Recourse to Alternative Medicine During Pregnancy: Motivations of Women and Impact of Research Findings

Abstract

Objectives:

The aims of this study were to gain a better understanding of the motivations of pregnant women utilizing moxibustion for breech presentation and to measure the impact of research results on these patients' treatment decisions regarding this alternative medicine technique.

Design:

The study involved a statistical analysis of two self-administered questionnaires to 212 women who had previously participated in a randomized clinical trial on the efficacy of moxibustion; in addition, a qualitative thematic content analysis for open-ended questions was also performed.

Results:

Most women (69%) reported treating themselves at least once with complementary and alternative medicine (CAM). Higher use of CAM was associated with higher education and Caucasian origin. Pregnancy was associated with a significant reduction in utilization of CAMs. After reading the results of a previous randomized clinical trial, which did not demonstrate efficacy of moxibustion, 60% of the women questioned expressed the intention of resorting to this technique in case of a subsequent pregnancy with a fetus in the breech position. The principal motivation was their desire to try anything that may possibly turn such fetuses to increase the chances of delivering them vaginally.

Conclusions:

It is important to consider the regard that pregnant women attribute to CAMs for self-care strategies. Despite a lack of scientific evidence supporting the use of moxibustion to address breech presentation, pregnant women consider CAMs, in general, to be safe and effective. Studies investigating the physical and psychologic effects of CAMs will enable clinicians to advise patients better about treatment options.

Introduction

A t the 37th week of pregnancy, ∼4% of fetuses are in breech presentation. Management of breech delivery is controversial, but the majority of women with this condition give birth by elective caesarean.^1,2 An external cephalic attempt to correct this fetal malpresentation prior to birth is not an option for all women, can be painful, is potentially risky for the fetus, and has a success rate that only approaches 50%. As such, women look for more-gentle alternatives to treat this complication. Breech presentation is one example of a condition for which complementary and alternative medicine (CAM) treatment, particularly moxibustion, is often considered to encourage fetal turning, thereby increasing the likelihood of a vaginal birth.^3,4 Moxibustion is a technique from Traditional Chinese Medicine (TCM), involving stimulation of acupoints located on the outer corner of the fifth toe with heat generated by a burning stick containing the herb Artemisia vulgaris (mugwort). A randomized clinical trial (RCT) was conducted to evaluate the effectiveness of moxibustion to promote a change of position in breech-presenting fetuses. The results did not demonstrate efficacy according to Western standards.⁵ Despite this, the majority of the women who participated in this RCT responded to a questionnaire evaluating their moxibustion experience by saying that they would undergo this treatment again, and if friends had fetusus in breech position, the study participants would advise their friends to undergo moxibustion. The participants filled out the questionnaire at the time of their last moxibustion session. Thus, they knew their own results of the intervention. This gap between the lack of effectiveness and the satisfaction with the technique was striking.

Utilization of CAMs has constantly increased over the past 2 decades in industrialized societies. Women use CAMs more frequently than men. Louik et al.⁶ found that pregnant women justified CAM use because they perceived CAMs as more natural and less potentially harmful to their fetuses than pharmacologic drugs. Breech presentation is one example of a condition for which CAM treatment is often considered to encourage fetal change of position, thereby increasing the likelihood of a vaginal birth.^3,4 These attitudes regarding CAMs modify consumer links to the conventional medical world. Eisenberg et al.⁷ have encouraged physicians to educate themselves on CAMs to advise their patients on their therapeutic choices better, and to avoid neglecting to suggest certain CAM treatments with demonstrated efficacy.⁸ Focusing more closely on obstetrics, the current authors found that both pregnant women and their caregivers assign CAM to an important place among their health care options.⁹ Despite this, few studies are done to evaluate CAM's efficacy and to understand pregnant women expectations about them better.

The main objective of this study was to measure the impact that learning about the publication of the scientific results of a previous RCT evaluating the effectiveness of moxibustion for correcting breech presentation had on the intentions of the participants to use moxibustion in future cases of breech presentation.

The secondary objective was to understand, 2 years after the end of the RCT, what had motivated pregnant women to participate in the original study and their regrets, or lack thereof, regarding that participation.

Materials and Methods

Two questionnaires were given, at two different times, to the same group of women. The first questionnaire addressed their use of alternative medicines before pregnancy and during the current pregnancy. This questionnaire was given, on the day of randomization, to 212 women who had previously participated in an RCT designed to evaluate the efficacy of moxibustion to induce change of position among breech fetuses.⁵ The questionnaire was comprised of two questions:

(1) “Have you used CAMs outside of pregnancy, and if yes, which ones?”

(2) “Have you used CAMs since the beginning of this pregnancy, and, if yes, which ones?”

Participants completed this questionnaire on the day of trial randomization, and there was a 100% response rate.

Two (2) years after the RCT was completed, these same women were sent the results of this study plus a second questionnaire. The questionnaire was designed to (first) determine the impact of the results (in which the CAM technique moxibustion did not demonstrate efficacy to turn breech into cephalic presentation) on the intentions of these women to use moxibustion in the future in case of new pregnancies with breech presentation, and (second) to understand the motivations of these women for participating in this RCT some years before, and their regrets, or lack thereof, about having participated in that RCT. This questionnaire was comprised of three questions:

1. “Why did you want to participate in this RCT on moxibustion?”

2. “Would you participate in a similar study in the future? Why?”

3. “After reading the results of the study, would you use moxibustion in the future if you were confronted with a case of breech fetal presentation during later pregnancy? Why?”

The first question included six suggestions for motivation to participate in the original study. These suggestions were listed in order of importance. Namely, subjects could have: (1) a desire to participate in medical research; (2) a belief in the potential of TCM; (3) a desire to try everything to make the baby turn and to increase the chance of a natural childbirth; (4) a belief in the potential effectiveness of alternative medicines in general; (5) pressure from personnel at the hospital to participate in the study; and (6) other motivations. There was also an open-ended response section for comments. Questions 2 and 3 included both closed (“yes/no”) and open portions. The ethics committee for Maternity at the University Hospital of Geneva approved the protocol of this research. All women gave their written permission for the data to be used for analysis and publication.

The quantitative results were analyzed with SPSS 18.0 software. The general and obstetric characteristics of women who reported already having used CAMs to treat themselves were compared to the same characteristics of women who had never used CAMs (Table 1). The same comparative variables were used as a function of their answers of “yes” or “no” to questions number 2 and 3 (Tables 2 and 3). To verify representativeness, the sociodemographic and obstetric characteristics were compared for the 114 women who responded to the second questionnaire (2 years after the RCT) with those of the 65 women who did not respond to it. All group differences were tested by chi-square test, and p<0.05 was considered to be statistically significant. Responses to open-ended questions were evaluated by a thematic-content analyses. The written answers from the 114 participants were grouped by question and then read and coded individually by two investigators. A consensus was found in each case of discordance. These results are reported in Table 4.

Table 1.

Characteristics of Women Using CAMs Prior to Study Compared to Those Who Had Never Used CAMs

	Never used CAMs priot to study	Had previously used CAM prior to study (outside of and during pregnancy)
Characteristics	n=65/212 (31%)	n=147/212 (69%)	p-Value
Age 18–30	25 (39%)	44 (30%)	0.2
Age 31–45	40 (61%)	103 (70%)
Primiparas	42 (65%)	97 (66%)	0.8
Multiparas	23 (35%)	50 (34%)
<14 years of education	16 (24%)	15 (10%)	0.02
15–19 years of education	27 (41%)	69 (47%)
≥20 years of education	22 (39%)	63 (43%)
Caucasian origin	48 (74%)	136 (93%)	0.0001
Other origin	17 (26%)	11 (8%)
Desire for vaginal birth with persistent breech presentation at 37 weeks' GA	19 (29%)	52 (%)	0.5
Desire for caesarean birth with persistent breech presentation at 37 weeks' GA	33 (51%)	72 (49%)
Vaginal breech birth	14 (8%)	41 (23%)	0.4
Caesarean breech birth	38 (22%)	83 (47%)
All vaginal births	60 (41%)	22 (34%)	0.3
All caesarean births	87 (59%)	43 (66%)

CAM, complementary and alternative medicine; GA, gestational age.

Table 2.

Comparison of Subjects by Willingness to Participate Again in This RCT if it were Conducted Again (N=114 *)

	Yes	No
Characteristics	93 (82%)	18 (16%)	p-Value
Had previously used CAM prior to study outside of and during pregnancy	73 (79%)	11 (61%)	0.1
No prior use of CAMs before study participation	20 (22%)	7 (39%)
Moxibustion group	49 (53%)	7 (39%)	0.3
Control group	44 (47%)	11 (61%)
Primiparas	60 (65%)	13 (72%)	0.5
Multiparas	33 (36%)	5 (28%)
Age 18–30	27 (29%)	2 (11%)	0.1
Age 31–45	6 (71%)	16 (89%)
<14 years of education	7 (8%)	4 (22%)	0.2
15–19 years of education	46 (50%)	7 (39%)
≥20 or more years of education	46 (%)	7 (%)
Caucasian origin	87 (94%)	12 (67%)	0.001
Other origin	6 (6%)	6 (33%)
Cephalic presentation at 37 weeks' GA	17 (18%)	1 (6%)	0.2
Podalic presentation at 37 weeks' GA	76 (82%)	17 (94%)
Desire for vaginal birth with persistent breech presentation at 37 weeks' GA	55 (59%)	4 (22%)	0.004
Desire for caesarean birth with persistent breech presentation at 37 weeks' GA	38 (41%)	14 (78%)
Cephalic presentation at birth	43 (46%)	3 (17%)	0.02
Podalic presentation at birth	50 (54%)	15 (83%)
Vaginal birth	42 (45%)	4 (22%)	0.07
Caesarean birth	51 (55%)	14 (78%)

111 respondents were included for analysis, because 3 women responded “I don't know.”

RCT, randomized controlled trial; GA, gestational age.

Table 3.

Comparison of Subjects by Willingness to Repeat Moxibustion in the Event of a Subsequent Fetal Breech Presentation After Reading the Trial Results, Which Failed to Show Moxibustion Effectiveness (N=114 *)

	Yes	No
Characteristics	68 (60%)	40 (35%)	p-value
Had previously used CAM prior to study outside of and during pregnancy	55 (81%)	28 (70%)	0.2
No prior use of CAMs before study	13 (19%)	12 (30%)
Moxibustion group	36 (53%)	19 (48%)	0.6
Control group	32 (47%)	21 (52%)
Primiparas	44 (65%)	28 (70%)	0.6
Multiparas	24 (35%)	12 (30%)
Age 18–30	20 (29%)	8 (20%)	0.3
Age 31–45	48 (71%)	32 (80%)
<14 years of education	46 (%)	6 (15%)	0.3
15–19 years of education	31 (46%)	15 (38%)
≥20 or more years of education	33 (49%)	19 (48%)
Caucasian origin	62 (91%)	35 (88%)	0.4
Other origin	6 (9%)	6 (12%)
Cephalic presentation at 37 weeks' GA	14 (21%)	4 (10%)	0.2
Podalic presentation at 37 weeks' GA	54 (79%)	36 (90%)
Desire for vaginal birth with persistent breech presentation at 37 weeks' GA	42 (62%)	17 (43%)	0.05
Desire for caesarean birth with persistent breech presentation at 37 weeks' GA	26 (38%)	23 (60%)
Cephalic presentation at birth	33 (49%)	13 (33%)	0.1
Podalic presentation at birth	35 (51%)	27 (67%)
Vaginal birth	34 (50%)	12 (30%)	0.04
Caesarean birth	34 (50%)	28 (70%)

111 respondents were included for analysis, because 3 women responded: “I don't know.”

CAM, complementary and alternative medicine; GA, gestational age.

Table 4.

Summary of the Thematic Analysis: Responses to Open-Ended Questions

“Why did you want to participate in this study on moxibustion?” (n=64 comments)
#1^a	Give oneself all possibilities to make the baby turn and be able to give birth vaginally	n=22 (34%)
#2	Start with a gentle method that is natural and comfortable for the mother and the baby	n=13 (20%)
#2	Curiosity (to test the potential of moxibustion treatment and to participate in an interesting research approach)	n=13 (20%)
#3	Avoid external cephalic version	n=10 (16%)
#4	Belief in the effectiveness of alternative medicines	n=8 (13%)
#5	Pressure by caregivers	n=5 (8%)
“If the study were to be redone, would you participate again? Why?”
82% responded “yes”(n=101 comments)
#1	Do everything to make the baby turn to give oneself all possibilities of having a vaginal birth	n=34 (34%)
#2	To benefit from moxibustion, a gentle and natural method that is not dangerous to the mother or the baby	n=33 (33%)
#3	It is important to do research; I have confidence in the medical world	n=27 (27%)
#4	For the regular appointments with a midwife; to ask questions, enjoy a moment of relaxation, take care of myself	n=24 (24%)
16% responded “no” (n=21 comments)
#1	Bad experiences with preceding participation (time and effort for the treatments)	n=14 (67%)
#2	Doubts about the effectiveness	n=7 (33%)
#3	Respect the choice of the baby to be breech	n=2 (10%)
“Through today, and after having read the results of the study, would you try moxibustion again if you were faced with the breech presentation of a future baby? Please explain why.”
60% responded “yes”(n=86 comments)
#1	Belief in the effectiveness of alternative medicines and scepticism of the study results	n=37 (43%)
#2	Because I would like to try everything to turn my baby, so I can birth naturally; because I hope that it will work for me	n=32 (37%)
#3	Because it is a gentle and natural method, which will not control the desire of the baby (the opposite of trying ECV)	n=19 (22%)
35% responded “no” (n=46 comments)
#1	It has been proven ineffective	n=29 (63%)
#2	Bad experience with prior treatment (time, effort)	v=11 (24%)
#3	Greater projection possibilities: age; marital; social; or obstetrical characteristics (e.g., antecedent 2 cesareans)	n=4 (9%)

Patient numbers.

ECV, external cephalic version.

Results

All 212 women who participated in the study completed the first questionnaire. Sixty-nine percent (69%) of women reported having self-treated at least once with CAMs outside of pregnancy and/or during pregnancy. Homeopathy was the most frequently cited CAM (35%), followed by osteopathy (31%) and acupuncture (13%). Women of Caucasian origin were more likely to treat themselves with CAMs than women from other continents who were living in Switzerland (93% versus 8%, p<0.0001). Likewise, women with higher education were more likely to utilize CAMs for self-treatment, compared to less-educated women (44% versus 10%; p<0.02). Pregnancy was associated with a significant reduction in utilization of CAMs (67% versus 47% p<0.001).

Two (2) years after completion of the RCT, 33 initial respondents could not be located at the time second questionnaire was being distributed. Of the 179 women contacted, 114 responded after one mailing with one follow-up, resulting in a response rate of 64%. Three variables were significantly higher in the group of women who responded to the questionnaire, compared to those who did not: access to CAMs for self-treatment, higher educational attainment, and Caucasian origin.

Motivation to participate in an RCT for moxibustion to encourage fetal change of position during the last pregnancy

On average, the participants' classifications of the six propositions by order of importance showed that the principal motivation to participate in the RCT was the desire to try everything to give birth vaginally. In second place, was belief in the potential effectiveness of CAMs, followed by the desire to contribute to the advancement of knowledge by participating in medical research.

The thematic analysis of written comments showed that participation in the study was motivated first by the desire to resolve the obstetrical problem (to turn the fetus to a cephalic presentation and increase the likelihood of vaginal birth). The following represents the type of responses received:

“For me, being a mother means birthing vaginally and breastfeeding.”

“I absolutely wanted ABSOLUTELY to give birth vaginally.”

Starting with a gentle method was a decisive element for women:

“I had wanted to start by trying gentle medicines before moving to an external cephalic version, which is more traumatizing.”

The desire to participate in medical research was an equally important motivating factor:

“I think that it is very enriching to have a complementarity of approaches at the heart of medicine, and this is the reason I decided to participate in this research.”

Participating again in the study if it were to be redone

Two years (2) after the end of the RCT, 82% of women affirmed that they would participate again in this study if it were to be redone. Significant determinants of envisioning re-participating included having been able to imagine a vaginal birth at 37 weeks' gestational age (GA; p<0.004), having had a fetus in cephalic presentation at birth independent of the mode of delivery (p<0.02) and being of Swiss-European nationality (p<0.001; Table 2).

The thematic analyses of the written comments clarified the quantitative analysis (Table 4). The thematic analysis indicated that the primary motivation to participate was linked to the desire to try everything to turn the baby for those reasons described earlier. Next in importance was the desire to participate in medical research, particularly regarding alternative medicine:

“Continuing to research alternative medicines is important. In my opinion, they ALSO have their place in the medical structure.”

And to “benefit from moxibustion, a gentle and natural method that is not dangerous to the mother or the baby.”

The women who were allocated to the moxibustion group in the original RCT were more enthusiastic about the idea of participating again in this type of study than those who had been allocated to the nonmoxibustion group (p<0.03). The thematic analyses of the written comments (Table 4) indicated that this was primarily because the women in the moxibustion group appreciated the discussions with the midwives who offered the treatment at the hospital, as reflected in this example:

“Through discussions with the midwife, the treatments permitted me to have a more humane and less technical approach to my pregnancy and birth. There was time for positive and reassuring discussion.”

Impact of learning the results of the RCT on patients' intention to use moxibustion if breech fetal presentation were to occur in a subsequent pregnancy

After reading about the results of the RCT, which did not demonstrate efficacy of moxibustion, 60% of the women questioned expressed the intention of resorting to this technique in case of a subsequent pregnancy with a fetus in the breech position. The women who were already habitual users of CAMs were slightly more likely to say that they would use moxibustion again (81% versus 70%), but this difference was not statistically significant (Table 3). The thematic analyses of the written comments provided a better understanding of the reasons behind this motivation (Table 4), which were principally associated with the belief in the effectiveness of alternative medicines and a degree of skepticism regarding the scientific results of the RCT:

“Some babies did not turn regardless; maybe moxibustion works only in certain cases.”

“I am sorry that the results didn't demonstrate the effectiveness of moxibustion, but I am persuaded that this technique should be maintained for those who desire it.”

The second most frequently cited argument is wanting to give oneself every chance to turn the baby and deliver vaginally:

“I think that it is preferable to try everything to avoid a caesarean, which deprives the mother of physically giving birth to the baby.”

In third place, women believed CAM to be a gentle and natural method that should, therefore, be tried first:

“It is a non-invasive method without imposing any danger or suffering to the baby and the mother.”

Finally, for certain women, the moxibustion sessions permitted rich discussions with the hospital midwives, calming the patients and allowing them to “re-center” themselves, which helped them through the period of doubt regarding the breech presentation:

“The sessions were moments where I could concentrate on my baby and what I felt, to re-centre at a time when everything sometimes seems to be going too fast. These moments permitted me to make the decision to try a vaginal delivery and not to accept that a caesarean was the only option.”

Discussion

In the current study, 69% of women stated that they had self-treated at least once with a CAM either outside of or during pregnancy. This is higher than the number generally observed, which typically ranges from 20% to 60%.¹⁰ This is potentially a true increase, as the use of CAMs is increasingly common, but it could also be attributed to a selection bias of the interviewed women, which is an inherent limitation of the current study. Indeed, the women were interviewed in the context of participating in an RCT designed to evaluate a CAM, which, in itself, may indicate that they already viewed these medical alternatives in a positive light. Nevertheless, the current authors previously observed during the RCT that many women refused to participate in the RCT because they believed in the effectiveness of the CAM treatment and did not want to take the risk of being allocated to the control group.⁵ It was also expected that women who did not believe in the treatment's effectiveness would have refused to participate. The skepticism of one group of participants regarding the scientific results could also be linked to the fact that habitual CAM users were more likely to respond at length to the questionnaires, especially to the second questionnaire, than women who had never used CAMs prior to study.

Women who responded to the second questionnaire explained that their principal reason for participating in this study (and considering participating again) was the desire to give themselves every chance of a vaginal delivery (as opposed to any conviction regarding the effectiveness of moxibustion). Complementary research methodologies (both quantitative and qualitative methods were used in this study) demonstrated a rich capacity to take into account the complexity of an observed phenomenon. It was determined that >50% of the participating women planned to use moxibustion in future pregnancies if their fetuses were in breech position, despite having participated in an RCT that was unable to show the efficacy of the method (only 18% of the fetuses had their heads down at the completion of the moxibustion sessions versus 16% in the control group; relative risk 1.12; confidence interval [CI]=0.62–2.03).⁵ The qualitative approach provided an understanding that the numbers alone do not explain everything. This approach also offered a way to discover that the women were driven not by blind faith in the efficacy of complementary medicines but rather by the desire to increase—by even a small amount—the likelihood of having a natural childbirth, which is more probable when the fetus is head-down at the moment of delivery. This desire to try all possibilities to improve the chance of a vaginal delivery surpassed the women's belief in the effectiveness (or lack thereof) of the moxibustion treatment for breech presentations as demonstrated by the scientific results of the RCT in which the women had previously participated. Recall that only 18% of the fetuses of the women in the moxibustion group had heads down at the completion of the sessions versus 16% of those in the control group women (RR 1.12, CI=0.62–2.03).⁵ Despite this, more than 1 of every 2 women expressed an intention to retry moxibustion in case of fetal breech presentation during a subsequent pregnancy. The importance of a vaginal delivery to these women should encourage reflection on the current obstetric debate regarding the vaginal delivery of breech babies.^11,12 The women frequently cited a desire for natural and gentle medical treatments, regarding their desires to deliver vaginally and to avoid an external cephalic change of fetal positioning; thus, this desire was an important reason behind the women's motivation to start using a CAM if possible. Conducting research evaluating the effectiveness of other CAM techniques that can encourage change of breech positioning (i.e., osteopathy, postural techniques, hypnosis, and chiropractic care) will address this demand.^10,13

It is difficult to characterize CAM users. From a socioeconomic standpoint, higher education was positively correlated with the likelihood that the women would self-treat with CAMs. Equally, the ethnic origins of women had a strong impact on the uses and choices of CAMs. These two points are consistent with the results of other authors, and professionals are encouraged to consider these characteristics when providing advice to pregnant women about treatment.^6,14
–16 It is evident that socioeconomic profiles are not sufficient for understanding this phenomenon. Mitchell has begun to explain the reasons for the interest of pregnant women with CAMs from a psychologic perspective. She associates women's increased perception of greater obstetric risk—which is a source of anxiety and uncertainty—causing these women to turn to CAMs. This would correspond to a need for autonomy and active participation in care.¹⁷ However, as highlighted by Adams et al., other studies are necessary to gain a better understanding of CAM utilization among women.¹⁰

The women reduced their use of CAMs significantly during pregnancy. This diminution corresponds to the decrease in general medical consumption during pregnancy. Louik et al. explained that it is the fear of indirectly harming their fetuses that drives women to avoid pharmaceutical treatments.⁶ The current authors hypothesize that this is also the reason that CAMs—which are represented as potentially efficacious and inoffensive treatments—continue to be used during pregnancy. That said, however, CAMs are not free of risk.^18,19 They can, for example, interact with pharmaceutical treatments.⁶ Health professionals play an important role in providing information about CAMs,¹⁰ and a previous study has demonstrated the professional opinions about, and barriers to greater utilization of, CAMs.²⁰ The most important question now appears to be how to best advise patients who CAM treatment. ²¹ Regarding research on CAMs, 82% of the women in the current study responded that they would participate again in the RCT if it were to be redone. Thus, the current authors deduce a strong interest in participating in medical research, with the goal of evaluating the effectiveness of CAMs. Paradoxically, as discussed previously, it would seem that the actual scientific results have little influence on the convictions of patients regarding utilization of CAMs for themselves.

Conclusions

This study reports important elements for understanding the utilization of moxibustion among pregnant women who had fetuses with breech presentations. The current authors were able to differentiate two levels of motivation for resorting to moxibustion and for participating in related research: (1) the desire to try everything to turn the fetus to a cephalic presentation and (2) the belief in the effectiveness and innocuousness of CAMs for the fetus. The strong motivation the women had to increase their chances of natural delivery with fetusus that were head-down shows the need for research on the psychologic consequences of the mode of delivery. Likewise, the percentage of women utilizing CAMs before and during pregnancy justifies the development of studies to understand this social phenomenon better, particularly with regard to the motivations and expectations of users, and physical and psychologic effects of this type of therapeutic approach.

Footnotes

Acknowledgments

Some of the data analyzed in this study were collected as part of a study sponsored by grants from the Swiss National Science Foundation (SNFS, DORE research grants), the University of Applied Sciences Western Switzerland (HEdS-SO), the Loterie Romande, and the Fondation Lebherz, Switzerland.

Disclosure Statement

No competing financial interests exist.

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