In a single tertiary care center on the East Coast of the United States, Complementary and Alternative Medicine is used commonly by women during their pregnancies, with 68.5% of women surveyed in 2013 reporting that they used at least one type of CAM. This prevalence closely matches those reported in the UK (57.1%), Switzerland (69%), Australia (50%), and Germany (50.7%) [7, 13–15]. In spite of similarities in prevalence of CAM use, the types of therapies used by women in each country vary greatly [16]. In 2013, the top five most common types of CAM therapies used in our population were prayer; supplements; yoga, meditation, and imagery; massage; and music, art, and dance therapy. These are similar to the top four CAM therapies used in the UK (vitamins, massage, yoga, and relaxation) [15], but fairly different from the top three CAM therapies reported in Germany (homeopathy, acupuncture, and massage) [7]. Just as overall rates of CAM use in our population stayed around two-thirds between 2006 and 2013, the therapies participants used also remained very similar. Three of the top five CAM therapies used in both years were Mind-body interventions with low potential for adverse effects.
We also found minimal differences in the frequency and type of CAM used between NICU and WBN participants. One significant difference was the higher use of spiritual healing, prayer, and homeopathy/naturopathy in NICU participants. There is evidence to suggest that people experiencing certain health problems are more likely to use CAM [17]. This could also hold true for women when it becomes apparent during pregnancy that their infant may have to spend time in the NICU. Unfortunately we were not able to separate the NICU participants who knew about complications beforehand from the participants whose infants had an unexpected NICU admission.
CAM use in pregnant women is associated with primiparous older women of higher education and income who have physical health problems and previous complementary medicine use [16]. When we analyzed these variables, as well as other factors, we found multiple statistically significant relationships. However, it is important to note that these statistically significant factors are not good enough predictors of CAM use to be useful clinically. This inability to accurately predict CAM use by these demographic variables emphasizes that “consumers of complementary and alternative products or services are far from a homogeneous group with similar beliefs, motivations, and needs” [16]. Because the group of women who use CAM is so diverse, communication about CAM becomes all the more important. Obstetrical providers cannot rely on demographic information to accurately predict who is using CAM; instead, they must specifically ask their patients about it if they want reliable information.
Although it is difficult to predict which patients are using CAM therapies, common trends help explain why CAM is used. In our study population, most participants who used CAM made that decision because they “felt it would improve their health and experience” or because they “felt it would be beneficial to their baby.” This evidence supports the concept of a “risk society [18],” in which growing CAM use could be a sign of “a desire for personal fulfillment and need for autonomy and active participation in healthcare during pregnancy and childbirth” [19]. CAM could provide women with an opportunity, often thought of as risk free, to have a positive effect on both themselves and their infants. However, the desire to use CAM is not just limited to pregnancy. The majority of participants said they used CAM during their pregnancies because they had used it previously. Finally, a relatively small number of participants, 1% in 2006 and 10% in 2013, stated they used CAM because they were unhappy with conventional medicine. This shows providers that CAM use should not be seen as an expression of dissatisfaction, but rather may be something that patients value along with conventional medicine [20]. Even so, because there was a rise in dissatisfaction between the two time periods, investigating explanations for this increase would be a good area for future research.
In the 2013 study, we found that the obstetrical provider knew about CAM use 60.8% of the time. This is similar to the rates found in the UK [15]. It is also comparable to the 20-77% of US cancer patients who disclosed their CAM use to doctors [21], and to the two-thirds of US Hispanic women who disclosed information about supplement use to their physicians [22]. Our study shows that there has been a substantial increase in the reporting of CAM use to obstetrical providers between 2006 and 2013, despite a lack of reported change in the participants’ comfort asking or providing information about CAM. This increase in provider knowledge between the two time periods could be the result of providers becoming more aware of how common CAM use is. Seven years ago, providers may not have directly asked questions about CAM use; and without the provider asking about it specifically, the patient may have never thought to disclose it. Nevertheless, even with this remarkable improvement in CAM use disclosure over the seven year time gap, it is important to recognize that half of the participants’ CAM use still is not known by their providers.
There were significant variations in the likelihood that participants would share their CAM use with providers. Supplements, the second most commonly used CAM therapy, were most likely to be disclosed, while prayer, the most common CAM therapy, was one of the least likely to be shared. This may reflect the perception that supplements are well-received by the medical field, which may make patients more comfortable and willing to share the information with their providers. This trend is a positive finding since some supplements have been associated with adverse effects [10]. Conversely, prayer, which has not been associated with negative health effects, is often associated with a person’s religious beliefs and may not be perceived as something that needs to be discussed with providers. Nonetheless, having knowledge about the practices and beliefs of the mother and family is still valuable, especially in the event of complications for the mother or infant.
When a conversation about CAM use does take place, participants perceived their obstetrical providers’ responses as largely positive. The two reported perceived negative responses were toward osteopathic manipulation and qigong, tai chi, and reiki. Since we did not ask the corresponding obstetricians about their attitudes toward CAM, it is impossible to assess whether this accurately reflects the provider’s actual attitude. In Australian and Israeli studies where obstetricians were asked directly about their attitudes toward CAM use, they too found favorable responses from providers [23, 24]. As was discussed previously, different types of CAM therapies have a wide range of risk profiles. Assuming that the CAM used was not harmful to the mother or fetus, the provider’s positive or neutral responses to CAM use can be viewed as beneficial to the provider-patient relationship. They may increase the patient’s willingness to share other information and put the patient more at ease with the provider.
Although obstetrical providers were largely receptive to disclosures of CAM use, they only recommended CAM therapies 15% of the time, while family and friends recommended them almost three-quarters of the time. This dynamic was echoed in studies which found that many people relied on advice from non-healthcare providers, such as friends and relatives, when deciding to use CAM [7, 25]. In our patient population, we also looked at whether CAM therapies were more likely to be recommended to patients who had a midwife on their obstetrical team, but the relationship was not statistically significant.
Although the participants perceived little trouble with the safety of the CAM they used, this confidence in CAM safety may be misguided. No harmful effects have been linked to mind-body CAM interventions, such as yoga, hypnotherapy, and imagery [9]. However, the effects of herbal preparations during pregnancy have not been well measured and have been linked to adverse events [10]. In our population, we found that supplement use was more common in the WBN than in the NICU. It is possible the use of this type of CAM does not lead to an increased likelihood that the infant will need admission to the NICU. However, our study was not powered to look at that difference. Since the exact risks associated with CAM use are often unknown, especially in the cases of some Alternative Medicine practices, Biologic-based therapies, and Manipulative and Body-based methods, it is prudent for women to use CAM only if the “benefit is clearly greater than the potential fetal risk” [26].
Weighing benefit with fetal risk may not just be useful when making decisions about CAM use, but also for making decisions about the safety of other medications with little safety data during pregnancy [10]. With around 80% of participants using OTC medication and over half using prescription medication, it is important that the safety and efficacy of these medications is established and that pregnant women are educated about possible risks.
Some limitations to this study include the cross-sectional design, exclusion criteria, sample population, small sample size, and demographic differences between the 2006 and 2013 populations. We excluded post-partum women whose infants died within 24 hours of delivery, women with limited English proficiency (LEP), and women under the age of 18. This may have altered our results, especially in the case of women with LEP, who may have had high levels of cultural CAM use. Because this was a single, large Mid-Atlantic center, these findings may only be generalizable to areas of the United States with demographics similar to this region. Finally, using a larger sample size could have allowed more detailed analysis of relationships between CAM use in the NICU and WBN and between people using specific types of CAM therapies. Future research could address these limitations by doing a multicenter evaluation with better matched groups and analyzing the data using sub-group stratification by different maternal attitudes and demographic characteristics. Future studies should also be done to investigate the safety and efficacy of CAM during pregnancy, the effects of communication about CAM on the provider-patient relationship, the possible relationship between pregnancy complications and when CAM use is initiated, and the increase in dissatisfaction with conventional medicine found between 2006 and 2013.
