Complementary therapies in pregnancy: a means to reduce ill health and improve well-being?

Recently, the Journal of Infant Psychology published a consensus statement detailing research objectives relating to measurement of well-being and psychological health in pregnancy (Alderdice et al., 2013). It was agreed among the authors that a paradigm shift is needed, with the emphasis of perinatal research not being purely to assess and treat negative symptomatology, but also to examine how we can improve the experience of pregnancy for all women. The use of complementary medicine requires a similar shift. From a funding body’s perspective, it may be difficult to justify expenditure on intervention studies aimed to promote well-being if they are unlikely to have a demonstrative impact on any adverse health outcome. Numerous psychosocial therapies have been developed to target and change maladaptive attitudes and cognitions; however, these may not apply to pregnant women considered ‘healthy’ where such thoughts are mostly absent. Complementary and alternative medications (CAMs) may provide an attractive solution as they may help to reduce ‘ill health’, and evidence highlights their beneficial value in low-risk pregnant women (Marc et al., 2011).

Defining’ complementary or alternative medicine’

The National Center for Complementary and Alternative Medicine (NCCAM) is the leading agency for scientific research of CAMs within the US Department of Health and Human Services and their definitions are used globally to define CAM (http://nccam.nih.gov/). While ‘complementary’ and ‘alternative’ are often used interchangeably, ‘complementary’ typically refers to a non-mainstream treatment used in conjunction with standard treatment, whereas ‘alternative’ refers to a treatment used in replacement of standard treatment. Thus, CAM therapies may be used as adjunctive therapies for serious mental health disorders or sole treatment where, for example, pregnant women feel they do not require specialist medical intervention. CAM therapies are further divided as involving natural products, such as aromatherapy and dietary supplements, and practices affecting mind and body, such as massage, hypnotherapy and yoga.

Which pregnant women may benefit from CAM?

The costing model of the National Institute for Health and Clinical Excellence guidelines for Antenatal and Postnatal Mental Health (NICE, 2007) reported that providing treatment to pregnant women with subthreshold (or mild-to-moderate) anxiety and/or depression symptoms was one of the recommendations that would have the most significant resource impact but was not considered one of the key priorities. This model also estimated that approximately 50% of women with subthreshold symptoms would be detected and offered treatment, with approximately 50% of these accepting such an offer of brief psychotherapy (e.g. CBT) or social support. A reluctance to engage with treatment may be in part due to perceptions of stigma, as women with mental health issues may report fears of being perceived as an unfit mother, custody concerns, and being undermined as a parent (Jeffrey et al., 2013). Thus, coupling the fears of stigma with the lack of strategic priority and limited treatment options advocated by NICE, women with subthreshold symptoms may be a relatively neglected population with regard to receiving treatment. Subthreshold levels of anxiety and depression during pregnancy have been shown to be quite debilitating and may lead to maladaptive coping strategies (Furber, Garrod, Maloney, Lovell, & McGowan, 2009). Pre-emptive action during pregnancy may be needed as such antenatal symptoms have been shown to be predictive of more severe mental illness postpartum (Skouteris, Wertheim, Rallis, Milgrom, & Paxton, 2009).

Multiple surveys have shown CAM therapies as frequently recommended by health care professionals (HCPs), particularly midwives; and pregnant women have cited greater choice and control of childbearing experiences and greater perceived safety than pharmaceuticals as reasons for adopting CAMs (Hall, Griffiths, & McKenna, 2011). The growing acceptability of CAM therapies by HCPs and pregnant women in treating physical-health concerns may provide a pathway through which women with subthreshold mood symptoms engage with treatment without threat of stigma. However, midwives’ and obstetricians’ knowledge and understanding of the possible risks to women is limited by the public’s enthusiasm for CAM exceeding the scientific evidence base for their use (Marc et al., 2011).

Issues of testing CAM therapies

Systematic reviews frequently report a paucity of randomised controlled trials (RCTs) of CAMs in pregnancy, and studies often suffer from poor methodological quality (Marc et al., 2011). This is often not at the fault of the researcher, but there are inherent difficulties in conducting RCTs of CAMs which include an inability to effectively blind participants, to maintain treatment fidelity and to select suitable comparison groups. Often the inability to blind participants results from public awareness of what the therapy entails and the reputed benefits. In contrast, many psychosocial interventions are quite ambiguous from a lay perspective, and there is potential to blind participants to the active components of an intervention. Treatment fidelity is complicated by many of the CAMs being accessible in the community and it is difficult to stipulate that a participant cannot attend services such as yoga, aquanatal, hypnobirth that are already actively encouraged by HCPs. Selecting suitable comparisons in RCTs is complicated in the context of pregnancy, leaving the undesirable option of providing solely standard care or offering an alternative form of intervention to the comparison group in parallel to the active intervention group. Numerous CAMs incorporate physical postures and movements, relaxation/breathing techniques and social elements (e.g. yoga, pilates, hypnobirthing techniques), and different women may benefit from different components. For instance, Guszkowska, Langwald and Sempolska (2013) reported that relaxation is more beneficial to women with poorer mood symptoms, whereas exercise was better for those experiencing fatigue and decreased energy levels. As CAMs such as yoga incorporate both relaxation and exercise, it would necessitate several comparison groups to control for the different possible benefits (e.g. relaxation-only, exercise-only, social support-only; Newham, Wittkowski, Hurley, Aplin, & Westwood, 2014).

Returning to the issue of CAMs being a possible way of improving well-being, measurement of efficacy may be more complex as while in clinical populations it is possible to identify positive impact changes in mood symptomatology, pregnant women generally show changes in anxiety and depression over time (Newham & Martin, 2013). More appropriate measurement is needed that encompasses the continuum of psychological well-being in pregnancy rather than simply dimensions of the concept (Alderdice et al., 2013; Ayers & Olander, 2013).

In summary, CAMs appear to be potentially useful treatment options for improving psychological health during pregnancy. However, it is important to consider how varied interventions labelled CAM can be and as with any treatment, it is crucial that it is appropriately tested for both efficacy and acceptability. In the same way that a psychiatric drug may not be ideal for everyone with the same disorder, it is important to consider that different CAMs may be suitable for different women.

Dr James Newham, PhD
Research Associate, Institute of Health and Society, Newcastle University, Newcastle, UK