Engaging Practitioners in Advancing Research on Acupuncture in Pregnancy

Abstract

Objectives:

Women across the globe seek acupuncture to treat pregnancy concerns. Randomized controlled trials have indicated limited benefits of acupuncture in pregnancy, but field studies involving practitioners are needed to better understand the outcomes of usual care. To advance research on pregnancy acupuncture, this study engaged field-based practitioners to discuss research strategies.

Settings/Location:

U.S. Pacific Northwest region.

Design and participants:

Live focus group with regional specialized acupuncturists. Content analysis involved research team and interviewees.

Results:

Practitioners generally focused on patient care, although they discussed valuing research for communicating with patients and biomedical practitioners. To increase research in this area, practitioners proposed partnering with professional organizations, using social media, assuring confidentiality, and designing brief measurement tools.

Conclusions:

Practitioners valued evidence for specific uses and proposed several novel research strategies. On the basis of these results, a framework is proposed for building a patient-centered collaboration between research and practice communities that is responsive to paradigmatic preferences and the overarching goals of science.

Introduction

Poor integration of acupuncture into the prevailing U.S. biomedical care system presents challenges to acupuncture research. This is especially true for acupuncture in pregnancy, which women generally obtain in private clinics that operate separately from biomedical obstetric services; the rare exceptions are large-scale nationally funded research programs.^1,2 Field studies are an option, although even teaching clinics involved in complementary and alternative medicine (CAM) outcome studies^3,4 exclude pregnant women. Collaborating with community-based practitioners therefore becomes all the more essential in providing what some have discussed as an ethical responsibility to provide evidence on “usual care” treatment effects and safety.^5
–7

Field research has a greater likelihood of success when practitioners participate in the research process.^3,7 Therefore, to advance field studies on acupuncture in pregnancy, this study conducted a focus group with specialized practitioners to gather their perspectives on and recommendations for research. This paper focuses on that discussion.

Pregnant women may seek acupuncture as a low-risk option to treat symptoms such as nausea and pain and to address pregnancy and birth issues, including fetal presentation, labor onset, and labor progress.⁸ One regional study of nurse-midwives indicated that about 19% treated their patients with acupuncture for musculoskeletal and back pain.⁹ Another showed that over half of the 50% of women who had used a CAM approach, such as acupuncture, before pregnancy continued use during pregnancy.¹⁰ Specialized training is available, and practice specialty registries and organizations exist (e.g., American Board of Oriental Reproductive Medicine, American Association of Acupuncture and Oriental Medicine).

In terms of research on acupuncture in pregnancy, fewer than 15 studies have originated from the United States over the past several decades.¹¹ Most are controlled trials assessing acupuncture effects on medical indicators, such as cesarean delivery.^12
–14 In the only United States–based observational study identified by the current authors, clinic patients treated for various pregnancy conditions reported benefits directly and indirectly related to treatment.¹⁵ The limited research leaves practitioners and patients with little formal evidence to guide treatment decisions.

Randomized controlled trials (RCTs) are generally viewed as the “gold standard” of research, but treatment approaches and patient characteristics in RCTs may differ from those in field settings. As one example, in RCTs on acupuncture in pregnancy, researchers excluded higher-risk patients, whereas field data indicated that higher-risk pregnant women sought acupuncture.⁸ The more heterogeneous practices and patients in “usual care” compared with RCTs also raise questions about generalizability, and sole reliance on these designs overlooks the opportunity to simultaneously compare multiple treatments. From an ethical perspective, field research is critical to guiding practitioner and patient decision making and healthcare policy.^5
–7,16,17

In sum, studying acupuncture in pregnancy within the currently fragmented U.S. care system necessitates connecting with practitioners and patients in the field to examine usual care outcomes. Field research is necessary for the short-term goal of informing patients and practitioners; field research could be used to better integrate care by informing the biomedical community on treatments that may be outside the scope of routine practice and that women seek because they view the biomedical alternative as higher risk. To gain insight into strategies that would lead to research success, this study began by conducting a focus group with regional specialized practitioners.

Materials and Methods

Study procedures were classified as “exempt” by the first author's institutional review board. An Oriental Medicine professional school research associate provided the names of five regional women's acupuncture specialists. All agreed to participate in a live focus group (one canceled but agreed to follow-up). Practitioners had a mean of 8 years of practice with pregnant women and saw a mean of 7.5 pregnant patients per week (range, 2–15 years).

The focus group was conducted in a public library meeting room and lasted approximately 75 minutes. Before the meeting, the facilitator (E.S.) e-mailed participants consent forms, study information, and interview prompts.

At the meeting, the facilitator introduced a few specific prepared questions/prompts (e.g., “What value does research have for you?”), but it was largely a free-flowing exchange about pregnancy acupuncture research and practice. To minimize bias, the first author directly acknowledged her background in related research and framed interview prompts to be nondirective. Three research assistants attended. The session was audiotaped. Participants received a $20 gift card.

Overview of data analysis

A study author (S.M.) transcribed the audiotape verbatim, with each speaker identified by number only (e.g., speaker 1, speaker 2). Identifying information was replaced with bracketed reference (e.g., [“city name”]). The first author circulated this transcript to authors and practitioners for correction and comment; no changes were suggested.

To identify, analyze, and report thematic patterns within the interview materials, thematic (qualitative) data analysis was applied. An inductive approach was used in which themes were identified as they appeared in the data rather than specifically in relation to a question.¹⁸

Strategies outlined by LaPelle¹⁹ were used to initially identify, code, and correct data because they allowed study authors to share and cross-validate themes. Text subjected to analysis could have ranged from short phrases to several sentences. Analytic steps include formatting data, developing a codebook, assigning thematic codes, and sorting data by index keys to validate and correct codes used in thematic pattern identification and analysis. Thematic categories were intended to be discrete so that text instances fit into only one category. Multiple data passes were carried out to refine and develop discrete categories and subcategories that described the data succinctly.

All study authors reviewed the transcript and identified thematic categories. The first author reviewed the full set of themes and subthemes, which were discussed until consensus was reached. The agreed-upon set of themes was circulated to practitioners for comment, and no changes were suggested.

Results

This study focused on key themes that were viewed as representative of the discussion rather than present themes in terms of frequency, which may not necessarily reflect their relative importance (and could be misleading with a small sample). This method is consistent with an accepted approach of identifying themes that capture critical features of the dataset.¹⁸ Table 1 lists major themes and subthemes, which are referred to by number in the text.

Table 1.

Primary Themes and Subthemes Appearing in Focus Group Data

Theme	Subthemes
Patient care is practitioners' primary concern	1. Treatment concerns range and include those directly (e.g., breech correction) and indirectly (e.g., allergy, anxiety) related to pregnancy
	2. Treatment varies by pregnancy stage, from conception to labor onset, and by parity
	3. Women seek acupuncture to avoid biomedical treatment, especially medications, including psychotropics
	4. Treatment relies on patient-practitioner trust and involves treating whole person from symptom to birth-related anxieties
	5. Practitioners responsible to treat only appropriate cases and to communicate/collaborate with biomedical practitioners
	6. Pregnant women are underserved; practitioners see treatment as a healthcare right despite others' expressed liability concerns
	7. Practitioners share goal of preventing cesarean deliveries
	8. Practitioners value treatment based on personal and clinical experience, including and cross-generation repeat clients
Research perspectives I: research valued for informing biomedical and patient communities	9. Formal research could better inform biomedical practitioners who view acupuncture as “dangerous”
	10. Some biomedical practitioners accept acupuncture on available data (e.g., fertility) or as a low-risk option (e.g., allergy treatment)
	11. Practitioners have responsibility to use research to treat only appropriate cases
	12. Patients are already informed; research useful to confirm practitioner and patient views on acupuncture benefit
	13. Neither practitioners nor patients view acupuncture as potentially harmful
	14. Findings have greater impact if published in mainstream, accessible outlets
Research perspectives II: ways to increase participation and create inviting studies	15. Appeal to practitioners' values and beliefs to gain their participation
	16. Establish researcher credibility to increase practitioner participation
	17. Connect to practitioners through trusted partners (e.g., seminar leaders)
	18. Must engage practitioners to find patients
	19. Use social media (e.g., Facebook postings) to reach practitioners who in turn recruit patients through social media
	20. Keep surveys short (can be longer if completed on Facebook)
	21. Use open-ended questions rather than Likert scales
	22. Assure confidentiality and that contact information will not be marketed, particularly if offering incentives

“Practitioner” refers to acupuncturists/Traditional Chinese Medicine practitioners; “biomedical practitioner” generally refers to MD-credentialed physicians.

Theme 1: patient care and related issues

The discussion content was divided into two major areas: research and patient care. Practitioners spoke most freely about the latter. Although practitioners did not connect patient care directly to research, numerous relevant points were revealed.

From interview outset, practitioners discussed conditions they treated in pregnancy (subtheme 1), including how conditions treated varied by pregnancy stage, from early pregnancy support and nausea treatment to back pain and labor facilitation in late pregnancy (subtheme 2). Regardless of condition treated or pregnancy stage, practitioners emphasized that patients sought treatment largely to avoid biomedicine (subtheme 3), particularly medications. Two practitioners (practitioners 2 and 4) listed medications their patients had sought acupuncture to replace, including those for nausea/gastrointestinal symptoms, migraine, and mood symptoms/problems (i.e., psychotropics). This quote reflects subtheme 3:

It's a time in your life where you don't want to take medication … or there's medication that you can no longer take while you're pregnant … [practitioner 4]

Important to advancing research on acupuncture in pregnancy, subthemes 1–3 indicate that developing a valuable evidence base would require more thorough assessment of treatment effects and adverse events on conditions directly and indirectly related to pregnancy. Developing that evidence base would also require attending to factors that have been acknowledged as important in research on nonbiomedical care and that better reflect the practice of energy medicine. Those include practitioner-patient relationship (i.e., trust), effects, and treatment of a whole person, not just symptoms (subtheme 4), seen in participant 3's words:

They're getting more from me than they may be getting from their provider … part of that is addressing anxiety and fear around labor and delivery … there isn't much anxiety about the acupuncture itself.

Until comprehensive data become available, practitioners and patients will be left to operate largely on faith and the experience of benefit, which these practitioners discussed as factoring into their clients' repeat visits, even across generations (e.g., a woman treated in pregnancy brought her child for treatment; see subtheme 8). Although practitioners may find faith and experience to be sufficient, patients, other practitioners, and policy makers may expect reliable, published evidence. Such evidence may also help practitioners reach expressed treatment goals, including reducing cesarean deliveries (subtheme 7) and treating only appropriate cases and communicating with biomedical practitioners (subtheme 5).

In the meantime, practitioners remain committed to their primary mission, which, despite liability-related discouragement from treating pregnant women (practitioner 4), is to treat patients they viewed as underserved (subtheme 6):

… It was just a sacred population that I wanted to work with … pregnancy and birth is what I do … it totally came from human rights in health care and childbirth (practitioner 2).

Themes 2 and 3: research perspectives

The first of the two broad research-related themes reflected the value practitioners placed on research relative to their practice, and the second covered ideas for conducting research. Research themes and subthemes, numbered for reference purposes, are in Table 1.

Research perspective I: research valued for informing biomedical and patient communities

This discussion arose largely in response to the prompts, “What value does research have for you as a professional?” and “What value does research have for your patients?” Content reflected practitioners' interest in using research results chiefly to inform the biomedical and patient communities of acupuncture benefits and safety.

Although the acupuncturists said many biomedical practitioners were open to acupuncture based on their familiarity with existing research or a general openness (subtheme 10), they were also interested in having data to counter what they viewed as some practitioners' mistaken beliefs that acupuncture is “dangerous” in pregnancy (subtheme 9). Participant 2 said:

I can't figure it out, if there's new research that I haven't seen … but I've had a lot of patients who are actually really distraught because their provider is saying, “This is dangerous to you,” like actually using the word “dangerous” … and it's extremely upsetting to them [patients].

To be clear, practitioners said nothing to indicate that they believed that acupuncture was in any way dangerous in pregnancy (subtheme 13). Moreover, practitioners viewed their patients as savvy consumers who informed themselves before seeking treatment (subtheme 12).

Although practitioners viewed acupuncture as safe in pregnancy, they mentioned a professional responsibility of possessing sufficient research-based knowledge to treat only appropriate cases (subtheme 11). Practitioner 1 said the she had on occasion deferred treatment, not because she viewed acupuncture as risky but because some patients' higher-risk pregnancies posed too great a risk for any treatment outside that recommended by an obstetrician.

Overall, practitioners viewed research as useful to confirm their belief in the benefits and safety of their practice. Perhaps from this perspective of wide-ranging benefits, practitioners expressed interest in seeing research published in mainstream outlets (The Atlantic was specifically mentioned) and accessible through electronic means, including social media (subtheme 14).

Research perspectives II: ways to increase participation and create inviting studies

Without prompting, two participants stated that practitioners were the best means for recruiting patients for research. The first author probed for additional detail on engaging practitioners and, in turn, their patients. Subthemes in this category covered specific suggestions for increasing practitioner and patient participation, which linked to ideas for creating inviting studies.

Similar to their views on the value of research, participants discussed their willingness to participate as depending on whether any proposed research aligned with their beliefs about acupuncture (subtheme 15) and on the researcher's credibility (subtheme 16), reflected in this quote from participant 2:

I would totally do a 30-minute survey if … it was from a source that I trusted … we shared the same, like, values, morals, ideas. …

To establish credibility and gain practitioners' trust, participants suggested that researchers connect with practice specialty/continuing education seminar leaders (subtheme 17) and continuing education organizations offering online courses and face-to-face conferences. Irrespective of the mechanism researchers might use to contact practitioners, all agreed that working with acupuncture professionals would be essential to reaching patients (subtheme 18).

The remaining subthemes reflected ideas for creating studies that would retain practitioner and patient participants. In addition to recruiting practitioners through seminar leaders, practitioners recommended posting study announcements and survey links on professional acupuncture organization Facebook pages. Practitioners said they would use their personal Facebook pages and other electronic means, such as online newsletters to recruit patients (subtheme 19).

Additional suggestions centered on designing studies to keep practitioners and patients from “clicking away” (i.e., to remain engaged long enough to complete the study). Practitioners recommended creating short surveys (subtheme 20), which they agreed was less than 30 minutes, that is, “about the time it takes me to see a patient … that I'm not getting paid for” (practitioner 4). They also expressed preference for open-ended rather than numeric questions (subtheme 21) and would want to be assured that their or their patients' contact information would not be marketed, especially if incentives were offered.

Discussion

This study focused on engaging practitioners in discussing how to advance research on acupuncture in pregnancy because practitioner participation is essential to obtaining quality, field-based evidence to guide practitioner and patient decision making. Content analyses indicated that practitioners considered research as most useful to confirm their experientially based views of treatment as safe and beneficial across various pregnancy concerns. Practitioners also discussed valuing research for communicating with biomedical professionals, patients, and the public at large. They offered specific ideas for obtaining field data useful to CAM and other treatment researchers, such as using electronic platforms, connecting with professional organizations, and creating brief assessment tools.

A central aim of qualitative analysis is applying findings to theory building.^20,21 On that aim, the study was based on the authors' previous results and from Cassidy²² to propose a unifying framework for advancing field-based research on benefits and safety of acupuncture in pregnancy. Cassidy²² discussed designing research in accordance with the rules of science, which are broad and paradigm-crossing and include theory building and hypothesis testing, systematic and replicable approaches, evidence-based (and rejected) models, and awareness of and techniques to reduce researcher bias. Unfortunately, the current participants' expressed views on the value of research—to confirm their belief in treatment as beneficial and safe and to refute contrasting views held by some outside their treatment community—align only minimally with the broad rules of science.

To advance much-needed field research on, for example, acupuncture treatments in early pregnancy²³ and for the pregnancy conditions the participants routinely treat (see Results), the issue becomes one of uniting researchers and practitioners while at the same time respecting both the rules of science and practitioner values, such as those raised in our interview. As a starting point, researchers and practitioners should adopt a shared mission of research in service of achieving the highest-quality acupuncture care for pregnant women. The shared mission should emphasize related subthemes the participants discussed, including a right to treatment for pregnancy concerns, interest in treatments that present lower risk than do certain available biomedical approaches, and a need for evidence to guide health care decision making (Table 2). With the results indicating practitioner focus on patient care, it is likely that collaborating from a foundation of a shared, patient-centered research mission would best engage practitioners and could be the basis for resolving differences in research values and related paradigmatic preferences that could otherwise complicate research progress.

Table 2.

Framework for Advancing Research on Acupuncture in Pregnancy Drawn from Study Subthemes

Paradigm-crossing mission for research on treatments in pregnancy	Paradigm-specific components in pregnancy acupuncture research design
• Safe, effective treatments for pregnancy concerns a healthcare right (6)• Women seek treatment for various conditions directly and indirectly related to pregnancy (1, 2)• Women seek treatments they view as lower risk than existing biomedical treatments (3)• Reliable information on treatment effects and safety warranted for patient decision making (9, 12)• Treat appropriate cases (11)	• Respect practitioner-patient relationship as central to treatment (4)• Respect practitioner-researcher relationship as central to collaboration (15–17)• Honor whole-person treatment perspective, from symptom focus to birth-related anxieties (4)

Subtheme numbers from Table 1 in parentheses.

“Paradigmatic preferences” are research and treatment considerations specific to defined professional communities,²² and the participants identified several central to their practice. Also in Table 2, these included honoring the whole-person treatment approach and respecting the relational component of treatment, subthemes consistent with previous interviews with acupuncturists.²⁴ Additional subthemes categorized as paradigmatic preferences centered on relational components in research collaboration.

Historically, the CAM community's paradigmatic preferences have been viewed as conflicting with the prevailing biomedical/social science research perspective, which emphasizes identifying uniquely effective components of treatment. Aligning acupuncture research with the prevailing paradigmatic perspective has resulted in acupuncture studies that deliberately remove the core “whole person” and relational features from acupuncture^25,26 and pregnancy acupuncture studies that restrict outcome measures to biomedical indicators.¹⁵ However, academic researchers and acupuncturists who treat pregnant women can successfully achieve research designs more satisfactory to their respective paradigmatic preferences if they ground their work in the previously defined rules of science. (Attempts to unify differing research perspectives appear in studies of acupuncture for other concerns^27

–31 but generally not those of pregnancy.)

Overall, the study's proposed framework, drawn from theory²² and from the participants' discussion of practice issues, research values, and specific strategies, makes a unique and important contribution to advancing field-based research on acupuncture in pregnancy. Advancing this research is consistent with ethically based calls to examine effects of “usual care”^5
–7 and with the U.S. American College of Obstetricians and Gynecologists' call to increase research on treating pregnancy concerns.³² This analysis indicated that encouraging research partners to share in a patient-centered mission could lead to effective collaboration on studies also respectful of paradigmatic perspectives.

Valuable as this contribution is to pregnancy acupuncture and CAM research in general, acknowledging study limitations will further help in moving forward. A small number of specialized practitioners from a single region were interviewed, and increasing participant numbers and expanding the geographic reach would strengthen findings. The study purposely focused on thematic content rather than response frequency to fully represent the interview results. Additional quantitative data on, for example, frequency of specific conditions treated could be useful to the maternal health community and in setting research priorities.

In conclusion, women across the globe use acupuncture to treat pregnancy concerns. The participants provided perhaps the most convincing rationale for studying pregnancy acupuncture outcomes, which is to better serve pregnant women's care needs. From that perspective, researchers and practitioners should unite to study pregnancy acupuncture effects and safety. Guided by a shared mission, collaborators will be better able to apply the rules of science to resolve their paradigmatic differences to produce evidence on usual care valuable to patients and to the maternal health community.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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