 2013, p 100). Mitchell found that the CAM modalities most frequently used are acupuncture, homeopathy, herbalism, osteopathy and chiropractry. Other frequently used CAM therapies include aromatherapy, massage and reflexology (2013). These therapies are going to be implied in the following

ETHICAL ISSUES discussion, as they all fall under the general category of complementary and alternative medicine. The following is a closer look at some of the more commonly used CAM therapies.

In one study, out of 14,115 women, 26 percent were found to have reported using a CAM product at least once during pregnancy. Herbals and homeopathic medicines account for the largest use of CAM in this specific population. The study found that the use of homeopathic medicine, which is included in CAM, increased steadily as pregnancies progressed from the first to second to third trimesters. The three most popular homeopathic products during pregnancy in this study were found to be Arnica tablets and cream (used for labor pain), Ipecac (used for morning sickness), and Calendula (used to reduce pain and swelling). The use of any herbal product (including herbal tea and herbal medicine) was reported by 20 percent of pregnant women, with chamomile, ginger, and peppermint being some of the most commonly used herbs to treat morning sickness (Bishop et al., 2011). This information is important to know, especially for maternal healthcare providers, because it is often not discussed between the provider and the patient. Audience The topic of CAM use during pregnancy addresses mostly women who are pregnant or are planning a pregnancy, as well as their healthcare providers. These can include midwives, obstetricians, labor and delivery nurses, and others who are professionally equipped to work with pregnant women. All of these individuals can benefit from a more in-depth knowledge of CAM and the options available to them in regards to treatment options as well as how the use of CAM will affect their other treatments during pregnancy. They should also be made aware of what is safe and what is not. The healthcare providers can use this knowledge to educate their patients on

ETHICAL ISSUES the risks and benefits of CAM use, and instruct them in making the best possible choices during pregnancy. There are several surveys that show that midwives generally perceive complementary interventions as safe, natural and concurrent with conventional medicine, however, a lack of knowledge on safety of the substances, fear of litigation and lack of acceptance by colleagues, doctors and clients are major concerns that have stopped some midwives from practicing or referring alternative therapies to their patients (Adams et al., 2011). For this reason, midwives are a primary audience that could substantially benefit from increased knowledge on CAM,

including its risk and benefits, which they could then use to educate their clients. Many pregnant women that consult midwives are looking for alternative, natural ways to treat their symptoms and to help them with natural birth, so this knowledge could facilitate better understanding and more confidence in both the midwife and the patient. The Positive Attributes of CAM Complementary and alternative medicine has many positive implications for pregnant women, specifically that it is prepared from all natural ingredients, it boosts patient immunity and strengthens other natural body defenses, and it saves patients from the necessities of medical treatments that are harsh on the body. CAM has also been used much longer than contemporary medicines (people know its history better), and it tends to be more holistic and cost-effective, which is what a lot of patients are looking for. Evidence shows that pregnant women regard complementary and alternative products as more natural and safe when compared with pharmaceutical drugs and also express a greater comfort and confidence with using these medicines as opposed to conventional treatments (Adams, Sibbritt, & Lui, 2011). Most CAM users regard it as more natural, safe, and just as effective as medical prescriptions when used for

ETHICAL ISSUES pregnancy and its related symptoms. Even many maternity care providers agree in considering that CAM is a useful supplement to conventional treatments (Adams et al., 2011).

The effectiveness of CAM appears to be rated highly by a majority of CAM users. Three studies reported that over 75 percent of their participants perceived CAM interventions to be beneficial and/or helpful, and another three reported high rates of participant satisfaction and perceived beneficial effect among various complementary modalities (Adams et al., 2009). Chamomile is an example of a CAM therapy that is commonly used during pregnancy. It has traditionally been taken as an herbal tea to reduce anxiety, aid sleep, and help alleviate gastrointestinal symptoms, and researchers have found that many pregnant women use chamomile for these reasons. They also found that 83 percent of those who take chamomile during pregnancy have found it to help their symptoms (Bishop et al, 2011). Many women also endorsed CAM products or practices because these gave them the opportunity to play a more active role in maintaining their own health. The attitudes expressed suggest an interest in self-care and an appreciation of a holistic approach to health. Feelings of empowerment after using homeopathic remedies were also reported (Adams et al., 2009, p 240). For this reason, health practitioners should be aware that pregnant women are looking to CAM to help them satisfy the desire of being in control of their own health, which could potentially result in some risk taking, as the next section will show. The Negative Attributes of CAM Complementary and alternative medicine use also carries quite a few negative implications that could potentially result in serious consequences for both mother and baby. Certain CAM modalities (especially concurrent to conventional treatments) have raised safety concerns, particularly with respect to the use of these medicines during pregnancy. There is a

ETHICAL ISSUES significant lack of evidence for safety of CAM therapies and health products, moreover, the effects of herbal medicine and over-the-counter medications on fetal development and the possibility of alternativeconventional drug interactions have been reported (Adams, Sibbritt, & Lui, 2011). All of these concerns are magnified when considering that women often do not disclose their use of CAM to their medical practitioners. Many pregnant women also appear to have little knowledge of, or are unable to correctly classify, the complementary and alternative products they consume (Adams, Sibbritt, & Lui, 2011, p 205). In one study by Nordeng and Havnen, 39 percent of participants who consumed herbal medications during pregnancy were found to have used herbal drugs that have been labeled as possibly harmful or have no information on safety at all (as cited by Adams et al., 2009). There are very few studies that explore the safety and efficacy of the use of CAM

products during pregnancy. Ginger is one of the exceptions, and chamomile used in tea at a dose not exceeding two cups per day has also been proven to show no fetal risk. However, chamomile is generally not recommended in large doses due to lack of safety evidence and potential for fetal harmthe same goes for peppermint, echinacea, and many other herbal products that are used for medicinal purposes (Holst et al, 2011). There is simply not enough support in the literature to prove that these remedies are safe or efficient, so taking them without that knowledge may not be worth the risk. It should also be noted that makers of herbal supplements do not have to get approval from the Food and Drug Administration before putting their products on the market, so any herbal remedies are always taken with a risk. Summary There are many different views and attitudes that surround complementary and alternative medicine and in particular its use during pregnancy. Healthcare providers in maternity

ETHICAL ISSUES care have been found to remain mostly positive about the use of CAM, however, there is still a substantial divergence of attitude towards alternative treatment for pregnancy between and within professions. Evidence still shows that midwives have a more positive view of complementary medicine, while obstetricians are not fully convinced of the efficacy of CAM methods, pointing towards the placebo effect as an explanation of positive efficacy results (Adams et al., 2011). Such a divergence of opinion may confuse patients and lead them to seek the opinions of their friends and family members, who may or may not give them sound, knowledgeable, evidence-based advice. It is the responsibility of the healthcare providers to be able to prevent this from happening by tackling the issue and creating evidence for practice, so that their patients can be comfortable knowing that their safety comes first and that their practitioners are well informed. CAM has been used in the past and can continue to be used in the future, given that more

evidence is available and that practitioners are offering guidance based on their knowledge of all treatment options.

ETHICAL ISSUES References Adams, J., Chi-Wai, L., Sibbritt, D., Broom, A., Wardle, J., & Homer, C. (2011). Attitudes and referral practices of maternity care professionals with regard to complementary and alternative medicine: an integrative review. Journal Of Advanced Nursing, 67(3), 472483. doi:10.1111/j.1365-2648.2010.05510.x Adams, J., Lui, C., Sibbritt, D., Broom, A., Wardle, J., Homer, C., & Beck, S. (2009). Women's

use of complementary and alternative medicine during pregnancy: a critical review of the literature. Birth: Issues In Perinatal Care, 36(3), 237-245. doi:10.1111/j.1523536X.2009.00328.x Adams, J., Sibbritt, D., & Lui, C. (2011). The Use of Complementary and Alternative Medicine During Pregnancy: A Longitudinal Study of Australian Women. Birth: Issues In Perinatal Care, 38(3), 200-206. doi:10.1111/j.1523-536X.2011.00480.x Bishop, J., Northstone, K., Green, J., & Thompson, E. (2011). The use of Complementary and Alternative Medicine in pregnancy: Data from the Avon Longitudinal Study of Parents and Children (ALSPAC). Complementary Therapies In Medicine, 19(6), 303-310. Holst, L., Wright, D., Haavik, S., & Nordeng, H. (2011). Safety and efficacy of herbal remedies in obstetricsreview and clinical implications. Midwifery, 27(1), 80-86. doi:10.1016/j.midw.2009.05.010 Mitchell, M. (2013). Women's use of complementary and alternative medicine in pregnancy: A journey to normal birth. British Journal Of Midwifery, 21(2), 100-106.

ETHICAL ISSUES

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Anna Maksimovich 4/30/13