Majority of Women Are Influenced by Nonprofessional Information Sources When Deciding to Consult a Complementary and Alternative Medicine Practitioner During Pregnancy

Abstract

Objectives:

Up to 87% of women are using some form of complementary and alternative medicine (CAM) during their pregnancy, and this study was conducted to investigate the information sources that these women find influential in relation to such use.

Design:

The study sample was obtained via the Australian Longitudinal Study on Women's Health. This article is based on a substudy of 1835 pregnant women who were surveyed in 2010. The women answered questions about CAM use, pregnancy-related health concerns, and influential information sources in relation to CAM use. Logistic regression models were used to determine the information sources that women reported as influential in their decision making regarding CAM use.

Results:

Of the respondents (n=1835, 79.2% response rate), 48.1% (n=623) of the pregnant women consulted a CAM practitioner and 91.7% (n=1485) used a CAM product during pregnancy. The results show that, of the women who used CAM, nearly half (48%, n=493) were influenced by their own personal experience of CAM and 43% (n=423) by family and friends. Other popular sources of information were general practitioners 27% (n=263), the media (television, radio, books, magazines, newspapers) 22% (n=220), obstetricians 21% (n=208) and midwives 19% (n=190). Numerous statistically significant associations between influential information sources and pregnancy-related health conditions were identified.

Conclusions:

Women utilize a wide variety of information sources regarding their CAM use during pregnancy. Nonprofessional sources of information were found to be particularly influential, and maternity health care professionals need to have a nonjudgmental and open discussion with women about their CAM use during pregnancy in order to ensure safe and effective maternal outcomes.

Introduction

The prevalence of complementary and alternative medicine (CAM) use has reached substantial levels in many countries over recent years.^1,2 It is well known that women of reproductive age are high consumers of CAM—a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine^3,4—with emerging research highlighting the popularity of CAM use during pregnancy.^3,5,6

CAM Use in Pregnancy

Research suggests that up to 87% of women are using some form of CAM during their pregnancy,^3,6 with one recent study showing that 48% of pregnant women consulted a CAM practitioner.⁷ Most studies have identified between 20% and 60% prevalence of CAM use among pregnant women,^3,6,8 with herbal medicine, nutritional supplements, massage, acupuncture, homoeopathy, aromatherapy, and yoga being particularly popular.^9

–14

CAM use in pregnancy appears to be partly mediated by some women's desire for a more “natural” approach to health care that they see as safe and effective.^12,15 Research has demonstrated that women are using these medicines to alleviate pregnancy-related symptoms such as nausea and vomiting, low-back pain, extreme tiredness, and urinary tract infections.^7,16,17 In light of such use and given the concerns about the safety of CAM use during pregnancy,^18

–22 it is imperative that the key information sources influencing women's decision making in relation to CAM use during pregnancy be examined.

Sources of Information Utilized for the Use of CAM in Pregnancy

Previous investigation has identified that up to 33% of pregnant women utilize conventional practitioners such as obstetricians, doctors, nurses, midwives and pharmacists for information on CAM.^{8,10,11,14,15,17,23} However, some women tend to rely less on information about CAM from conventional medical practitioners, with past research showing that up to 71% of women utilize nonprofessional sources of information on CAM during pregnancy, including a reliance on their own experience, friends, family, media, books, magazines, internet, and health-food shops.^{8

–15,17,23,24} Of these information sources, friends and family were found to be particularly popular across all studies.^{8

–15,17,23,24} This earlier work, while providing insights from preliminary data on this topic, has only drawn upon small-scale and localized populations of pregnant CAM users. As such, there is a need for examination of this area drawing upon large-scale population-based data. In response, this article reports the findings from the first large, nationally representative study worldwide to examine the information sources women identify as influential in their decision making regarding CAM use during pregnancy.

Materials and Methods

Sample

The study sample was obtained via the Australian Longitudinal Study on Women's Health (ALSWH). The ALSWH is a longitudinal study of women in three age groups (“young” 18–23, “mid age” 45–50, and “older” 70–75 years) who were randomly selected from the national Medicare database to investigate multiple factors affecting health and well-being of women. These women were shown to be broadly representative of the national population of women in this target age group.²⁵ The present study is based on a substudy survey of 1835 women, administered in 2010. Participants in the substudy survey were identified as pregnant or had recently given birth in the 2009 ALSWH Survey 5 (n=2445) of the young cohort. Ethics approval for the substudy reported here was gained from the relevant ethics committees at the University of Newcastle, University of Queensland, and the University of Technology Sydney.

Demographic measures

Women were asked about marital status, education, income, and employment. Postcode of residence was used to categorize urban or rural residence.

Pregnancy-related health concerns

Women were asked about their pregnancy-related health concerns in the substudy questionnaire. Information was collected on a range of common pregnancy complaints including back pain and other musculoskeletal complaints, nausea, vomiting, and other gastrointestinal complaints, headaches and migraines, sleeping problems, varicosities, fatigue, hypertension, pre-eclampsia and anemia.

Use of CAM

Women were asked about their use of CAM practitioners for pregnancy-related health complaints, as listed above. CAM practitioners included acupuncturist, chiropractor, herbalist/naturopath, massage therapist, and other CAM practitioner.

Pregnancy-related health information-seeking behavior

Women were also asked about various sources of information that were influential in their decision to use CAM during pregnancy including general practitioner, obstetrician, midwife, pharmacist, friends and family, own personal experience, media, internet, and other.

Statistical analysis

Influential information sources for women choosing to visit a CAM practitioner for pregnancy-related health concerns during their most recent pregnancy were investigated and bivariate relationships determined using a chi-square analysis. Identification of the significant information sources predicting CAM use for treatment of pregnancy-related health concerns was determined through multiple logistic regression modeling. All information sources were entered into a model to determine which ones predicted CAM use for common pregnancy-related symptoms. A stepwise backward elimination process was employed, using a likelihood ratio test, to eventually produce the most parsimonious model. Statistical significance was set at p<0.05. All analyses were conducted using statistical program STATA^® 11.2 (StataCorp LP, College Station, TX).

Results

A total of 2316 women were invited to participate in the substudy; 1835 women responded to the substudy survey and were included in the analysis (79.2% response rate). Most respondents were married or living with a partner (96.3%, n=1760), held a tertiary qualification (60.1%, n=1095), were working before the baby was born or on maternity leave (full-time 31. 5%, n=574; part-time 32.8%, n=599; and casual 28.9%, n=529) and were usually able to manage on available income (42.1%, n=768). The women more commonly had private health insurance (72.0%, n=1316) but were only slightly more likely to give birth in a public hospital (48.7%, n=882 vs. 46.9%, n=850 for private hospitals).

The use of CAM in pregnancy was found to be widespread, with 48.1% (n=623) of women consulting a CAM practitioner for a pregnancy-related health complaint. Table 1 shows that 48% (n=493) of respondents who used CAM were influenced by their own personal experience of using CAM in the past and 43% (n=423) were influenced by family and friends when making decisions about CAM use during gestation. Other popular sources of information on CAM use by women were general practitioners (27%, n=263), the media (television, radio, books, magazines, newspapers) (22%, n=220), obstetricians (21%, n=208), and midwives (19%, n=190). The internet (11%, n=113) and pharmacists (7%, n=70) were less popular information sources for CAM among the women surveyed.

Table 1.

Influential Information Sources for Pregnant Women Regarding Complementary and Alternative Medicine Use

Information source	Percent influenced by the information source
Personal experience	48% (n=493)
Family and friends	43% (n=423)
General practitioner	27% (n=263)
Media	22% (n=220)
Obstetrician	21% (n=208)
Midwives	19% (n=190)
Internet	11% (n=113)
Pharmacist	7% (n=70)
Other	2% (n=31)

Bivariate analyses showed (Table 2) that women were influenced by a variety of information sources when deciding to visit a CAM practitioner. Personal experience and friends and family were a positive influence about CAM use for women when deciding to visit a CAM practitioner for the treatment of back pain, sciatica, hip/pelvic pain, headaches/migraines, preparation for labor, and nausea (all p<0.05). Women were positively influenced by their general practitioner when deciding to consult a CAM practitioner for sciatica and headaches/migraines. However, the women were not influenced by their general practitioner's opinion in relation to CAM use during pregnancy if they suffered from sleeping problems (all p<0.05). Women found their obstetrician positively influential if they suffered from back pain, sciatica, hip/pelvic pain, and headaches (all p<0.05).

Table 2.

Association Between Influential Information Sources and Complementary and Alternative Medicine Practitioner Consultations for Pregnancy-Related Symptoms

Information sources	Back pain (65%; n=229)		Sciatica (57%; n=269)		Hip/pelvic pain (54%; n=249)		Headaches/migraines (32%; n=110)		Preparation for labor (24%; n=129)		Sleeping problems (15%; n=45)		Nausea (11%; n=72)
	Yes (n=)	No (n=)	Yes (n=)	No (n=)	Yes (n=)	No (n=)	Yes (n=)	No (n=)	Yes (n=)	No (n=)	Yes (n=)	No (n=)	Yes (n=)	No (n=)
Personal experience^{a,b,c,d,e,f,g}
Yes	144	70	151	60	158	81	151	84	201	92	243	95	190	88
No	208	282	201	289	194	271	201	268	151	260	109	257	165	264
Friends/family^{a,b,c,d,e,f,g}
Yes	109	63	123	67	116	70	137	81	176	99	155	102	215	84
No	243	289	229	285	236	282	215	271	176	253	197	250	137	268
General practitioner^c,d,f
Yes	63	53	74	46	70	63	95	56	49	63	25	67	42	60
No	289	299	278	306	282	289	257	296	303	289	327	285	310	292
Obstetrician^a,b,c,d,e
Yes	56	35	60	32	63	32	70	39	53	49	25	63	42	46
No	296	317	292	320	289	320	282	313	299	197	327	289	310	306
Media^a,b,c,e
Yes	53	32	60	35	70	42	53	49	102	56	56	60	60	49
No	299	320	292	317	282	310	299	303	250	296	299	292	292	303
Midwife^c,d
Yes	46	35	46	28	63	32	70	39	84	60	63	56	63	42
No	306	317	306	324	289	320	282	313	268	292	289	296	189	310
Internet^c,e,g
Yes	28	18	25	32	42	21	32	18	74	25	39	25	53	21
No	324	334	327	320	310	331	320	334	278	327	313	327	299	331
Pharmacist^a,d
Yes	21	11	25	11	21	14	28	7	7	18	25	25	14	14
No	331	341	327	341	331	338	324	345	345	334	327	327	338	338

Statistically significant association with back pain (p<0.05).

Statistically significant association with sciatica (p<0.05).

Statistically significant association with hip/pelvic pain (p<0.05).

Statistically significant association with headaches/migraines (p<0.05).

Statistically significant association with preparation for labor (p<0.05).

Statistically significant association with sleep (p<0.05).

Statistically significant association with nausea (p<0.05).

Various sources of information on the use of CAM were found to be influential for specific pregnancy-related complaints via multiple logistic regression modeling, as presented in Table 3. Women with back pain (odds ratio [OR]=2.52; 1.80–3.53, 95% confidence interval [CI]; p<0.001) and/or sciatica (OR=3.21; 2.06–5.00, 95% CI; p<0.001) were found to be positively influenced by their own personal experience with CAM use and friends and family (back pain OR=1.77; 1.24–2.53, 95% CI; p=0.002; sciatica OR=2.00; 1.27–3.14, 95% CI; p=0.003) when deciding to consult a CAM practitioner. Women with hip or pelvic pain were positively influenced by their own personal experience (OR=2.70; 1.79–4.07, 95% CI; p<0.001) and their obstetrician (OR=2.13; 1.20–3.80, 95% CI; p=0.010) when making decisions about using CAM during pregnancy.

Table 3.

Logistic Regression Analyses Demonstrating Statistically Significant Information Sources Utilized by Pregnant Women for the Use of Complementary and Alternative Medicine

Information sources	Back pain (65%; n=229)	Sciatica (57%; n=269)	Hip/pelvic pain (54%; n=249)	Headaches/migraines (32%; n=110)	Preparation for labor (24%; n=129)	Sleeping problems (15%; n=45)	Nausea (11%; n=72)
Personal experience	OR 2.52 (95% CI: 1.80–3.53)	OR 3.21 (95% CI: 2.06–5.00)	OR 2.70 (95% CI: 1.79–4.07)	OR 2.32 (95% CI: 1.42–3.80)	OR 3.65 (95% CI: 2.36–5.63)	OR 6.97 (95% CI: 3.44–14.09)	OR 2.86 (95% CI: 1.68–4.85)
	p<0.001	p<0.001	p<0.001	p=0.001	p<0.001	p<0.001	p<0.001
Friends/family	OR 1.77 (95% CI: 1.24–2.53)	OR 2.00 (95% CI: 1.27–3.14)	—	—	OR 1.86 (95% CI: 1.19–2.91)	—	OR 4.59 (95% CI: 2.69–7.85)
	p=0.002	p<0.003			p=0.006		p<0.001
General practitioner	—	—	—	—	—	OR 0.20 (95% CI: 0.06–0.70)	OR 0.39 (95% CI: 0.18–0.85)
						p=0.012	p=0.017
Obstetrician	—	—	OR 2.13 (95% CI: 1.20–3.80)	OR 1.93 (95% CI: 1.02–3.67)	—	—	—
			p=0.010	p=0.043
Internet	—	—	—	—	OR 3.21 (95% CI: 1.70–6.04)	—	—
					p<0.001
Pharmacist	—	—	—	OR 5.52 (95% CI: 1.62–18.85)	—	—	—
				p=0.006

CI, confidence interval; OR, odds ratio.

Women with headaches were positively influenced by their own personal experience of CAM (OR=2.32; 1.42–3.80, 95% CI; p=0.001) and by their obstetrician (OR=1.93; 1.02–3.67, 95% CI; p=0.043) and pharmacist (OR=5.52; 1.62–18.85, 95% CI; p=0.006) in relation to CAM use during pregnancy. When preparing for labor, women were found to be positively influenced by personal experience (OR=3.65; 2.36–5.63, 95% CI; p<0.001), friends and family (OR=1.86; 1.19–2.91, 95% CI; p=0.006), and the internet (OR=3.21; 1.70–6.04, 95% CI; p<0.001) when deciding to consult a CAM practitioner. When suffering from sleeping difficulties (OR=6.97; 3.44–14.09, 95% CI; p<0.001) and nausea (OR=2.86; 1.68–4.85, 95% CI; p<0.001), women were more likely to be influenced by their own personal experience of CAM and less influenced by advice from their general practitioner (sleeping problems OR=0.20; 0.06–0.70, 95% CI; p=0.012; nausea OR 0.39; 0.18–0.85, 95% CI; p=0.017) when deciding to visit a CAM practitioner. Women suffering from nausea were also likely to be positively influenced by advice from family and friends (OR=4.59; 2.69–7.85, 95% CI; p<0.001) when deciding to visit a CAM practitioner.

Discussion

This is the first analysis of a large, nationally representative sample of pregnant women to investigate the information sources women identify as influential in their decision to visit a CAM practitioner for pregnancy-related health conditions. Our findings show that CAM practitioners are consulted by a majority of the women surveyed during pregnancy. Women appear to be influenced more by nonprofessional sources of information such as personal experience, and friends and family, than by professional sources such as obstetricians, general practitioners, and midwives when deciding to visit a CAM practitioner.

Nearly half of the women surveyed who visited a CAM practitioner were influenced by their own personal experience of CAM and 43% were influenced by family and friends, in line with results from previous research.^{3,8

–15,17,23,24} When making decisions about consulting a CAM practitioner, women were significantly influenced by their own experience of CAM if they were seeking help for back pain, sciatica, hip/pelvic pain, headaches/migraines, sleeping problems, nausea, and to prepare for labor. Additionally, women's decisions regarding CAM practitioners were also significantly influenced by advice from friends and family if they were seeking help for back pain, sciatica, nausea, or to prepare for labor. Although it is not surprising that women are influenced to try treatments that have provided positive results for themselves or someone they trust in the past, it is noteworthy that women were not significantly influenced by professional maternity health care providers when deciding to consult a CAM practitioner.

Professional maternity care providers such as obstetricians, general practitioners, and midwives appear to be underutilized as a potential information source about the use of CAM during pregnancy, which appears to be consistent with previous research in this area.^10,11,17 Studies from the United Kingdom, Canada, and Australia have reported that less than 10% of women seek their physician's advice when making decisions about CAM use during pregnancy.^10,12,17 Conversely, two European studies found that slightly more women consulted their physician for advice on CAM. An Italian study found that 33% of women consulted their gynecologist and 20% consulted their midwife²³ about CAM use, whereas a Norwegian study reported that 59% of women sought advice from their doctor regarding using herbal medicines.¹⁴ Most work previously has only looked at CAM product use in this regard, and there would appear to be a need for further research exploring CAM practitioner use in these terms. Our research shows that some pregnant women are influenced by information from obstetricians (21%) in their decision making regarding consulting CAM practitioners. However, our study found a significant correlation between women who are influenced by information from their obstetrician regarding CAM use and only women seeking help for hip/pelvic pain and headaches. In general, women were not influenced by their obstetrician's advice any more than by any other maternity health professional, friend, or family member, in relation to consulting a CAM practitioner for pregnancy-related health concerns. We also found that women were less likely to be influenced by advice they received from their general practitioner about CAM practitioner use if they suffered from sleeping problems or nausea. Possible concerns about a doctor's lack of knowledge or disdain for CAM may underpin women's lack of confidence in the guidance given to them about consulting with a CAM practitioner.¹²

Midwives were not found to be significantly influential in their advice about CAM use for women with any of the pregnancy-related health conditions. A recent article reviewing the attitudes and referral practices of midwives with regard to CAM found that the majority of respondents reported practicing, recommending, or referring pregnant women for CAM treatments or products.¹ In light of this, it is perhaps surprising that midwives were not considered to be a more influential source of information on CAM use, and further research should explore the disparity between the perceptions and understandings of midwives and pregnant women regarding the role of the midwife in CAM use during pregnancy.

The notion that women may not be influenced by maternity health care professionals as sources of information on CAM use during pregnancy and instead favor personal experience and information from family and friends requires follow-up research to clarify women's opinions and behaviors around information searching when pregnant. The issue of pregnant women favoring such nonprofessional information sources in their CAM use decision making is an issue of pertinence to those practicing and managing conventional maternity care as well as policy-makers interested in pregnancy and services for pregnant women. The safety implications of such information-seeking behaviors are further amplified when considered within the context of a vacuum of clinical evidence evaluating CAM use during pregnancy.³

Our study has some limitations that need to be considered when interpreting the findings. We relied on self-reported data and women's recall of information from their most recent pregnancy, thus potentially introducing bias. However, this limitation is countered by the opportunity to examine a large nationally representative sample of pregnant women to investigate the use of CAM during gestation. Additionally, due to the small sample size for two of the pregnancy-related health concerns (headaches/migraines and sleeping problems), the logistic regression model produced estimates of OR with wide confidence intervals. Therefore, caution needs to be used when interpreting the findings for these two health concerns.

Conclusions

Overall, women appear to be largely influenced by nonprofessional sources of information when deciding to visit a CAM practitioner for a pregnancy-related health issue. Although it is acknowledged that informal information-sharing is an ancient and exceedingly common way for women to pass on information about health and pregnancy, maternity health care professionals need to have a nonjudgmental and open discussion with women about their CAM use during pregnancy in order to ensure safe maternal outcomes.

Footnotes

Acknowledgments

The Australian Longitudinal Study on Women's Health, which was conceived and developed by groups of interdisciplinary researchers at the Universities of Newcastle and University of Queensland, is funded by the Australian Department of Health and Ageing. We thank all participants for their valuable contribution to this project. We also thank the National Health and Medical Research Council for funding Professor Jon Adams via an NHMRC Career Development Fellowship as well as the Australian Research Council for funding this project via their Discovery Project Funding (DP1094765) and for funding Associate Professor Alex Broom via an Australian Research Council Future Fellowship.

Author Disclosure Statement

All authors declare that no competing financial interests exist.

References

Adams

, Sibbritt

, Broom

, et al. A comparison of complementary and alternative medicine users and use across geographical areas: A national survey of 1,427 women. BMC Complement Altern Med, 2011; 11:85.

Harris

, Cooper

, Relton

, Thomas

. Prevalence of complementary and alternative medicine (CAM) use by the general population: A systematic review and update. Int J Clin Pract, 2012; 66:924–939.

Adams

, Lui

, Sibbritt

, et al. Women's use of complementary and alternative medicine during pregnancy: A critical review of the literature. Birth, 2009; 36:237–245.

Adams

, Easthope

, Sibbritt

. Exploring the relationship between women's health and the use of complementary and alternative medicine. Complement Ther Med, 2003; 11:156–158.

Sibbritt

, Adams

, Lui

. Health service utilisation by pregnant women over a seven-year period. Midwifery, 2011; 27:474–476.

Hall

, Griffiths

, McKenna

. The use of complementary and alternative medicine by pregnant women: A literature review. Midwifery, 2011; 27:817–824.

Frawley

, Adams

, Sibbritt

, et al. Prevalence and determinants of complementary and alternative medicine use during pregnancy: Results from a nationally representative sample of Australian pregnant women. Aust N Z J Obstet Gynaecol, 2013; 53:347–352.

Cagayan

, Oras

. Use of complementary and alternative medicines among women with gestational trophoblastic diseases: A survey at the Philippine General Hospital. J Reprod Med, 2010; 55:327–332.

Pettigrew

, King

, McGee

, Rudolph

. Complementary therapy use by women's health clinic clients. Altern Ther Health Med, 2004; 10:50–55.

10.

Forster

, Denning

, Wills

, et al. Herbal medicine use during pregnancy in a group of Australian women. BMC Pregnancy Childbirth, 2006; 6:21.

11.

Holst

, Wright

, Haavik

, Nordeng

. The use and the user of herbal remedies during pregnancy. J Altern Complement Med, 2009; 15:787–792.

12.

Holst

, Wright

, Nordeng

, Haavik

. Use of herbal preparations during pregnancy: Focus group discussion among expectant mothers attending a hospital antenatal clinic in Norwich, UK. Complement Ther Clin Pract, 2009; 15:225–229.

13.

Maats

, Crowther

. Patterns of vitamin, mineral and herbal supplement use prior to and during pregnancy. Aust N Z J Obstet Gynaecol, 2002; 42:494–496.

14.

Nordeng

, Havnen

. Use of herbal drugs in pregnancy: A survey among 400 Norwegian women. Pharmacoepidemiol Drug Saf, 2004; 13:371–380.

15.

Westfall

. Herbal healing in pregnancy: Women's experiences. J Herb Pharmacother, 2003; 3:17–39.

16.

Adams

, Sibbritt

, Lui

. The use of complementary and alternative medicine during pregnancy: A longitudinal study of Australian women. Birth, 2011; 38:200–206.

17.

Hollyer

, Boon

, Georgousis

, et al. The use of CAM by women suffering from nausea and vomiting during pregnancy. BMC Complement Altern Med, 2002; 2:5.

18.

Adams

, Lui

, Sibbritt

, et al. Attitudes and referral practices of maternity care professionals with regard to complementary and alternative medicine: An integrative review. J Adv Nurs, 2011; 67:472–483.

19.

Gossler

. Use of complementary and alternative therapies during pregnancy, postpartum, and lactation. J Psychosoc Nurs Ment Health Serv, 2010; 48:30–36.

20.

Mitchell

. Risk, pregnancy and complementary and alternative medicine. Complement Ther Clin Pract, 2010; 16:109–113.

21.

Nordeng

, Bayne

, Havnen

, Paulsen

. Use of herbal drugs during pregnancy among 600 Norwegian women in relation to concurrent use of conventional drugs and pregnancy outcome. Complement Ther Clin Pract, 2011; 17:147–151.

22.

Adams

. Growing popularity of complementary and alternative medicine during pregnancy and implications for healthcare providers. Expert Rev Obstet Gynecol, 2011; 6:365–366.

23.

Lapi

, Vannacci

, Moschini

, et al. Use, attitudes and knowledge of complementary and alternative drugs (CADs) among pregnant women: A preliminary survey in Tuscany. Evid Based Complement Alternat Med, 2008; 7:477–486.

24.

Hepner

, Harnett

, Segal

, et al. Herbal medicine use in parturients. Anesth Analg, 2002; 94:690–693.

25.

Brown

, Dobson

, Bryson

, Byles

. Women's Health Australia: On the progress of the main cohort studies. J Womens Health Gend Based Med, 1999; 8:681–688.